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Existential*Therapy*&*EBPP* * *
1*
Existential*Therapy,*Culture,*and*Therapist*Factors**
in*Evidence<Based*Practice1*
*
Heatherlyn*Cleare<Hoffman*
Argosy*University,*San*Francisco*Campus*
*
Louis*Hoffman*
Saybrook*University*
*
Sivan*Wilson*
Saybrook*University*
*
Although*there*is*a*solid*basis*for*existential*therapy*as*an*Evidence<Based*
Practice*in*Psychotherapy*(EBPP),*this*has*not*been*adequately*articulated*in*
the* scholarly* literature* (Hoffman,* Dias,* &* Soholm,* 2012).* This* paper*
advances* two* important* aspects* of* the* evidence<based* foundation* of*
existential* therapy:* therapist* factors* and* implications* for*
diversity/individual* differences.* The* three* pillars* of* EBPP* include* 1)*
research,* 2)* experience/expert* opinion,* and* 3)* individual* differences* and*
diversity.*Wampold*(2001)*has*successfully*advocated*that*therapist*factors*
are*one* of* the* most* important* contributions* to* successful* outcomes* in*
psychotherapy.* Furthermore,* Wampold* (2008)* maintained* that* existential<
integrative* psychotherapy* could* “form* the* basis* of* all* effective* treatments”*
(p.* * 6).* In* large* part,* Wampold* can* make* this* argument* about* existential*
therapy*due*to*its*foundation*in*the*relational*factors*of*therapy,*and*these*
relational* factors* are* strongly* supported* in* psychotherapy* research.*
Existential* therapy* has* well* articulated* the* relational* factors,* particularly*
those* connected* to* the* person* of* the* therapist.* However,* an* area* that*
requires* further* development* is* the* cultural* variations*of*the* therapy*
relationship* in* existential* practice.* Although* relational* factors* in*
psychotherapy* may* be* important* regardless* of* the* individual* or* culture,*
these*must*always*be*interpreted*within*the*context*of*culture.*For*example,*
authenticity*may*be*experienced*differently*in* varied*cultural*contexts,*such*
as* individualistic* and* collectivistic* cultures.* Similarly,* the* conveying* of*
concern* and* empathy* may* be* quite* different* in* high* context* versus* low*
context*cultural*communication*styles.*Drawing*upon*the*research*literature*
and*clinical*experience,*this*presentation*addresses*ways*in*which*relational*
factors* in* existential* practice* can* be* adapted* and* applied* in* a* culturally*
sensitive*manner.**
!
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1*Paper*presented*at*the*121st*Annual*Convention*of*the*American*Psychological*Association*held*in*Honolulu,*
HI,*July/August*2013.*
Existential*Therapy*&*EBPP* * *
2*
!All*therapists,*regardless*of*theoretical*orientation*or*therapeutic*approach,*should*
be*committed*to*assuring*the*therapy*they*provide*is*effective.*Too*often*existential*and*
humanistic*therapists*have*resisted*this.*Although*there*are*many*legitimate*concerns*
about*many*of*the*approaches*to*assessing*therapy*outcomes*that*have*been*popular*in*
recent*years,*this*does*not*necessitate*rejecting*all*approaches*to*evaluating*therapy.*
Evidence<Based*Practice*in*Psychology*(EBPP),*the*current*zeitgeist*in*evaluating*therapies,*
is*a*more*flexible*approach*that*can*be*a*good*fit*for*existential*and*humanistic*
psychotherapies*(Hoffman,*Dias,*&*Soholm,*2012).**
*While*EBPP*is*an*approach*that*could*be*considered*a*good*fit*with*existential*
therapy,*Wampold,*Goodheart,*and*Levant*(2007)*warn*that*if*there*are*not*intentional*
efforts*to*keep*a*broad,*inclusive*understanding*of*EBPP*that*it*could*easily*gravitate*
toward*being*understood*in*a*more*narrow,*restrictive*manner*consistent*with*previous*
approaches*to*evaluating*therapy*modalities.*Thus,*Hoffman*et*al.*(2012)*argued*that*it*is*
important*for*existential*and*humanistic*therapists*to*be*active*in*the*discussions*about*
how*EBPP*is*understood*and*defined,*as*well*as*working*to*demonstrate*that*existential*
and*humanistic*therapy*meets*the*criteria*for*being*EBPP*in*psychology.**
*This*paper*builds*upon*previous*arguments*that*assert*that*existential*therapy*can*
rightly*be*considered*an*evidence<based*practice*(Hoffman,*2009a,*Hoffman,*et*al.,*2012).**
However,*it*should*be*cautioned*that*EBPP*is*not*about*establishing*specific*therapy*
modalities*as*evidence<based,*but*rather*conceives*of*evidence<based*practice*as*
something*that*extends*beyond*a*particular*therapeutic*approach*to*also*consider*factors*
about*the*individual*therapist*and*their*competencies.*Thus,*when*saying*that*existential*
therapy*can*rightly*be*considered*an*evidence<based*practice*we*are*stating*this*within*the*
provision*that*the*therapist*implementing*this*approach*must*have*established*a*number*
of*basic*competencies*relevant*across*therapy*modalities.**
*
Brief!Overview!of!Evidence/Based!Practice2!
*
* The*American*Psychological*Associations*(APA)*Task*Force*on*Evidence<Based*
Practice*(EBPP)*(2006)*identified*three*cornerstones*of*EBPP:*1)*Research,*2)*Expertise*
(i.e.,*established*expertise*or*competency),*and*3)*consideration*of*individual*differences.*
How*each*of*these*is*conceived,*however,*is*still*being*debated.*It*is*important*for*
existential*psychology*to*be*involved*in*this*debate.*If*this*is*done*from*solely*a*critical*or*
defensive*posture,*it*is*not*as*likely*that*it*will*be*taken*seriously*or*influence*the*broader*
field.**
*
********************************************************
2*For*a*more*detailed*history*and*overview*from*an*existential*and*humanistic*perspective,*see*Hoffman,*Dias,*
and*Soholm*(2012),*“Existential<Humanistic*Therapy*as*a*Model*for*Evidence<Based*Practice.”*This*article*is*
available*at:*http://www.academia.edu/1843926/Existential<Humanistic_Therapy_as_a_Model_for_Evidence<
Based_Practice.**
Existential*Therapy*&*EBPP* * *
3*
Research!
* *Research*evidence*is*broadly*conceived*in*EBPP,*and*can*include*both*quantitative*
and*qualitative*approaches*(APA*Task*Force*on*EBPP,*2006).*Existential*therapy,*along*
with*many*other*approaches,*have*long*been*critical*of*the*narrow*use*of*quantitative*
research,*or*even*randomized*clinical*trials,*as*the*“gold*standard”*of*therapy*research*and*
outcome*studies*(see*Elkins,*2009;*Wampold,*2001).*These*critiques*are*important*and*
valid*critiques;*however,*not*applicable*to*EBPP,*which*takes*a*much*broader*
interpretation*of*what*is*constituted*as*appropriate*research.**
* Hoffman*et*al.*(2009)*maintained*that*it*was*important*to*move*beyond*research*
focusing*narrowly*on*outcomes*of*therapy*modalities.*Within*most*therapeutic*approaches,*
including*existential*therapy,*there*are*variations*between*therapists.*Additionally,*
therapist*will*vary*their*approach*to*therapy*based*upon*the*client.*While*there*are*some*
foundations*to*these*approaches*as*well*as*consistency*in*how*the*therapy*is*implement*
across*client,*no*two*therapies*look*alike*with*many*approaches.*Thus,*it*may*be*more*
appropriate*to*consider*the*core*components*of*the*therapy*approaches.*For*example,*
empathy,*the*therapy*alliance,*and*congruence*are*important*foundations*of*humanistic*
and*existential*psychology*that*have*strong*support*in*the*research*literature.**
*
Clinical!Expertise!
