Existential Concerns and Cognitive-Behavioral Procedures An Integrative Approach to Mental Health

Clients enter therapy grappling with a range of difficulties. They don’t speak in diagnostic terms, but instead focus on the everyday problems that confront them. Their struggles may include isolation, loneliness, anxiety, guilt and regret, and problems making decisions in a world that offers seemingly endless choice. In contrast, the cognitive-behavior therapist is trained in the language of conditioning and extinction, avoidance and safety behaviors, behavioral activation and attentional biases. This book explores the ideas of the existentialist philosophers as a bridge between the suffering client and technically trained clinician. The volume is not a rejection of cognitive behavior therapy (CBT), but seeks to place CBT in the broader context of the most popular philosophic tradition of the 19^th and 20^th centuries. 

Therapists versed in existentialism argue that the individual's starting point is characterized by a sense of disorientation in the face of an apparently meaningless and absurd world. Each individual must become solely responsible for giving meaning to life and living it passionately and authentically. Each of us must confront the ‘Big 5’ existential issues of death, isolation, identity, freedom and meaning and find our solutions to these problems. 

The present volume explores each of these existential themes in turn. Each section opens with a theoretical chapter describing the relevant existential dilemma and its impact on human experience. The second chapter in each section explores its relationship to mental health disorders and psychopathology. The third chapter in each section explores the evidence for treating the existential issue from a CBT framework. This book will be of value to those interested in CBT, philosophy and mental health, and will appeal to psychotherapists, clinical psychologists and psychiatrists.

Section 1. Introductory Issues

Chapter 1. Existentialism and the problems of being – Gerard Kuperis, University of San Francisco.

This opening chapter provides a history and overview of the central ideas of the existential philosophers. A thorough grounding in the theoretical orientation of these thinkers, and the common claims of existentialism, sets the scene for the rest of the volume.

Chapter 2. Existentialism and its place in contemporary cognitive-behavior therapy - Michael Worrell, Regent’s University London and Head of Department, London CBT Training Centre

Chapter 2 examines the way in which existentialism and CBT can be successfully integrated. The education of cognitive behavior therapists has not traditionally included any direct engagement with existential philosophy or existential psychology. This is despite the fact that Beck, and other founding figures in the history of CBT, have highlighted the relevance of existentialism to their thinking. The chapter describes the benefits of experiential practice exercises that ask therapists to ‘just listen’ to their clients and note the presence of ‘existential givens’.

Section 2. Death

Chapter 3. Death awareness and terror management theory – Ilan Dar-Nimrod, University of Sydney

Terror Management Theory (TMT) is the dominant social psychological theory examining the relationship between death awareness and human behaviour. According to TMT, cultural worldviews and self-esteem are thought to serve an important anxiety-buffering function in order to manage (or ‘tranquilise’) existential fear of death. This chapter will review the evidence for TMT and alternative accounts of the role of death awareness on human behaviour.

Chapter 4. Death fears and their relationship to mental health – Rachel E. Menzies, University of Sydney

Recent research suggests that death anxiety may be a transdiagnostic construct that mediates a range of mental health symptoms and disorders. It has been linked to OCD, Panic Disorder, Illness Anxiety Disorder and more recently to Somatic Symptom Disorder, PTSD, Depression and even Eating Disorders. This chapter will review the evidence and discuss the implications of these relationships between death anxiety and mental health.

Chapter 5. Creative approaches to treating the dread of death – David Veale, The Priory Hospital North London and Visiting Professor, Department of Psychology, Kings College London

Building on his work on death anxiety and Illness Anxiety Disorder, Professor Veale will explore contemporary approaches to treating the dread of death. Unlike other phobic reactions (e.g. fear of dogs, spiders, water), which may be characterised as irrational, death anxiety is based on an inevitable event or an ‘existential given’. As such, it requires a more creative and imaginative approach to treatment.

Section 2. Isolation

Chapter 6. Interpersonal, intrapersonal and existential isolation – Jeff Greenberg, University of Arizona

The existential psychotherapist Irvin Yalom (1980) describes three types of isolation. Interpersonal isolation refers to the loneliness created by social distance. Intrapersonal isolation refers to the dissociation between parts of oneself. Finally, existential isolation refers to the unbridgeable gap between oneself and any other being i.e. the fact that we can only ever experience our own consciousness. Chapter 6 examines the three types of isolation described in existential theory.

Chapter 7. Isolation, loneliness and mental health – Peter Kelly & Isabella Ingram, University of Wollongong, NSW

Chapter 7 reviews the considerable evidence that interpersonal isolation is strongly associated with poor physical health, mental health and high rates of addictive behaviours. Further, the inability to share phenomenological experience, which is associated with existential isolation, has been found to correlate significantly with depression, purpose in life, and non-specific loneliness in several studies. The relationships between non-specific loneliness, depression and mental health more broadly will be thoroughly explored in this chapter.

Chapter 8. Social prescribing: A review of the literature – Genevieve Dingle & Leah Sharman, University of Queensland.

Chapter 8 presents a social identity approach to mental health that has been championed by Professor Alex Haslam and colleagues at the University of Queensland (UQ). The growing evidence for social prescribing will be explored, with particular reference to the development of UQs ‘Groups 4 Health’ program (G4H). Their five-module program is the first to specifically target the development of social group relationships to treat psychological distress.

