What is distinctive about the Existential approach to working with addiction

First of all, what is Addiction? There is a struggle around the concept of addiction and what constitutes addiction. One important perspective views addictive behaviours as a dysfunctional solution to a developmental wound while other theorists see it to be an entity of itself with its own meaning (Baker, 1996). Addiction has been defined as the continuing, habitual and merciless nature that motivates a particular behaviour despite physical and psychological harm to the abuser or society (Baker, 1996).

Over 50 years ago, Horney (1950, cited in Baker, 1996) astutely described addiction as a ‘Comprehensive neurotic solution… solution not only for a particular conflict but one that implicitly promises to satisfy all the inner needs that have arisen in an individual… it promises not only a riddance from his painful and unbearable feelings of being lost, anxious, inferior and divided, but in addition an ultimately mysterious fulfilment of himself and his life… no wonder that… it becomes compulsive. ” A phenomenological definition by Black (1991) is that addiction ‘involves sensation, that to begin with, are immediate, brief pleasant and repetitive, without producing satiation.

Repetition leads to habituation with an accompanying loss, or reduction, of pleasurable sensations, and stopping is an aversive experience; but any discomfort may be relieved by further repetition of the addictive behaviour’. There are many kinds of addictive behaviours often presented and worked on in therapy. Some themes have involved: substance abuse, sex and pornography, the internet, eating disorders and gambling but even ordinary functional behaviours, such as shopping, have also been presented to be a problem for some clients (Baker, 1996).

Addiction has been controversially categorised as an inherited disease, a choice, as well as a maladaptive behaviour due to environment. Specifically, this disease concept suggests that biological vulnerability and psychosocial behaviours contribute to addiction. This has proved effective convincing clients, who doubted their abilities to change, of the seriousness of their addictions but unfortunately, also gives the message that they are victims of their disease and powerless to change their behaviour (Ford, 1996).

This concept challenges the entire core dimensions of Existentialism and in this essay, the main argument addressed is that of the distinction in Existential therapy when dealing with addictions. Existential therapy confronts the misinterpreted disease concept, which suggests an addict is ‘powerless victim’ of the disease of addiction (Ford, 1996). While Existentialists accept the importance of inherited and environmental influences on a person, a clear distinction is made that addiction is a matter of choice rather than part of the disease concept (Black, 1991).

Existentialism is an eclectic approach of applied philosophy used in psychotherapy that prides itself on a positive view of human nature, where the self is in a constant state of ‘transition… and becoming’ (Pesciallo, 2000). Existential therapy (and it’s counterpart, Logotherapy, which will not be discussed in this essay but has been used effectively in the treatment of drug addiction since 1966), is a phenomenological and person-orientated approach aiming to promote clients to make emotionally free experiences, authentic decisions and to bring about responsible ways of dealing with life-on life’s terms (Langle, 1994; Durzen-Smith, 1996).

Existentialists focus on a higher level of well being for the client, rather than diminishing pathology and see not the content of what is said between counsellor and client but the process of the therapeutic encounter the most critical component in therapy (Waldo, 1998). Insight and self-awareness are of value to an individual, in and out of therapy, with an emphasis put on responsibility and the freedom to choose one’s own fate (Pesciallo, 2000).

Existentialists see this choice as a never-ending freedom for action and responsibility in an individual’s life; that a person is defined through their choices regardless of past or present experience. Furthermore, the autonomous self is defined upon the continuing requirement of having to make choices, and of accepting the consequences that those choices have on themselves and others (Black, 1991). This is best summed up from the words of Sartre, ‘to choose is possible, but what is not possible is not to choose.

I can always choose, but I ought to know that if I do not choose, I am still choosing’ (Langle, 1994). The belief that humans have a freedom to choose is what is known to be so productive in working with addiction and therefore integrated into all aspects of therapy (Waldo, 1998). The client who indulges in addictive behaviours is choosing to keep him or herself in a state of turmoil. Out of fear of the unknown, he may strive to avoid new behaviours or ways of thinking. An existential therapist confronts drinking, purging or any other addictive behaviour as a way of avoiding change, potential growth and intimacy.