* Clinical*expertise*is*where*EBPP*most*clearly*goes*beyond*evaluating*therapy*
effectiveness*beyond*the*theoretical*orientation.*Instead,*the*focus*is*more*on*competency,*
which*the*APA*Task*Force*on*EBPP*(2006)*understands*as*including,*
*
(a)*assessment,*diagnostic*judgment,*systematic*case*formulation,*and*treatment*
planning;*(b)*clinical*decision*making,*treatment*implementation,*and*monitoring*
patient*progress;*(c)*interpersonal*skills;*(d)*continual*self<reflection*and*
acquisition*of*skills;*(e)*appropriate*evaluation*and*use*of*research*evidence*in*both*
basic*and*applied*psychological*science;*(f)*understanding*the*influence*of*
individual*and*cultural*differences*on*treatment;*(g)*seeking*available*resources*
(e.g.,*consultation,*adjunctive*or*alternative*services)*as*needed;*and*(h)*having*a*
cogent*rationale*for*clinical*settings.*(p.*276)**
*
Many*of*these*are*competencies*that*will*be*implemented*similarly*across*theoretical*
orientations.*However,*many*of*them*will*be*quite*different*based*upon*the*therapeutic*
modality.*For*instance,*diagnostic*judgment*may*vary*between*approaches*that*rely*
heavily*upon*traditional*diagnostic*approaches,*such*as*the*American*Psychiatric*
Association’s*Diagnostic*and*Statistical*Manual*of*Mental*Disorders,*as*compared*to*
approaches*that*may*take*different*approaches*to*conceptualizing*the*individual’s*
problems.*Similarly,*the*cogent*rationale*for*clinical*settings*necessarily*will*be*dependent*
upon*the*therapy*approach.**
Existential*Therapy*&*EBPP* * *
4*
* Hoffman*et*al.*(2009)*that*a*supplement*to*the*competencies*it*should*be*
considered*whether,*
*
(a)*there*is*sufficient*demonstration*that*the*various*clinical*competencies*are*
utilized*within*the*framework*of*these*therapeutic*modalities*and*(b)*approaches*to*
existential<humanistic*psychology*have*been*appropriate*vetted*in*the*peer<
reviewed*literature*by*experts*in*the*field.*(p.*6)*
*
This*serves*to*root*the*clinical*competencies*into*a*particular*therapeutic*approach,*such*as*
existential*therapy.*With*regard*to*existential*therapy,*this*literature*is*particularly*robust*
including*a*number*of*important*publications*that*provide*extensive*clinical*examples*and*
case*formulations*(see*Bugental,*1990;*Hoffman*&*Granger,*2009;*Schneider,*2008;*
Schneider*&*Krug,*2009;*Yalom,*1989,*1999)**
*
Individual!and!Cultural!Differences!
* According*to*the*APA*Task*Force*on*EBPP*(2006)*the*individual*difference*criteria*
focuses*on*the*ability*of*the*therapist*and*therapy*approach*to*adapt*to*work*with*a*variety*
of*individual*differences*including*ethnicity,*gender,*development,*and*sexual*orientation,*
among*others.*This*is*an*area*of*weakness*within*existential*and*humanistic*psychology*
historically;*however,*this*is*beginning*to*change.*However,*there*is*an*increasingly*ample*
body*of*literature*addressing*how*existential*psychology*can*be*adapted*to*work*with*
cultural*differences*(see*Hoffman,*Cleare<Hoffman,*&*Jackson,*in*press;*Hoffman,*Yang,*
Kaklauskas,*&*Chan,*2009;*Quinn,*2013;*Schneider,*2008).*
*
Therapist!Factors!and!Existential!Therapy!
*
*In*this*section,*we*review*seven*important*components*of*psychotherapy*that*are*
important*factors*in*change*regardless*of*one’s*therapy*orientation.*These*factors*have*
been*extensively*researched*and*fit*well*with*foundational*clinical*competencies,*which*are*
the*first*two*components*of*EBPP.*Each*of*these*also*can*be*understood*as*foundational*
components*of*existential*therapy*practice.*In*the*following*section,*we*will*discuss*the*
implication*of*cultural*and*individual*differences*when*implementing*these*factors*in*
therapy.**
*
The!Therapy!Alliance!
Bohart*and*Greenberg*(1997)*assert*that*the*therapeutic*relationship*is*the*best*
predictor*of*success*in*therapy.**This*pithy,*profound*statement*pays*rightful*tribute*to*the*
complexity*and*wonder*of*the*psyche*by*concluding*that*there*is*no*single*tangible*
mechanism*with*which*therapeutic*change*can*be*accomplished.**Further,*the*psychologist,*
even*with*expertise*of*both*scientific*and*clinical*nature,*is*not*capable*of*conducting*
Existential*Therapy*&*EBPP* * *
5*
productive*therapy*alone.**The*client’s*own*skills*and*strengths*must*be*utilized*and*
mobilized*to*facilitate*change*(Bohart*&*Tallman,*2010;*Hubble,*Duncan,*&*Miller,*1999).***
The*therapeutic*relationship*is*evolving*and*changing*across*time.**However,*
Lambert*and*Barley*(2001)*describe*three*elements*of*the*therapeutic*relationship*that*can*
be*useful*in*organizing*its*development.**The*first*element,*tasks,*constitutes*the*actual*
work*in*therapy*while*the*second*element,*goals,*refers*to*the*objectives*of*therapy*that*
both*the*client*and*therapist*endorse.**The*final*element,*bonds,*encompasses*the*mutual*
interpersonal*attachment*between*client*and*therapist*that*includes*trust,*genuineness,*
and*acceptance.***
The*summaries*and*reviews*of*the*research*on*the*importance*of*the*therapy*
relationship*and*therapy*alliance*consistently*demonstrate*that*the*relationship*accounts*
for*a*significant*amount*of*the*change*that*occurs*in*psychotherapy*(Horvath*&*Bedi,*2002;*
Norcross,*2010;*Norcross*&*Lambert,*2006;*Wampold,*2001).*Furthermore,*the*therapeutic*
relationship,*in*many*ways,*is*the*foundational*element*that*is*necessary*for*all*the*other*
components*of*therapy*to*be*effective.*Thus,*the*next*several*sections*are*essential*a*
further*explication*of*therapy*relationship*and*alliance.**
*
Empathy!
Empathy*is*an*essential*element*of*existential*therapy*that*provides*a*further*
example*of*its*ephemeral*and*depth<oriented*nature*(Bohart*&*Greenberg,*1997).**
Empathic*attunement*allows*the*therapist*to*vicariously*experience*the*feelings,*thoughts,*
and*attitudes*of*another*in*order*to*deeply*understand*the*struggles*of*the*client.**This,*
however,*does*not*capture*the*full*range*and*weight*of*empathy,*as*much*of*this*is*an*
emotional*process*hard*to*capture*in*words.**
Empathy*presents*a*dilemma*for*EBPP*due*to*its*intangibility.*Yet,*several*research*
studies*have*managed*to*overcome*these*challenges*(Bohart*&*Greenberg,*1997;*Johnson,*
et*al.,*2005).**In*an*effort*to*quantify*empathy,*studies*sometimes*use*specific*empathic*
phrases*provided*by*the*therapist*in*the*Rogerian*mold*in*order*to*show*a*causal*
relationship*between*these*phrases*and*client*therapeutic*outcomes.*Yet,*this*is*subject*to*
the*same*scrutiny*of*research*method*and*design*as*any*other.**Some*may*contest*that*
empathy*has*been*equated*to*a*particular*response*technique,*empathic*reflection*or*
empathetic*phrasing,*which*does*not*fully*capture*the*impact*of*empathy.**In*attempting*to*
find*legitimacy*with*respect*to*the*scientific*method,*the*intangibles*of*empathy*may*be*
relegated*to*mere*concrete*variables*that,*while*reflecting*an*aspect*of*the*variable,*do*not*
capture*the*fullness*of*the*relational*experience.****
Further,*empathy*is*not*objective*in*that*it*exists*within*the*genuine*exchange*
between*client*and*therapist*engaged*in*therapeutic*work.**This*exchange*is*rooted*in*each*
person’s*subjective*experience*embedded*in*the*broader*context*of*his*or*her*life*
experiences*(Flaskas,*2009).**As*the*commonalities*of*living*are*explored*in*therapy,*the*
avenues*of*empathic*understanding*are*opened*between*two*distinct*individuals.**Yet,*their*
Existential*Therapy*&*EBPP* * *
6*
subjective*underpinnings*make*these*avenues*difficult*to*define*and*research.**This*does*
not*detract*from*their*importance,*but*rather*speaks*to*the*magnitude*of*personal*meaning*
that*can*be*found.**Relationships,*individuals,*moments,*and*the*ever<changing*rhythm*of*
living*are*necessary*to*consider*when*experiencing*an*empathic*exchange.***
Despite*the*challenges*in*measuring*empathy,*the*reviews*of*the*research*have*
consistently*found*empirical*support*that*empathy*does*contribute*to*therapeutic*change*
(Bohart,*Elliott,*Greenberg,*&*Watson,*2002;*Wampold,*2001;*Watson,*2001).*This*finding*
seems*particularly*impressive*given*the*inherent*limitations*in*measuring*a*relational*
process*such*as*empathy.**
*
Positive!Regard!