Section 3. Identity

Chapter 9. Identity and the courage to be – Paul Rhodes, The University of Sydney

Identity is a complex concept that is a relatively recent addition to models of existential concerns. It arises through ‘the courage to be a part of’ an ingroup, or through affirming and participating in the unique self which is typically referred to as ‘the courage to be’. Like each of the existential themes, it is inextricably linked to related concerns like isolation. Chapter 9 reviews the literature on identity from an existentialist perspective.

Chapter 10. The role of identity concerns and the self in psychopathology – Richard Moulding, Deakin University, Melbourne, Victoria

Chapter 10 reviews the range of mental health disorders that have been associated with the existential construct of identity. The ‘self’, and several overlapping constructs, have been implicated in obsessive compulsive and related disorders as well the anxiety disorders, mood disorders, eating disorders, trauma-related disorders and gender dysphoria.

Chapter 11. Clarifying identity and the self in a CBT context – Michael Kyrios, Flinders University, South Australia

Professor Kyrios will review the variety of ways that therapists may challenge faulty thoughts, beliefs and attitudes related to identity and the self. Metacognitive strategies, schema work, psychoeducation about the nature of consciousness, rational restructuring and a range of other cognitive and behavioural strategies will be explored.

Section 4. Freedom

Chapter 12. Freedom, responsibility and guilt – Thomas Heidenreich, Hochschule Esslingen, Esslingen am Neckar, Germany & Alexander Noyan, Hochschule Mannheim, Mannheim, Germany

Humans have the freedom to live in whatever way they choose. However, with freedom comes responsibility, and with responsibility comes ‘ontological guilt’. This was the basis for Tillich’s (1959) third domain of anxiety. Regret may arise as soon as a course of action is chosen, since inevitably one door opening implies that another has been shut. Chapter 12 examines the constructs of freedom, responsibility, guilt and regret and their importance in existential thinking.

Chapter 13. Failed potentialities, regret and their link to depression and related disorders – Ross Menzies, University of Technology Sydney.

A variety of studies have linked mood disorders to a ruminative style of thinking, particularly involving events and happenings from the past. When an individual’s early expectations of life are not met, depression may fol

Ross Menzies completed his undergraduate, masters and doctoral degrees in psychology at the University of NSW. He is currently Professor of Psychology in the Graduate School of Health, University of Technology Sydney (UTS). In 1991, he was appointed founding Director of the Anxiety Disorders Clinic at the University of Sydney, a post which he held for over 20 years.  He is the past NSW President, and twice National President, of the Australian Association for Cognitive Behaviour Therapy (AACBT). He is the previous editor of Australia's national CBT journal, Behaviour Change, and has trained psychologists, psychiatrists and allied health workers in CBT around the globe. Professor Menzies is an active researcher with nearly three decades of continuous funding from national competitive sources. He currently holds over $AUS7 million in research funding. He has produced 10 books and more than 200 journal papers and book chapters and was the President and Convenor of the 8th World Congress of Behavioural and Cognitive Therapies (WCBCT) in Melbourne in 2016. He has recently been appointed a founding director and Treasurer of the newly formed World Confederation of Cognitive and Behavioural Therapies (WCCBT). Ross lives with his wife and three youngest children in the inner west of Sydney.

Rachel Menzies is a post-doctoral fellow at the University of Sydney, where she completed her honours, masters and doctoral degrees in psychology. She published her first paper on death fears in Clinical Psychology Review as an undergraduate student, and followed this by convening a symposium on the topic at the 8th World Congress of Behavioural and Cognitive Therapies in Melbourne in 2016. Her experimental work on fear of death and psychopathology has been published in several leading journals, and she can regularly be heard on national and international radio, popular podcasts and at relevant public events (e.g. The Festival of Death and Dying, Adelaide Writers Week). In 2017, she gave her first invited plenary address on death anxiety, and an invited workshop, at the 47th Congress of the European Association of Behavioural and Cognitive Therapies (EABCT). Since then, she has published five books on existential issues and completed an invited workshop tour on the dread of death across seven cities for the Australian Association for Cognitive Behaviour Therapy (AACBT). In 2021, she won the national PhD Prize from the Australian Psychological Society for her work of death anxiety and its relationship with mental health. Rachel lives with her husband and runs a private practice in the inner city of Sydney.

Genevieve Dingle is an Associate Professor and Director of Clinical Psychology Programs at the University of Queensland with a research interest in how groups and communities can influence mental health and wellbeing. This includes both formal groups (such as cognitive behaviour therapy groups, and therapeutic communities for alcohol and other drug treatment), as well as arts-based groups such as choirs and creative writing groups. Genevieve worked for over a decade as a clinical psychologist in hospitals and private practice. She is the Editor of the journal Behaviour Change and serves on the executive of the Australian Music and Psychology Society and the Arts Health Network (QLD), and convenes the interdisciplinary UQ Music, Dance & Health research group. She is one of five authors of Routledge’s text, The New Psychology of Health - Unlocking the Social Cure, that was awarded the British Psychological Society Book of the Year Award in 2020. Genevieve lives in Brisbane with her husband and two daughters.