Also, as many addicts view the world in black and white polarities, therapy enables clients to perceive the world in colour. Existential counsellors explore dimensions like; the natural, public, private and ideal worlds of clients and encourage discovery and recognition of their own inner feelings, values and beliefs separate from what others expect of them. They are encouraged to accept ways they have lived in according to others expectations and introjections yet examine the ways they are not living true to, or authentically to, their own evaluations, beliefs, values and standards (Pesciallo, 2000).

Goals for the future are explored and any hidden or unspoken talents are encouraged, recognised and elaborated on. This is because addicts are known to be future orientated and it is the anticipation of the immediate future that is the important proximal goal that influences the addicted person (Black, 1991). Heidegger (1927/1962, cited in Black, 1991) supported this by stating that a persons ‘relation to the future was more crucial than his relationship to the present’. In therapy, the client will come to recognise the rewards from tolerating a certain amount of uncertainty, going from dependency to autonomy (Pesciallo, 2000).

Existentialism’s recognition of the four givens of human condition being death, freedom, isolation and meaningless have been infiltrated throughout the foundations of its theory, (Waldo, 1998; Yalom, 1989) and enabled further insight into clients who have chosen the path of addiction. Death and its inevitability arouse terror in humans because it threatens a person’s existence with the notion of nonbeing. Death is not portrayed negatively but as significance to living and a motivation for determination and creativity (Pesciallo, 2000).

In regards to freedom, a person cannot avoid freedom because they are creators of themselves and the world around them. Nevertheless, an individual who wishes otherwise seeks a structure or foundation outside of himself or herself to ease the burdens of this ‘terrible freedom’ (Waldo, 1998). Isolation, or rather human fear of it, from an existentialist’s point of view, suggests how people can choose to be overly dependent on other people, places or things to the point of ‘being strangers to ourselves’ (Pesciallo, 2000).

Although humans are known to be relational beings that thrive on social connectedness, there must be balance of being alone as well. Relationships with others are seen to be for fulfilment rather than deprivation. Existentialists believe that human beings should be able to be comfortable in their ‘own skin’ and able to stand alone, which further develops an inner strength developing towards identity and autonomy, of ‘being’ rather then ‘doing’ (Pesciallo, 2000). The last human condition, meaning, is a factor presented in therapy by many clients in conflicting life-situations.

Finding one’s meaning and purpose in life is from the development of an, ‘internally derived value system’ (Pesciallo, 2000). Increased meaningfulness in life is associated with an increase of self-control (Black, 1991). Reflecting the words of Alice Miller (1979) ‘… in what is described… and experienced as emptiness… and loneliness can usually be recognised as the tragic loss of self. ‘ The lack of meaning in one’s life is a prevalent root in addiction because a person who feels an emptiness and nothingness inside themselves tries to deny, hide from or fill the emptiness through addictive behaviours.

Lack of awareness of a meaning worth living for, initiates an ‘existential vacuum’ an experience coined by Frankl (1964). The Holocaust is a poignant example of the importance of finding meaning in one’s life. Memoirs from both Viktor Frankl (1964) and Oskar Schindler (cited in Waldo, 1998) are interesting and somewhat opposing examples of man’s hunger for existence. Frankl, being one of the Jewish survivors of concentration camp, and Schindler, a catholic who risked his own life to save the lives of many Jews found meaning in their lives in different ways, survival and the saving of others.

Through Viktor Frankl’s experiences, he suggested that the will to meaning is the main human motivation and that meaning is only discovered by the individual rather than sources outside themselves (Frankl, 1964). He also believed one could find meaning even in suffering (Waldo, 1998). Schindler, on the other hand, lived a somewhat superficial pre-war existence but found meaning through the lives of others, the Jewish people he saved. Allport (cited in Waldo, 1998) suggested, ‘… no man can tell another what his purpose is.

Each must find out for himself, and must accept the responsibility that his answer prescribes. ‘ For the existentialist, life is more of a confrontation with negative internal forces such as existential guilt and anxiety (Waldo, 1998). Existential anxiety arises from a person’s awareness of their responsibility to create their own existence and is seen to be positive and very useful in that it motivates change in people (Corey, 1996). Without some sort of tension a person can become stuck and unable to grow.