Rogers*(1951)*identified*positive*regard*as*the*way*the*therapist*feels*about*a*client*
that*helps*bring*about*change*in*the*client*during*therapy.*In*1957,*Carl*Rogers*concluded*
that*positive*regard*was*one*of*the*necessary*and*sufficient*conditions*needed*for*
therapeutic*change.*He*believed*that*this*entails*caring*for*the*client*as*a*unique*individual*
with*no*conditions*on*acceptance*and*allowing*the*client*to*have*her*or*his*own*feelings*
and*experiences.*This*allows*for*the*client*to*be*seen*as*a*person*of*worth*(Farber*&*Lane,*
2002).*
** In*order*for*this*to*be*a*successful*component*of*therapy,*the*therapist*must*not*
only*experience*these*feelings*towards*the*client,*but*also*share*them*with*his*client*in*a*
caring*and*respectful*manner*(Rogers,*1957/1992).*Farber*and*Dolin*(2011)*note*that*
positive*regard*needs*to*be*continually*monitored*and*adjusted*to*meet*the*needs*of*the*
client.*The*personalities*of*both*the*client*and*the*therapist*dictate*this*adjustment.*Just*as*
therapists*may*vary*in*the*extent*to*which*they*can*show*positive*regard*to*their*clients,*
clients*vary*in*the*way*they*can*receive*and*use*it*effectively*in*therapy.*
** This*condition*has*been*difficult*to*study*because*it*cannot*be*easily*defined*or*
quantified.*It*has*been*known*by*many*names*including*but*not*limited*to*unconditional*
positive*regard,*affirmation,*warmth,*respect,*and*acceptance*as*well*as*non<possessive*
warmth.*(Farber*&*Lane*2002;*Wilkins,*2000)*Despite*this,*positive*regard*has*been*
beneficial*in*other*forms*of*therapy*besides*client*centered*therapy*For*example,*Farber*
and*Doolin*(2011)*indicated*that*in*behavioral*therapy*positive*regards*helps*the*client*to*
become*more*engaged*in*the*therapeutic*process*and*from*a*psychodynamic*perspective*
this*aids*in*strengthening*the*clients*ego.*
** Similar*to*empathy,*positive*regard*is*a*difficult*concept*to*operationally*define,*
quantify,*and*measure;*however,*there*is*still*support*that*this*is*an*important*factor*in*
therapy*outcomes.**
*
Congruence!
Rogers*saw*congruence*as*the*most*important*of*the*conditions*necessary*for*
personality*change*(Rogers,*1957/1992).*There*are*two*important*aspects*of*congruence.*
Existential*Therapy*&*EBPP* * *
7*
First,*the*therapist*must*be*fully*aware*of*him*or*herself*while*with*the*client.*Second,*the*
therapist*must*convey*this*to*the*client.*Rogers*believed*that*the*optimal*situation*is*where*
both*the*therapist*and*client*embark*upon*this*process*together*(Cooper,*Watson*&*
Holldampf,*2010),*meaning*that*they*both*acknowledge,*label,*and*discuss*the*relevant*
issues*in*terms*of*their*past*experiences*and*their*present.*
** The*terms*genuineness*and*authenticity*are*sometimes*likened*to*congruence*
(Koldem,*Klein,*Wang,*&*Austin,*2011),*which*they*posit*as*the*willingness*to*be*who*
oneself*truly*is*in*the*relationship.*Being*congruent*means*that*the*therapist*must*be*
authentic*in*the*therapy*relationship*or*in*touch*with*their*own*experience.*Rogers*is*clear*
that*the*therapist*does*not*need*to*be*integrated*in*the*rest*of*his*life,*but*does*need*to*be*
congruent*in*the*time*that*he*or*she*is*with*the*client*(Cooper*et*al*2010).*
** Klein,*Kolden,*Micheals,*and*Chisholm<Stockard*(2002)*indicate*that*congruence*has*
intrapersonal*and*interpersonal*qualities.*The*intrapersonal*qualities*are*those*of*the*
therapist*and*the*interpersonal*qualities*are*a*function*of*the*relationship*between*the*
therapist*and*the*client.*With*regards*to*the*interpersonal*facet*of*congruence,*they*also*
believe*that*this*is*evident*in*one*of*two*ways:*either*by*the*therapist*providing*personal*
information*in*the*form*of*self<disclosure*or*by*the*therapist*reflecting*thoughts*and*
feelings*while*in*the*actual*session*with*the*client.*Both*of*these*can*be*used*effectively*to*
enhance*therapeutic*outcome.*
** As*with*other*therapist*factors,*congruence*must*be*tailored*to*the*client*according*
to*Klein*et*al.*(2002).*They*also*indicate*that*in*order*to*foster*congruence,*therapists*must*
model*congruence*for*their*clients*and*be*aware*of*when*it*is*being*disrupted.*Therapists*
and*clients*also*have*different*comfort*levels*and*abilities*to*maintain*higher*levels*of*
congruence.*Therapists*should*be*sensitive*to*this*and*adjust*as*is*needed.**
*Research*consistently*supports*that*congruence,*genuineness,*and*authenticity*do*
contribute*to*positive*therapy*outcomes*(Klein,*et*al.,*2002;*Koldem,*et*al.,*2011;*Sachse*&*
Elliott,*2002).*Along*with*positive*regard*and*empathy,*congruence*can*be*considered*
closely*related*to*or*an*aspect*of*the*existential*concept*of*“presence,”*which*is*generally*
conceived*as*a*cornerstone*of*existential*therapy*practice*(Hoffman,*2009a;*Schneider,*
2008;*Schneider*&*Krug,*2009).***
*
Working!with!Resistance!!
* Resistance*is*a*given*in*psychotherapy.*All*clients*demonstrate*at*least*some*
resistance*at*times*in*therapy.*Additionally,*there*are*times*and*degrees*to*which*
resistance*can*be*beneficial.*For*example,*resistance*can*serve*to*protect*clients*in*
situations*where*they*feel*vulnerable*or*unsafe.*However,*as*is*self<evident,*too*much*
resistance*is*problematic.**
* Research*on*resistance*demonstrates*that*the*therapist’s*ability*to*work*with*
resistance*is*an*important*component*of*positive*therapy*outcomes*(Beutler,*Molerio,*&*
Talebi,*2002).*However,*there*are*different*types*of*resistance,*such*as*state*versus*trait*
Existential*Therapy*&*EBPP* * *
8*
resistance.*Trait*resistance*is*a*more*generalized*resistance*that*can*be*understood*as*a*
client*factor*that*is*associated*with*poorer*therapy*outcomes.*It*is*important*for*therapists*
to*be*able*to*distinguish*between*types*of*resistance,*recognize*when*they*are*present,*and*
respond*appropriately.**
*Bugental*(1999)*developed*an*approach*to*resistance*consistent*with*the*themes*in*
the*research*literature.*He*advocated*for*an*empathetic*approach*to*addressing*resistance*
in*which*the*therapist*seeks*to*empathetically*understand*resistance*and*the*positive*role*
it*was*serving*with*the*client.*Only*after*understanding*the*resistance*does*the*therapist*
begin*to*address*it;*however,*resistance*frequently*begins*to*lower*as*the*therapist*works*
to*understand*it.***
*
Emotional!Expression!and!Processing!Emotion!
