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Existential–Humanistic Therapy and Disaster Response- Lessons From the COVID-19 Pandemic

Authors:
  • Rocky Mountain Humanistic Counseling and Psychological Association

Abstract

The COVID-19 pandemic has dramatically affected the mental health field. The unique distress caused by the pandemic along with the need for many to transition their therapy practices to TeleHealth/Telepsychology modalities caught many therapists, including existential–humanistic therapists, unprepared to make the necessary adjustments to treat clients in a manner that is safe and effective. Existential–humanistic therapy often is neglected with trauma and disaster relief work, despite its relevancy and important contributions. All therapies must adjust in crisis situations, particularly when adjustments to how services are offered are disrupted; however, the impact of these changes varies by therapeutic orientation. As an approach that values genuineness, empathy, and presence, existential–humanistic therapy faces unique challenges when employed with disaster response. However, when these challenges are faced, existential–humanistic therapy has much to offer disaster response, including consideration of existential guilt, existential shattering, existential anxiety, and existential perspectives on self-care. Article available open access at: https://journals.sagepub.com/doi/pdf/10.1177/0022167820931987
https://doi.org/10.1177/0022167820931987
Journal of Humanistic Psychology
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DOI: 10.1177/0022167820931987
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Article
Existential–Humanistic
Therapy and Disaster
Response: Lessons From
the COVID-19 Pandemic
Louis Hoffman1
Abstract
The COVID-19 pandemic has dramatically affected the mental health field.
The unique distress caused by the pandemic along with the need for many to
transition their therapy practices to TeleHealth/Telepsychology modalities
caught many therapists, including existential–humanistic therapists,
unprepared to make the necessary adjustments to treat clients in a manner
that is safe and effective. Existential–humanistic therapy often is neglected
with trauma and disaster relief work, despite its relevancy and important
contributions. All therapies must adjust in crisis situations, particularly when
adjustments to how services are offered are disrupted; however, the impact
of these changes varies by therapeutic orientation. As an approach that
values genuineness, empathy, and presence, existential–humanistic therapy
faces unique challenges when employed with disaster response. However,
when these challenges are faced, existential–humanistic therapy has much to
offer disaster response, including consideration of existential guilt, existential
shattering, existential anxiety, and existential perspectives on self-care.
Keywords
disaster response, trauma, existential–humanistic therapy, existential–
integrative therapy, COVID-19
1Rocky Mountain Humanistic Counseling and Psychological Association, Colorado Springs,
CO, USA
Corresponding Author:
Louis Hoffman, Rocky Mountain Humanistic Counseling and Psychological Association, 655
Southpointe Court, Suite 200, Colorado Springs, CO 80906, USA.
Email: lhoffman@rmhcpa.org
931987JHPXXX10.1177/0022167820931987Journal of Humanistic PsychologyIn additional to developing the necessary knowledge and skills, therapists wanting to expand their services to help clients affected by pandemics and disasters will need to learn how to market their services in times of crisis or network with individuals that work directly with disaster response
for referrals. This can come in various forms. With most disasters, it is ideal to begin with face-to-face crisis services as quickly after the disaster as possible (<xref ref-type="bibr" rid="bibr26-0022167820931987">Ruzek, 2006</xref>). For therapists who provide these services, they may not be able to offer continuity of care, especially if their practice location is not close to the disaster location. It is important to address these limitations
upfront with clients. Telepsychology is one option for providing continuity of care. In situations where there are insufficient mental health resources at the location, Telepsychology may be an option for supplementing face-to-face services, particularly for individuals not in active crisis. Triaging can help assure that individuals experiencing a mental health crisis are directed to face-to-face services, while guiding individuals in less distress to
other options, such as Telepsychology. In the situation of a pandemic or disaster in a remote area, Telepsychology may be the only option for many individuals, even if less than ideal.Homan
research-article2020
2 Journal of Humanistic Psychology 00(0)
COVID-19 dramatically affected mental health practice as well as many
aspects of society. Over the past couple of months, many health practitioners
awoke to the rapidly changing context unprepared for the necessary adjust-
ments needed to practice safely in the times of such crises. Crisis situations
bring existential issues into critical focus, yet existential–humanistic perspec-
tives often are left out of disaster response options.
