Technique & Structure

Another dimension emerging from the literature is the question of intervention structure and the integration of therapeutic tools and techniques.

Particularly with the rise of manualised interventions in the wake of programmes such as IAPT the notion of pre-defined intervention structure is increasingly prevalent in the wider psychotherapy literature (Westen, 2002; Wilson, 2007) including the use of therapeutic techniques that show effectiveness in research trials such as diaries or behavioural experimentation in CBT (Hawton et al., 1989) or problem formulation Dynamic Interpersonal Therapy (Lemma, Target, & Fonagy, 2011a). Conversely, existential-phenomenological practitioners tend to be weary of ‘once-size-fits-all’ thinking (van Deurzen-Smith, 1997), as it is argued to distract from how phenomena authentically arise. Cohn (1997; 2002) adds that structure in the form of therapeutic techniques are a

EPP in Primary Care — Literature Review

sign of the anxiety facing uncertainty and a loss of connection with ourselves and the clients.

The approach that most exemplifies this perspective in the literature is that of Strasser and Strasser (1997). Their approach is non-prescriptive, has no underlying fixed session structure apart from a suggested 12 week modular programme. Strasser and Strasser argue that the urgency of the time-limited encounter gives rise to those phenomena that are important to the client (and hence for the therapy) and therefore the resulting structure of each session is lead by the idiosyncratic encounter between therapist and client.

However, there are also a minority of practitioners, who argue that the openness of the phenomenological attitude offers the potential to integrate useful tools and techniques.

Langdridge (2006), for example, acknowledges the tension between the therapeutic techniques and the non-directive phenomenological method, but also argues that that the methods of constructivist and narrative approaches, particularly Solution-Focused Therapy “notably the miracle question, deconstructing the problem and exception questions, directly correspond with the methods of phenomenological psychology” (p.

366). He points out the ethical dimension of ignoring methods that are established to be successful, particularly within a brief timeframe. Langdridge is joined by voices such as Nanda and Claessens (Claessens, 2010; Nanda, 2009) who advocate that third-wave CBT practices such as mindfulness to be compatible with existential-phenomenological therapy.

Further, Rayner and Vitali’s (2015) use of the concept of collaboration or homework which is more commonly at home in the cognitive traditions. In addition, research shows that technique is not always construed as counterproductive in practice. Wilkes and Milton quote one of their participants as saying:

[..] some people in the existential perspective who say there is no technique, I think that`s rubbish, it’s a mystification, it’s something extreme, I think its lying, of course there`s a technique, phenomenology is a technique (Wilkes & Milton, 2006, p. 76).

From the literature it appears therefore that there is a spectrum on which integration of therapeutic methods in the British School takes place, from un-structured to the integration of concrete techniques. The position that practitioners take on this spectrum might be influenced by the extent to which they perceive existential-phenomenological therapy as an attitude or a therapeutic modality: Craig, for example talks about existential-phenomenological therapy as démarche, French for “a manner of walking, the kind of intention and purpose one brings to a particular learning or practice” (Craig, 2012, p. 8).

This attitude might facilitate the integration of a range of practices. Others, such as Strasser and Strasser (1997) seem to conceptualise existential-phenomenological therapy as a therapeutic modality alongside other modalities, such as CBT and psychoanalysis and are more concerned with delineation than integration.

For practitioners in the primary care context, the question is equally raised on where to position their practice and how to balance a focus on client concerns with the potential usefulness of therapeutic techniques, especially within the short space of time and an

EPP in Primary Care — Literature Review

2.3.4.Existential Practice in Primary Care: A Faustian Plight

Overall, there is a broad diversity of voices and perspectives taken in the review of the literature, reflecting the diversity of existential-phenomenological therapy within the UK and the wider field of the existential therapies (Cooper, 2015). Despite this and despite the foundational relevance existential therapy has within the profession of counselling psychology, existential therapy traditionally remained outside the territory of primary care.

Indeed, the struggle with the public sector, as a marketplace in which evidence-based practice is the currency has been termed a Faustian plight for existentialists (Schneider &

du Plock, 2012) and it seems that many existentialists are veritably fear losing their soul were they to dare enter it (Tantam & Kumar, 2009).

However, the literature outlines several important contributions that existential therapy potentially makes to primary care psychological intervention delivery: sensitivity to the contextual nature of therapy, a focus on working within limitations of time, responsiveness to the diverse range of clinical presentations, an individualised and personal approach to distress as well as a sensitivity to clients needs that goes beyond the technical application of therapeutic tools. Moreover, the UK literature also provides some inspiration for practitioners within primary care including several concrete models of therapeutic working. These are supplemented by a number of approaches developed outside of the UK, which adapt to managed care settings.

Yet, as primary care clinicians, existential therapists are likely to practice in the tension between the primacy of the idiosyncrasies of praxis and the common aspects of existential therapy as a psychological intervention (Vos, Cooper, Correia, & Craig, 2015).

That is, on the one hand existential therapists have to pursue their critique of essentialist notions of ‘thingifying’ and reducing practice to a set of techniques and universal laws or procedures. On the other hand, they situate themselves within the territory of managed care with its emphasis on homogenisation, standardisation, measurability, risk- and harm management, which is likely to lead to practice dilemmas. From the perspective of this research, the question is raised if and how practitioners are able to manage and negotiate these tensions and dilemmas.


EPP in Primary Care — Literature Review