*Therapists*often*speak*of*“processing*emotion,”*yet*what*this*means*often*lacks*
clarity.*There*are*at*least*two*important*components*of*processing*emotion:*experiencing*
emotion*and*bridging*understanding*or*meaning*with*the*emotion.*Watson,*Greenberg,*and*
Lietaer*(2010),*in*their*review*of*the*research,*demonstrate*that*having*the*ability*to*
experience*moderate*or*high*levels*of*emotions,*or*developing*this*ability,*is*consistently*
associated*with*better*treatment*outcomes.**
* Bugental*(1987)*advocated*for*helping*clients*move*in*and*out*of*the*depths*of*
emotional*experiencing.*While*some*therapists*tend*to*stay*on*the*surface*level*of*
emotions,*with*mild*or*no*emotional*arousal,*other*therapists*tend*to*try*to*maintain*a*
more*intense*level*of*emotional*arousal.*According*to*Bugental,*both*of*these*are*generally*
mistakes.*Moving*in*and*out*of*the*depths*of*emotional*process*assists*clients*in*
experiencing*the*emotion*and*then*connecting*the*emotion*with*meaning.**
* Although*the*different*humanistic*and*existential*approaches*have*different*
approaches*to*facilitating*the*emotional*processing,*there*tends*to*be*agreement*that*this*is*
necessary.*Process<experiential*therapies*tend*to*focus*on*techniques*to*facilitate*
emotional*experiencing*(Elliott*&*Greenberg,*2001;*Watson,*et*al.,*2010),*while*existential*
approaches*tend*to*more*frequently*use*the*therapy*relationship*to*encourage*emotional*
expression*(Bugental,*1987,*1999;*Hoffman,*2009a,*Schneider*&*Krug,*2009).*However,*
many*therapists*will*draw*from*various*humanistic*and*existential*approaches*to*
encourage*clients*to*experience*their*emotions.**
*The*research*evidence*does*appear*particularly*strong*that*the*facilitating*of*
experiencing*and*processing*emotions*contributes*to*therapeutic*change*(Elliott*&*
Greenberg,*2001;*Greenberg,*Korman,*&*Paivio,*2001;*Watson,*et*al.,*2010).**
!
Meaning!
* Existential*therapy*is*a*meaning<centered*therapy.*As*alluded*to*in*the*previous*
section,*the*creation*of*meaning*is*often*connected*with*emotion.*For*example,*Clarke*
(1996)*noted*that*the*lack*of*emotion*was*often*connected*with*unsuccessful*creation*of*
Existential*Therapy*&*EBPP* * *
9*
meaning.*Similarly,*as*suggested*in*the*previous*section,*the*experiencing*of*emotion*
without*creating*meaning*is*less*effective*in*promoting*change*than*when*connected*with*
meaning.**
* There*is*some*evidence*that*meaning*making*is*connected*to*successful*outcomes*in*
therapy.*For*instance,*Boals*(2012)*found*that*when*engaging*in*expressive*writing*
process*with*therapy*the*inclusion*of*meaning*making*was*related*to*positive*change.*
Similarly,*meaning*has*been*found*an*important*protective*factor*for*individuals*in*
stressful*situations*(Breitbart,*et*al.,*2010;*Kelley*&*Chan,*2012;*McLennon,*Habermann,*&*
Rice,*2011)*as*well*as*being*a*factor*that*is*associated*with*psychological*well<being*
(Lightsey,*2006;*Tavernier*&*Willoughby,*2012;*Thoits,*2012).*
*
Cultural!Factors,!Individual!Differences,!and!Existential!Therapy!
*
* A*number*of*authors*have*noted*that,*in*general,*there*is*an*insignificant*amount*of*
research*that*has*explored*cultural*differences*in*regard*to*evidence*based*treatment*and*
customizing*therapy*relationships*when*working*with*diverse*clients*(Brown,*2006;*
Levant*&*Silverstein,*2006;*Olkin*&*Taliaferro,*2006;*Sue*&*Lam,*2002;*Sue*&*Zane,*2006).*
Yet,*as*Morales*and*Norcross*(2010)*advocate,*evidence<based*practice*and*
multiculturalism*need*each*other.*In*the*previous*section,*we*identified*seven*factors*that*
are*generally*considered*part*of*the*foundation*of*existential*therapy*and*discussed*their*
evidence<basis*for*these*factors.*In*this*section,*we*will*discuss*how*to*work*with*these*
factors*from*the*perspective*of*individual*and*cultural*differences.***
*
The!Therapy!Alliance!
* Vasquez*(2007)*maintained*that*“unintentional*bias”*frequently*may*interfere*with*
the*development*of*a*therapeutic*alliance.*Furthermore,*she*noted*this*may*play*a*role*in*
higher*psychotherapy*dropout*rates*of*some*ethnic*groups*as*well*as*interfering*with*
therapeutic*effectiveness*with*individuals*from*these*groups.*Given*this,*it*is*important*that*
existential*therapists*utilize*culturally*sensitive*language,*stay*appraised*of*culturally*
sensitive*issues,*and*continually*work*to*examine*their*own*implicit*biases.**
* Cultures*often*have*significantly*different*norms*pertaining*to*relationships,*
including*family,*social,*and*hierarchical*relationships*(Dias,*Chan,*Ungvarsky,*Oraker,*&*
Cleare<Hoffman,*2011).*While*it*is*not*possible*to*be*aware*of*all*cultures*relational*norms,*
therapist*must*develop*sufficient*knowledge*to*recognize*differences*and*appropriately*
adapt*their*therapeutic*approach.*For*example,*with*some*cultures*the*therapy*alliance*
extends*beyond*the*individual*to*also*include*the*family.*If*therapists*working*with*clients*
from*these*cultures*do*not*involve*the*family,*or*consider*the*implications*of*the*family*on*
the*therapeutic*alliance,*they*may*have*difficulty*in*establishing*a*good,*working*
relationship*with*these*clients.****
*
Existential*Therapy*&*EBPP* * *
10*
Empathy!
* Empathy*can*be*challenged*when*the*therapist*and*client*are*from*different*cultural*
backgrounds.*In*part,*this*is*because*it*is*very*difficult*to*fully*put*oneself*in*the*shoes*of*a*
person*from*another*culture.*For*example,*therapists*from*a*privileged*culture*will*often*
talk*about*experiences*where*they*were*in*the*role*of*being*a*minority*for*a*brief*period*of*
time.*However,*it*is*very*different*to*have*a*transitory*experience*in*the*role*of*a*minority*
as*opposed*to*the*daily,*pervasive*experience*of*encountering*prejudice*and*discrimination.**
*Riley*(1995,*as*cited*in*Chung*&*Bemak,*2002),*noted*that*to*communicate*empathy*
across*cultures*it*is*important*to*acknowledge*one’s*lack*of*awareness*of*the*client’s*
culture*and/or*cultural*experience,*show*an*interest*in*learning*about*the*client’s*culture,*
and*affirm*the*client’s*cultural*experience.*When*therapists*try*to*present*themselves*as*
knowledgeable*or*experts*in*the*client*culture,*this*may*inadvertently*interfere*with*the*
client*being*able*to*experience*empathy*as*it*does*not*communicate*an*interest*to*learn*
from*the*client*about*their*culture*and*experiences.**
*Therapists*also*ought*to*be*cautious*in*helping*clients*cope*with*their*experiences*of*
prejudice*and*discrimination.*For*example,*in*contemporary*culture,*prejudice*and*racism*
often*come*in*the*form*of*microaggressions,*which*are*subtle*and*often*unintentional*forms*
of*racism*(Sue,*2010).*Microaggressions*are*often*ambiguous,*leaving*it*unclear*as*to*
whether*the*behavior*really*was*reflective*of*prejudice.*It*is*important*for*therapists*to*be*
cautious*in*helping*clients*process*through*these*experiences.*If*the*therapist*is*quick*to*
suggest*that*the*experience*was*unintentional*or*not*really*the*result*of*prejudice,*the*
client*could*experience*this*as*invalidating*even*if*the*therapist*was*correct.*It*is*important*
prioritize*validating*the*client’s*experience*and*to*be*sensitive*when*addressing*potential*
misperceptions*of*racism.**
*
Positive!Regard!