Black (1991) described two escapes from anxiety and they were suicide or alcoholism and drug addiction. Also, anxiety is judged to be a result of the ‘flight-fall-creation’ analogy, where flying high on the drug and falling to crisis ultimately infuses the desire for recreation of oneself. Firestone, (cited in Waldo, 1998) considered drug abuse and compulsive sexuality to be secondary defences against death anxiety which would need to be worked through in order for the client to establish a more meaningful life. Existential guilt is unique from reality-based guilt and results from irresponsibility.

It is a message to oneself to take charge of their life or a signal that one’s behaviour is inconsistent with ones values (Waldo, 1998; Ford, 1996). Existential guilt initiates many people’s desire for counselling, and can be interpreted as the first stage towards positive growth, a perspective exclusive to existentialism (Ford, 1996). Another interesting and somewhat overlooked suggestion is that recovery can increase feelings of guilt because it dissolves any credibility of being a victim to addiction (Ford, 1996).

Lastly, other aspects in existentialism such as boundary situations and the concept of being thrown are analogous to the phrase ‘hit rock bottom’ frequently used in Alcoholics Anonymous. They are situations like a near-death experience or loss of a loved one, which brings the four givens of human condition into focus and also impedes the desire for therapy. Being thrown is one way to conceptualise these situations where one is faced with their ‘essential self’ (Waldo, 1998).

It is the lived experience of addiction that is the focus of an existential approach to treatment and that includes relapse and recovery (Black, 1991). Another phenomenon in the disease concept is that there is a common held conviction among recovering addicts that a even one episode of relapse will undoubtedly cause them to ‘lose control’ and activate their addictive behaviour (Ford, 1996). They perceive themselves as powerless in the face of their disease. Existentialism views of relapse challenge this idea.

A core construct of existentialism is that humans are in a constant state of becoming; therefore relapse is seen as a choice that does not permanently alter a person’s destiny back to a life of addiction. Meaningful recovery and personal responsibility are interdependent and when clients may realise that life without addiction is not all fun and happy experiences, this can result in existential frustration, the major cause for relapse in drug and alcohol abuse (Haines, 1997). Preceding relapse, clients’ behaviours and thoughts tend to become more self-orientated.

They argue sobriety to be just as meaningless as when they were using and believe they are not worthy for recovery. Once a client sees themselves with little or no purpose and no vision for the future, this results in dwelling or glorifying the past, failing to take personal responsibility and ultimately choosing to relapse (Haines, 1997). The way forward from these self-fulfilling prophecies is through affirmation of the self (Haines, 1997). Frankl’s suggestion of self-detachment is another useful tactic when dealing with relapse (1978; Cited in Wurm, 1997).

Humour, particularly the ability to laugh at oneself can take enormous pressure off of the addict and used as a positive reinforcement for change. Another existential approach is ‘motivational interviewing’ which attempts to de-emphasise and avoid these self-fulfilling prophecies (Miller, cited in Wurm, 1997). Miller (1985, cited in Black 1991) stated that ‘therapist characteristics such as hostility, expectancy and empathy powerfully influence whether a client will … ucceed in treatment. ‘ Therefore, existential therapists adopt a diplomatic style of questioning, intended to bring forth awareness in the client rather than telling them what to do (Wurm, 1997). ‘Motivation interviewing’ is non-traditional and avoids the medical model. It enables confidence in the client and in their ability to change. In conclusion, according to Laing (1960) a person’s behaviour is expressive of his or her existence.

Existentialism strives towards both behavioral change and a changed perception of existence so the individual establishes increased self-control to the point where life makes sense (Black, 1991). It is the empowerment of hope within the addicted person and the freedom of choice that enables them to choose meaningful lives and although the meaning that a person attaches to life may differ and change from one person to the next, the common bond between humans is their need for meaning to their existence (Black, 1991).

Existentialism does not promote powerlessness over addiction or playing the role of victim. Infact, it reinforces the notion of authenticity and autonomy and uses guilt and anxiety as a motivation for change. Existential therapeutic approaches may be particularly appropriate for short-term substance abuse treatment because they tend to facilitate therapeutic rapport, increase self-awareness and establish the client as the person responsible for recovery.