For the past 13 years, I have worked with Mark Yang, Xuefu Wang, and
other colleagues offering trainings on existential–humanistic and humanistic
psychology in China. This work led to the establishment of the International
Institute for Existential-Humanistic Psychology (IIEHP), which now offers
systematic training in China (see Hsu et al., 2019; Thrash et al., 2019). This
work began around the time of the 2008 Sichuan earthquake (see Dias & Ren,
2019; Ren et al., 2018; Ren et al., 2020), and was influenced by the disaster
response efforts. When the COVID-19 crisis began to emerge in China, many
individuals affiliated with IIEHP in China and the United States quickly vol-
unteered to be part of the response efforts. My familiarity with using video
conferencing and involvement in response efforts to COVID-19 in China pre-
pared me for the issues that emerged in the United States and serve as a
foundation for this article.
TeleHealth and Telepsychology
COVID-19 forced many therapists to quickly begin learning how to adapt
therapy in a manner that prioritizes the safety of their clients and themselves.
One positive outcome that may emerge from COVID-19 is that most thera-
pists likely will have crisis and pandemic strategies in place to quickly adapt
to similar situations in the future. Most likely, this will rely heavily on
TeleHealth and Telepsychology. In a short period of time, the therapy land-
scape changed from TeleHealth and Telepsychology being relatively rare to
where most therapists were using Telepsychology with their clients, even if
only temporarily. Many therapists struggled to quickly immerse themselves
in the legal, ethical, and practical issues of transitioning to Telepsychology.
TeleHealth is a broader term used in medical and psychological settings to
refer to a variety of interventions including phone calls, email, text messages,
the use of health and mental health apps, and other interventions employed
through technological mediums. Perle et al. (2011) note that TeleHealth can
be traced back to 1959 when it was first utilized through a closed-circuit
television network by the University of Nebraska School of Medicine. It
remained in relative obscurity for many years with the exception of some
rural settings where clients had limited access to treatment, especially from
specialists. In recent years, it has grown in popularity.
Hoffman 3
Telepsychology is one approach within the broader domain of TeleHealth.
In 2013, the American Psychological Association’s Joint Task Force for the
Development of Telepsychology Guidelines for Psychologists (2013) pub-
lished “Guidelines for the Practice of Telepsychology” in the American
Psychologist. In this article, Telepsychology is defined as “the provision of
psychological services using telecommunication technologies” (p. 791).
This includes, but is not limited to, providing therapy through HIPPA com-
pliant video services. In recent years, many states introduced legislation spe-
cifically targeting mental health professionals practicing Telepsychology.
Similarly, insurance companies have begun reimbursing for Telepsychology.
A specific CPT code modifier (95), has been introduced for reimbursement
for TeleHealth; however, some insurance companies still use different
approaches to coding for TeleHealth.
While insurance companies were slow with beginning to pay for
Telepsychology before COVID-19, most began opening up this option more
widely as the pandemic spread. This may be temporary, but also may encour-
age insurance companies to make this a more readily available option after
the pandemic. The acceptance of TeleHealth and Telepsychology has been
more rapid with licensing as compared with reimbursement. Although vary-
ing from state to state, the standard practice has been that the therapist must
be licensed in the state where the client is currently located in order to prac-
tice Telepsychology. However, the Association of State and Provincial
Psychology Boards (ASPPB) began working on standards for practicing
TeleHealth in psychology across state lines in 2015 (www.asppb.net). Their
initiative, called PSYPACT, was to be enacted when seven states passed leg-
islation approving PSYPACT, which occurred in 2019. As of the time of this
article, 12 states have enacted PSYPACT legislation with another 16 states
and the District of Columbia having pending legislation (https://www.asppb.
net/mpage/legislative). However, ASPPB is still finalizing the Bylaws and
Rules necessary prior to implementing PSYPACT.