* Comparable*to*the*therapy*relationship,*with*positive*regard*it*is*important*for*
therapists*to*regularly*engage*in*a*self<reflective*process*in*order*to*increase*one’s*
awareness*of*potential*biases*or*prejudices*that*may*reside*at*the*unconscious*level.*
Therapists*often*express*positive*regard,*as*well*as*disapproval*or*rejection,*through*
nonverbal*behaviors,*which*may*at*times*be*outside*of*their*awareness.***
* Doolin*and*Farber*(2011)*note*that*therapists*may*be*more*inclined*to*convey*
positive*regard*to*clients*who*demonstrate*strong*motivation*for*therapy,*take*risks,*and*
show*courage*in*facing*their*challenges.*What*is*interpreted*as*risk*taking*may*vary*across*
cultural*groups.*For*instance,*individuals*from*traditionally*oppressed*groups*may*
perceive*just*coming*to*therapy*to*be*a*significant*risk.*Similarly,*they*may*not*have*much*
of*a*frame*of*reference*as*to*what*to*expect*from*therapy,*including*the*ongoing,*emergent*
risks*often*part*of*existential*and*other*depth*psychotherapy*approaches.*Thus,*after*the*
risk*of*coming*to*therapy,*these*clients*may*be*more*cautious*as*they*try*to*ascertain*what*
is*expected*of*them*and*whether*they*can*trust*the*therapist,*who,*regardless*of*the*
Existential*Therapy*&*EBPP* * *
11*
therapist’s*culture,*often*symbolically*represents*privilege*and*power.*This*is*comparable*
to*what*individuals*from*collectivist*cultures*may*experience*coming*to*therapy.*For*these*
clients,*stepping*away*from*the*typical*structures*from*which*they*seek*assistance*in*order*
to*seek*help*from*outside*of*the*family*may*be*experienced*as*a*significant*risk.**
* It*is*common*for*some*degree*of*mistrust*to*be*present*when*clients*from*
traditionally*oppressed*cultures*see*therapists*who*represent*the*privileged*culture.*
According*to*Sue*and*Sue*(2003),*some*research*suggests*that*the*intentional*use*of*
positive*regard*may*help*overcome*this*mistrust*therefore*solidifying*the*therapeutic*
alliance*and*enhancing*therapy.*For*example,*therapists*may*be*more*intentional*in*
expressing*their*positive*regard*for*certain*clients*if*they*are*aware*of*some*mistrust*that*
may*be*present*due*to*cultural*differences.*However,*cultural*variations*also*exist*in*regard*
to*the*comfort*level*of*direct,*verbal*expression*of*positive*regard.*Some*cultures,*such*as*
individuals*from*Chinese*backgrounds,*may*be*uncomfortable*with*the*direct*verbal*
expression*of*positive*regard*and*may*respond*better*to*intentional,*but*more*subtle*and*
nonverbal*forms.**
*
Congruence!
*Heery*(2009),*in*discussing*global*authenticity,*states,*“What*we*experience*as*an*
essential*quality*of*authenticity*is*humility,*of*allowing*ourselves*to*not*know*and*be*
humbled*by*the*not*knowing*for*others*and*ourselves”*(p.*215).*Consistent*with*what*was*
discussed*earlier*in*regards*to*empathy,*congruence*calls*for*therapist*to*be*honest*about*
their*limited*cultural*knowledge.*Therapists,*in*developing*cultural*competency,*are*often*
encouraged*to*develop*and*be*able*to*demonstrate*some*cultural*knowledge*when*working*
with*clients*representing*a*different*cultural*background*than*their*own.*While*this*can*be*
beneficial,*therapists*must*be*cautious*as*their*attempts*to*demonstrate*some*knowledge*
of*the*client’s*culture*may*be*experienced*as*disingenuous*by*the*client.*Even*for*therapists*
who*share*a*similar*cultural*background,*they*can*never*fully*know*the*cultural*experience*
of*the*client.*Therefore,*the*acknowledgement*of*not*knowing*is*often*more*congruent*than*
the*experience*of*knowing.**
*
Working!with!Resistance!
* It*can*be*easy*for*therapists*to*misidentify*cultural*differences*as*resistance.*For*
instance,*clients*who*tend*to*be*quiet,*deferring*to*authority,*and*express*little*emotion*
may*be*perceived*as*being*resistant;*however,*within*their*cultural*context*this*is*quite*
normal.*Similarly,*existential*perspectives*are*often*quick*to*pathologize*conformity*or*
deferring*to*group*pressures*or*perspectives.*However,*within*collectivist*cultures,*some*of*
these*behaviors*might*be*experienced*very*differently.**
* Additionally,*clients*may*be*resistant*to*particular*suggestions*of*the*therapist*as*
well*as*conceptualizations*the*therapist*brings*at*times*because*of*cultural*differences.*It*is*
quite*easy*for*therapists,*often*without*any*intentions*of*doing*so,*to*impose*certain*beliefs,*
Existential*Therapy*&*EBPP* * *
12*
ideas,*and*even*behaviors*upon*clients.*When*encountering*resistance,*it*is*often*helpful*to*
return*to*Bugental’s*(1999)*approach*of*working*with*the*resistance*while*considering*the*
cultural*implications*of*what*the*therapist*perceives*to*be*resistance.*As*the*therapist*
develops*empathy*and*greater*understanding*of*what*they*perceive*as*resistance,*they*may*
find*that*it*is*not*resistance*at*all.**
*
Emotional!Expression!and!Processing!Emotion!
*Significant*cultural*differences*exist*pertaining*to*the*outward*expression*of*
emotion*and*even*the*way*individuals*experience*emotions*internally.*Therapists*often*
hold*assumptions*or*biases*pertaining*to*emotions*and*emotional*expression.*For*instance,*
many*southwest*Asian*cultures*express*their*emotions*very*subtly,*whereas*much*of*
American*culture*is*more*expressive*with*their*emotions*(Hoffman*&*Cleare<Hoffman,*
2011).**
*Previously,*it*was*discussed*that*moderate*and*high*levels*of*experiencing*emotions*
was*associated*with*better*therapy*outcomes.*However,*how*clients*hold*and*experience*
moderate*and*high*levels*of*emotions*may*greatly*very.*In*some*cultures,*the*individual’s*
emotions*may*be*very*evident*in*body*posture,*voice*tone,*and*other*aspects*of*nonverbal*
behavior;*however,*in*other*cultures,*there*may*be*very*little*change*in*the*nonverbal*
expression*of*emotion*across*different*emotional*states.*If*therapists*are*not*aware*of*these*
differences,*it*could*lead*to*misinterpreting*client’s*emotional*expression*as*being*overly*
dramatic*or*repressed.**
* While*experiencing*and*expressing*emotion*may*be*a*beneficial*aspect*of*therapy*
for*most*clients,*how*this*looks*and*what*it*entails*may*be*very*different*from*culture*to*
culture.*When*encouraging*clients*to*experience*and*express*their*emotions,*it*is*important*
that*therapists*not*impose*particular*ways*of*doing*this*upon*clients.*As*Hoffman*and*
Cleare<Hoffman*(2011)*advocate,*what*constitutes*a*healthy*way*to*experience*and*express*
emotions*for*clients*may*be*partially*culturally*determined.*Thus,*imposing*upon*clients*a*
particular*way*to*experience*and*express*emotions*may*cause*a*rupture*in*the*therapeutic*
alliance*and*potentially*even*be*harmful*to*the*client.**
!
Meaning!
Hoffman*(2009b),*building*upon*the*ideas*of*Rollo*May,*advocated*that*myths*often*
serve*as*primary*systems*through*which*individual*and*cultural*meaning*is*organized.*As*
such,*myths*are*not*something*that*are*false,*but*rather*myths*are*unable*to*be*proven*to*
be*true*(May,*1991).*Furthermore,*myths*often*stand*in*relation*to*the*existential*givens,*or*
facts*of*existence*that*everyone*must*face,*such*as*death,*freedom,*isolation,*emotions,*and*
meaning.*Myths*can*be*operationalized*as*stories,*songs,*and*movies*as*well*as*in*rituals,*
traditions,*and*beliefs.**
According*to*Hoffman*(2009b),*the*existential*givens*are*universal*challenges*that*
require*a*personally*and*culturally*specific*response.*For*instance,*everyone*must*
Existential*Therapy*&*EBPP* * *
13*
eventually*face*death.*Yet,*no*universal*answer*to*the*challenge*of*how*death*and*loss*are*
understood*and*experienced*can*be*provided.*Different*cultures*have*different*beliefs*and*
rituals*surrounding*death.*Therapists*can*help*clients*explore*meaning,*in*part,*by*helping*
them*explore*their*personal,*familial,*and*cultural*myths.*At*times,*clients*may*work*to*
deepen*their*connection*with*cultural*myth*and*meaning;*at*other*times*they*may*become*
aware*of*how*these*have*influenced*them*and*choose*to*pursue*meaning*in*a*different*
direction.**
It*is*important*for*therapists*to*remain*aware*of*the*client’s*values*and*meaning*
system*in*order*to*avoid*imposing*one’s*own*meaning*system*upon*the*client.*Often,*this*
will*begin*by*working*to*become*familiar*with*the*client’s*individual*meaning*and*cultural*
meaning*as*understood*by*the*client.*As*both*the*client*and*the*therapist*come*to*
understand*the*client’s*meaning*and*its*impact*upon*the*client,*then*therapist*is*able*to*
empower*the*client*to*make*more*informed*choices.**
*
Conclusion!
*
*In*this*paper,*we*have*advocated*that*existential*therapy*can*rightly*be*considered*
an*appropriate*treatment*approach*within*the*standards*of*EBPP.*After*a*brief*overview*of*
EBPP,*we*identified*seven*aspects*of*existential*therapy*that*can*rightly*be*considered*as*
part*of*EBPP.*For*each*of*these,*we*began*with*discussing*their*foundation*in*research*and*
clinical*expertise.*In*the*last*section*of*the*paper,*we*discussed*how*these*several*aspects*of*
existential*therapy*and*evidence<based*practice*could*be*adapted*with*consideration*of*
individual*and*cultural*differences.*Through*this*process,*we*have*demonstrated*that*these*
seven*factors*fit*well*with*the*criteria*of*EBPP.*This,*in*itself,*does*not*assure*that*
existential*therapy*is*an*evidence<based*practice*as*it*is*necessary*that*the*therapist*is*able*
to*implement*this*therapeutic*approach*in*a*manner*consistent*with*basic*therapeutic*
competencies*while*making*the*adaptations*for*the*particular*client*in*regard*to*individual*
and*cultural*differences.**
*
*
References!
*
American*Psychological*Association*(APA)*Task*Force*on*Evidence<Based*Practice.*(2006).*
Evidence<based*practice*in*psychology.*!"#$%&'()*+,&-./.0%+12)342*271<285.**
Beutler,*L.*E.,*Moleiro,*C.*M.,*&*Talebi,*H.*(2002).*Resistance.*In*J.*C.*Norcross*(Ed.),**+,&-.1-#$'5,)
$#/'1%.(+-%5+)1-'1)6.$78)9-#$'5%+1)&.(1$%:;1%.(+)'(<)$#+5.(+%=#(#++)1.)5'1%#(1+*(pp.*129<143).*
New*York,*NY:*Oxford*University*Press.**
Boals,*A.*(2012).*The*use*of*meaning*making*in*expressive*writing:*When*meaning*is*beneficial.*
>.;$('/).?)@.&%'/)'(<)A/%(%&'/)*+,&-./.0,2)B42*393<409.**
Existential*Therapy*&*EBPP* * *
14*
Bohart,*A.*C.,*Elliott,*R.,*Greenberg,*L.*S.,*&*Watson,*J.*C.*(2002).*Empathy.*In*J.*C.*Norcross*(Ed.),*
*+,&-.1-#$'5,)$#/'1%.(+-%5+)1-'1)6.$78)9-#$'5%+1)&.(1$%:;1%.(+)'(<)$#+5.(+%=#(#++)1.)5'1%#(1+*
(pp.*89<108).*New*York,*NY:*Oxford*University*Press.*
Bohart,*A.*&*Greenberg,*L.*(1997).*C"5'1-,)$#&.(+%<#$#<8)D#6)<%$#&1%.(+)%()5+,&-.1-#$'5,E)
Washington,*DC:*American*Psychological*Association.**
Bohart,*A.*&*Tallman,*K.*(2010).*Clients:*The*neglected*common*factor*in*psychotherapy.*In*B.*L.*
Duncan,*S.*D.*Miller,*B.*E.*Wampold,*&*M.*A.*Hubble*(Ed.),*9-#)-#'$1)'(<)+.;/).?)&-'(0#8)
F#/%=#$%(0)6-'1)6.$7+)%()1-#$'5,)(2nd*ed.;*pp.*83<111).*Washington,*DC:*American*
Psychological*Association.**
Breitbart,*W.,*Rosenfeld,*B.,*Gibson,*C.,*Pessin,*H.,*Poppito,*S.,*Nelson,*C.,*Tomarken,*Z.,*Timm,*A.*K.,*
Berg,*A.,*Jacobson,*C.,*Sorger,*B.,*Abbey,*J.,*&*Olden,*M.*(2010).*Meaning<centered*group*
psychotherapy*for*patients*with*advanced*cancer:*A*pilot*randomized*controlled*trial.*
*+,&-.GH(&./.0,2)4I2*21<28.**
Brown,*L.*S.*(2006).*The*neglect*of*lesbian,*gay,*bisexual,*and*transgendered*clients.*In*J.*C.*Norcross,*
L.*E.*Beutler,*&*R.*F.*Levant*(Eds.),*C=%<#(&#G:'+#<)5$'&1%&#+)%()"#(1'/)-#'/1-8)F#:'1#)'(<)
<%'/.0;#).()1-#)?;(<'"#(1'/)J;#+1%.(+*(pp.*346<353).*Washington,*DC:*American*
Psychological*Association.*
Bugental,*J.*F.*T.*(1987).*9-#)'$1).?)1-#)5+,&-.1-#$'5%+1.*New*York,*NY:*Norton.*
Bugental,*J.*F.*T.*(1990).*K(1%"'1#)L.;$(#,+8)@1.$%#+)?$.")/%?#G&-'(0%(0)1-#$'5,.*San*Francisco,*CA:*
Jossey<Bass.**
Bugental,*J.*F.*T.*(1999).**+,&-.1-#$'5,)%+(M1)6-'1),.;)1-%(78)N$%(0%(0)1-#)5+,&-.1-#$'5#;1%&)
#(0'0#"#(1)%(1.)1-#)/%=%(0)"."#(1E*Phoenix,*AZ:*Zieg,*Tucker*&*Theisen.**
Chung,*R.*C.*Y.*&*Bemak,*F.*(2002).*The*relationship*of*culture*and*empathy*in*cross<cultural*
counseling.*Journal*of*Counseling*and*Development,*80,*154<159*
Clarke,*K.*M.*(1996).*Change*process*in*a*creation*of*meaning*event.*>.;$('/).?)A.(+;/1%(0)'(<)
A/%(%&'/)*+,&-./.0,2)3O2)465<470.*
Dias,*J.,*Chan,*A.,*Ungvarsky,*J.,*Oraker,*J.,*&*Cleare<Hoffman,*H.*P.*(2011).*Reflections*on*marriage*
and*family*therapy*emergent*from*international*dialogues*in*China.*9-#)P;"'(%+1%&)
*+,&-./.0%+12)BI2*268<275.*
Elkins,*D.*N.*(2009).*P;"'(%+1%&)5+,&-./.0,8)!)&/%(%&'/)"'(%?#+1.E)!)&$%1%J;#).?)&/%(%&'/)5+,&-./.0,)'(<)
1-#)(##<)?.$)5$.0$#++%=#)'/1#$('1%=#+.*Colorado*Springs,*CO:*University*of*the*Rockies*Press.**
Farber,*B.*A.*&*Lane,*J.*S.*(2002).*Positive*regard.*In*J.*C.*Norcross*(Ed.),**+,&-.1-#$'5,)$#/'1%.(+-%5+)
1-'1)6.$78)9-#$'5%+1)&.(1$%:;1%.(+)'(<)$#+5.(+%=#(#++)1.)5'1%#(1+*(pp.*175<194).*New*York,*
NY:*Oxford*University*Press.*
Flaskas,*C.*(2009).*The*therapist’s*imagination*of*self*in*relation*to*clients:*Beginning*ideas*on*the*
flexibility*of*empathic*imagination.**!;+1$'/%'()'(<)D#6)Q#'/'(<)>.;$('/).?)R'"%/,)9-#$'5,2)
BS,*147<159.*
Greenberg,*L.*S.,*Korman,*L.*M.,*&*Paivio,*S.*C.*(2001).*Emotion*in*humanistic*psychotherapy.*In*D.*J.*
Cain*&*J.*Seeman*(Eds.),*P;"'(%+1%&)5+,&-.1-#$'5%#+8)P'(<:..7).?)$#+#'$&-)'(<)5$'&1%&#)(pp.*
499<530).*Washington,*DC:*American*Psychological*Association.*
Heery,*M.*(2009).*Global*authenticity.*In*L.*Hoffman,*M.*Yang,*F.*J.*Kaklauskas,*&*A.*Chan*(Eds.),*
CT%+1#(1%'/)5+,&-./.0,)#'+1G6#+1*(pp.*205<219).*Colorado*Springs,*CO:*University*of*the*
Rockies*Press.**
Existential*Therapy*&*EBPP* * *
15*
Hoffman,*L.*(2009a).*Introduction*to*existential*psychotherapy*in*a*cross<cultural*context:*An*East<
West*dialogue.*In*L.*Hoffman,*M.*Yang,*F.*J.*Kaklauskas,*&*A.*Chan*(Eds.),*CT%+1#(1%'/)
5+,&-./.0,)#'+1G6<J#+1)(pp.*1<67).*Colorado*Springs,*CO:*University*of*the*Rockies*Press.**
Hoffman,*L.*(2009b).*Gordo’s*ghost:*An*introduction*to*existential*perspectives*on*myths.*In*L.*
Hoffman,*M.*Yang,*F.*J.*Kaklauskas,*&*A.*Chan*(Eds.),*CT%+1#(1%'/)5+,&-./.0,)C'+1GU#+1*(pp.*
259<274).*Colorado*Springs,*CO:*University*of*the*Rockies*Press.*
Hoffman,*L.*Dias,*J.,*&*Soholm,*H.*C.*(2012,*August).*CT%+1#(1%'/G-;"'(%+1%&)1-#$'5,)'+)')".<#/)?.$)
#=%<#(&#G:'+#<)5$'&1%&#E)In*S.*Rubin*(Chair),*Evidence*in*support*of*existential<humanistic*
psychology:*Revitalizing*the*‘third*force.’*Symposium*presented*at*the*120th*Annual*
Convention*of*the*American*Psychological*Association,*Orlando,*FL.*
Hoffman,*L.*&*Cleare<Hoffman,*H.*P.*(2011).*Existential*therapy*and*emotions:*Lessons*from*cross<
cultural*exchange.*9-#)P;"'(%+1%&)*+,&-./.0%+1,*BI,*261<267.*
Hoffman,*L.,*Cleare<Hoffman,*H.*P.,*&*Jackson,*T.*(in*press).*Humanistic*psychology*and*
multiculturalism:*History,*current*status,*and*advancements.*In*K.*J.*Schneider*&*J.*F.*
Pierson*(Eds.),*9-#)-'(<:..7).?)-;"'(%+1%&)5+,&-./.0,8)V#'<%(0)#<0#+).?)1-#.$,2)$#+#'$&-2)
'(<)5$'&1%&#)(2nd*edition).*Thousand*Oaks,*CA:*Sage.*
Hoffman,*L.,*Yang,*M.,*Kaklauskas,*F.*J.,*&*Chan,*A.*(Eds.)*(2009).*CT%+1#(1%'/)5+,&-./.0,)#'+1G6#+1.*
Colorado*Springs,*CO:*University*of*the*Rockies*Press.**
Hovarth,*A.*O.*&*Bedi,*R.*P.*(2002).*The*alliance.*In*J.*C.*Norcross*(Ed.),**+,&-.1-#$'5,)$#/'1%.(+-%5+)
1-'1)6.$78)9-#$'5%+1)&.(1$%:;1%.(+)'(<)$#+5.(+%=#(#++)1.)5'1%#(1+*(pp.*37<69).*New*York,*NY:*
Oxford*University*Press.**
Hubble,*M.*A.,*Duncan,*B.*L.,*&*Miller,*S.*D.*(1999).*Directing*attention*to*what*works.*In*M.*A.*Hubble,*
B.*L.*Duncan,*&*S.*D.*Miller*(Eds.),*9-#)-#'$1)'(<)+.;/).?)&-'(0#8)U-'1)6.$7+)%()1-#$'5,*(pp.*
407<447).*Washington,*DC:*American*Psychological*Association.**
Johnson,*J.*E.,*Burlingame,*G.,*Olsen,*J.,*Davies,*R.,*&*Gleave,*R.*(2005).*Group*climate,*cohesion,*
alliance,*and*empathy*in*group*psychotherapy:*Multilevel*structural*equation*models.*
>.;$('/).?)A.;(+#/%(0)*+,&-./.0,2)WX,*310<321.*
Kelley,*M.*M.*&*Chan,*K.*T.*(2012).*Assessing*the*role*of*attachment*to*god,*meaning,*and*religious*
coping*as*mediators*in*the*grief*experience.*F#'1-)@1;<%#+2)B32*199<227.**
Klein,*M.*H.,*Kolden,*G.*G.,*Michaels,*J.*L.,*&*Chisholm<Stockard,*S.*(2002).*Congruence.*In*J.*C.*
Norcross*(Ed.),**+,&-.1-#$'5,)$#/'1%.(+-%5+)1-'1)6.$78)9-#$'5%+1)&.(1$%:;1%.(+)'(<)
$#+5.(+%=#(#++)1.)5'1%#(1+*(pp.*195<215).*New*York,*NY:*Oxford*Press.**
Kolden,*G.*G,*Klein,*M.*H.,*Wang,*C.,*&*Austin,*S.*B.*(2011).*Congurent/genuineness.**+,&-.1-#$'5,2)
OY2*65<71.**
Lambert,*M.,*&*Barley,*D.*(2001).*Research*summary*on*the*therapeutic*relationship*and*
psychotherapy*outcomeE)*+,&-.1-#$'5,8)9-#.$,2)Z#+#'$&-2)*$'&1%)'(<)9$'%(%(02)BY,*357<
361.*
Levant,*R.*F.*&*Silverstein,*L.*B.*(2006).*Gender*is*neglected*by*both*evidence<based*practice*and*
treatment*as*usual.*In*J.*C.*Norcross,*L.*E.*Beutler,*&*R.*F.*Levant*(Eds.),*C=%<#(&#G:'+#<)
5$'&1%&#+)%()"#(1'/)-#'/1-8)F#:'1#)'(<)<%'/.0;#).()1-#)?;(<'"#(1'/)J;#+1%.(+*(pp.*338<345).*
Washington,*DC:*American*Psychological*Association.*
Lightsey,*W.*R.,*Jr.*(2006).*Resilience,*meaning,*and*well<being.*9-#)A.;(+#/%(0)*+,&-./.0%+12)BO2*96<
107.**
May,*R.*(1991).*9-#)&$,)?.$)",1-E*New*York,*NY:*Delta.*
Existential*Therapy*&*EBPP* * *
16*
McLennon,*S.*M.,*Habermann,*B.,*&*Rice,*M.*(2011).*Finding*meaning*as*a*mediator*of*burden*on*the*
health*of*caregivers*of*spouses*with*dementia.*!0%(0)'(<)[#(1'/)P#'/1-2)4W2*522<530.**
Morales,*E.*&*Norcross,*J.*C.*(2010).*Evidence<based*practices*with*ethnic*minorities:*Strange*
bedfellows*no*more.*>.;$('/).?)A/%(%&'/)*+,&-./.0,8)K()@#++%.(2)332*821<829.**
Norcross,*J.*C.*(2010).*The*therapeutic*relationship.*In.*B.*L.*Duncan,*S.*D.*Miller,*B.*E.*Wampold,*&*M.*
A.*Hubble*(Eds.),*9-#)-#'$1)'(<)+.;/).?)&-'(0#8)F#/%=#$%(0)6-'1)6.$7+)%()1-#$'5,)(pp.*113<
141).*Washington,*DC:*American*Psychological*Association.**
Norcross,*J.*C.*&*Lambert,*M.*J.*(2006).*The*therapy*relationship.*In*J.*C.*Norcross,*L.*E.*Beutler,*&*R.*
F.*Levant*(Eds.),*C=%<#(&#G:'+#<)5$'&1%&#+)%()"#(1'/)-#'/1-8)F#:'1#)'(<)<%'/.0;#).()1-#)
?;(<'"#(1'/)J;#+1%.(+*(pp.*208<218).*Washington,*DC:*American*Psychological*Association.**
Olkin,*R.*&*Taliaferro,*G.*(2006).*Evidence<based*practices*have*ignored*people*with*disabilities.*In*J.*
C.*Norcross,*L.*E.*Beutler,*&*R.*F.*Levant*(Eds.),*C=%<#(&#G:'+#<)5$'&1%&#+)%()"#(1'/)-#'/1-8)
F#:'1#)'(<)<%'/.0;#).()1-#)?;(<'"#(1'/)J;#+1%.(+*(pp.*353<359).*Washington,*DC:*American*
Psychological*Association.*
Quinn,*A.*(2013).*A*person<centered*approach*to*multicultural*counseling*competence.*>.;$('/).?)
P;"'(%+1%&)*+,&-./.0,,*53,*202<251.**
Rogers,*C.*R.*(1951).*A/%#(1G&#(1#$#<)1-#$'5,.*Boston,*MA:*Houghton*Mifflin.**
Rogers,*C.*R.*(1992).*The*necessary*and*sufficient*conditions*of*therapeutic*personality*change.*
>.;$('/).?)A.(+;/1%(0)'(<)A/%(%&'/)*+,&-./.0,2)3S2*827<832.*(Original*work*published*in*
1957)*
Sachse,*R.*&*Elliott,*R.*(2001).*Process<outcome*research*on*humanistic*therapy*variables.*In*D.*J.*
Cain*&*J.*Seeman*(Eds.),*P;"'(%+1%&)5+,&-.1-#$'5%#+8)P'(<:..7).?)$#+#'$&-)'(<)5$'&1%&#)(pp.*
83<115).*Washington,*DC:*American*Psychological*Association.**
Schneider,*K.*J.*(Ed.).*(2008).*CT%+1#(1%'/G%(1#0$'1%=#)5+,&-.1-#$'5,8)\;%<#5.+1+)1.)1-#)&.$#).?)5$'&1%&#E)
New*York,*NY:*Routledge.**
Schneider,*K.*J.*&*Krug,*O.*T.*(2009).*CT%+1#(1%'/G-;"'(%+1%&)1-#$'5,E*Washington,*DC:*American*
Psychological*Association.**
Sue,*D.*W.**&*Sue,*D.*(2003).*A.;(+#/%(0)1-#)&;/1;$'//,)<%=#$+#8)9-#.$,)'(<)5$'&1%&#*(4th*ed.).*New*
York,*NY:*John*Wiley*&*Sons.**
Sue,*D.*W.*(2010).*[%&$.'00$#++%.(+)%()#=#$,<',)/%?#8)Z')0#(<#$2)'(<)+#T;'/).$%#(1'1%.(E*New*York,*
NY:*John*Wiley*&*Sons.*
Sue,*S.*&*Lam,*A.*G.*(2002).*Cultural*and*demographic*diversity.*In*J.*C.*Norcross*(Ed.),*
*+,&-.1-#$'5,)$#/'1%.(+-%5+)1-'1)6.$78)9-#$'5%+1)&.(1$%:;1%.(+)'(<)$#+5.(+%=#(#++)1.)5'1%#(1+*
(pp.*401<421).*New*York,*NY:*Oxford*Press.*
Sue,*S.*&*Zane,*N.*(2006).*Ethnic*minority*populations*have*ben*neglected*by*evidence<based*
practices.*In*J.*C.*Norcross,*L.*E.*Beutler,*&*R.*F.*Levant*(Eds.),*C=%<#(&#G:'+#<)5$'&1%&#+)%()
"#(1'/)-#'/1-8)F#:'1#)'(<)<%'/.0;#).()1-#)?;(<'"#(1'/)J;#+1%.(+*(pp.*329<337).*Washington,*
DC:*American*Psychological*Association.*
Tavernier,*R.*&*Willoughby,*T.*(2012).*Adolescent*turning*points:*The*association*between*
meaning<making*and*psychological*well<being.*F#=#/.5"#(1'/)*+,&-./.0,2)OY2*1058<1068.*
Thoits,*P.*A.*(2012).**;$5.+#)'(<)"#'(%(0)%()/%?#2)'(<)6#//G:#%(0)'".(0)=./;(1##$+2)]W2*360<384.**
Vasquez,* M.* J.* T.* (2007).* Cultural* differences* and* the* therapeutic* alliance:* An* evidence<based*
analysis.*!"#$%&'()*+,&-./.0%+12)3X2*878<885.*
Existential*Therapy*&*EBPP* * *
17*
Wampold,* B.* E.* (2001).* 9-#) 0$#'1) 5+,&-.1-#$'5,) <#:'1#8) [.<#/+2) "#1-.<+2) ?%(<%(0+E*Mahwah,* NJ:*
Erlbaum.*
Watson,* J.* C.* (2001).* Re<visioning* empathy.* In* D.* J.* Cain* &* J.* Seeman* (Eds.),* P;"'(%+1%&)
5+,&-.1-#$'5%#+8) P'(<:..7) .?) $#+#'$&-) '(<) 5$'&1%&#) (pp.* 445<471).* Washington,* DC:*
American*Psychological*Association.**
Watson,*J.*C.,*Greenberg,*L.*S.,*&*Lietaer,*G.*(2010).*Relating*process*to*outcome*in*person<centered*
and* experiential* psychotherapies:* The* role* of* the* relationship* conditions* and* clients’*
experiencing.* In* Cooper,* M.,* Watson,* J.* C.* &* Holldampf,* D.* (Eds.),* *#$+.(G&#(1#$#<) '(<)
#T5#$%#(1%'/) 1-#$'5%#+) 6.$7E) !) $#=%#6) .?) 1-#) $#+#'$&-) .() &.;(+#/%(02) 5+,&-.1-#$'5,) '(<)
$#/'1#<)5$'&1%&#+*(pp.*132<163).*Herefordshire,*UK:*PCCS*Books.*
Watson,*J.*C.,*&*Watson,*N.*(2010).*Operationalizing*incongruence:*Measuring*of*self<discrepancy*
and*affect*regulation.*In*Cooper,*M.,*Watson,*J.*C.*&*Holldampf,*D.*(Eds.),**#$+.(G&#(1#$#<)'(<)
#T5#$%#(1%'/)1-#$'5%#+)6.$7E)!)$#=%#6).?)1-#)$#+#'$&-).()&.;(+#/%(02)5+,&-.1-#$'5,)'(<)
$#/'1#<)5$'&1%&#+*(pp.*164<187).*Herefordshire,*UK:*PCCS*Books.*
Wilkins,*P.*(2000).*Unconditional*regard*reconsidered.*N$%1%+-)>.;$('/).?)\;%<'(&#)'(<)A.;(+#/%(02)
XY2*23<36.*
Yalom,*I*D.*(1989).*V.=#M+)#T#&;1%.(#$.*New*York,*NY:*HarperPerennial.*
Yalom,*I.*D.*(1999).*[.""')'(<)1-#)"#'(%(0).?)/%?#E*New*York,*NY:*Perennial.**
*