TeleHealth and Telepsychology are poised to become essential compo-
nents of mental health disaster plans in the future. It will be valuable for
therapists to have foundational knowledge and basic skills for practicing
Telepsychology, even if preferring to primarily practice face-to-face therapy.
Additionally, it will be important for training programs to address founda-
tional issues of Telepsychology.
Telepsychology is different than face-to-face therapy in many ways;
however, there is limited research to clarify these differences. I have been
practicing Telepsychology on a limited basis with clients and supervisees
since 2017. However, following the COVID-19 pandemic, I temporarily
shifted to doing this fulltime. My experience is that Telepsychology is
4 Journal of Humanistic Psychology 00(0)
more physically and emotionally tiring. In conversations with colleagues,
this appears to be a common experience. Telepsychology may require dif-
ferent types of self-care to offset the unique impact of providing
Telepsychology services. Therapists must have HIPPA compliant secure
video systems with a signed Business Associates Agreement and adapt
their informed consent or have an additional informed consent specifically
for Telepsychology. Additional considerations include having appropriate
technology available, having an Internet connection with adequate speed
for video conferencing, having a backup plan for technology failures, hav-
ing appropriate lighting and nondistracting backgrounds for the video,
knowing how to coach clients less familiar with technology, knowing how
to address client’s questions about Telepsychology, and learning how to
attain appropriate resources local to the client in case of crisis situations.
While there are a number of good guides to help therapists learn what is
necessary to transition to Telepsychology, even if temporarily, there is a
significant time commitment necessary to do the transition well.
In addition to developing the necessary knowledge and skills, therapists
wanting to expand their services to help clients affected by pandemics and
disasters will need to learn how to market their services in times of crisis or
network with individuals that work directly with disaster response for refer-
rals. This can come in various forms. With most disasters, it is ideal to begin
with face-to-face crisis services as quickly after the disaster as possible
(Ruzek, 2006). For therapists who provide these services, they may not be
able to offer continuity of care, especially if their practice location is not
close to the disaster location. It is important to address these limitations
upfront with clients. Telepsychology is one option for providing continuity of
care. In situations where there are insufficient mental health resources at the
location, Telepsychology may be an option for supplementing face-to-face
services, particularly for individuals not in active crisis. Triaging can help
assure that individuals experiencing a mental health crisis are directed to
face-to-face services, while guiding individuals in less distress to other
options, such as Telepsychology. In the situation of a pandemic or disaster in
a remote area, Telepsychology may be the only option for many individuals,
even if less than ideal.
While all types of therapy are affected by shifting to Telepsychology,
some approaches may be more significantly affected. Existential–
humanistic therapists rely heavily on therapeutic presence, which is differ-
ent when conducting therapy through video technologies. The therapist
has a more limited view of the client due to the camera, which means a
more limited range of nonverbals from which to draw as well as the loss of
the felt energy in the room. If the client does not have adequate lighting or
Hoffman 5
has a bright light behind them, it may be difficult to clearly see the client’s
nonverbals. If the client or therapist do not have good quality cameras,
microphones, and speakers, this, too, can limit the ability to clearly com-
municate, particularly some of subtleties that are important for existential–
humanistic therapy.
After several years of practicing Telepsychology on a limited basis, my
professional opinion is that Telepsychology is not ideal for existential–
humanistic therapy. However, I also believe that it has its place. In addition to
use during pandemics and crisis situations, Telepsychology can be useful for
clients who may have physical issues preventing them from traveling, clients
who move but would benefit from continuity of care, and clients who live in
remote areas with limited access to therapy services. As there are many areas
where there are no existential–humanistic therapists, it also provides access
to this type of therapy for many individuals who otherwise may not be able to
seek out existential–humanistic therapy.
Short-Term and Long-Term Strategies
Disaster work is filled with complexities that require mental health profes-
sionals to respond differently in various contexts and points in the timeline.
For existential–humanistic therapists, it requires the use of integrative strate-
gies (Schneider, 2008b, 2008c; Schneider & Krug, 2017) that allow the thera-
pist to adjust the frame and intentions to the needs of the client. Short-term
and long-term strategies may vary, stretching therapists’ ability to maintain a
consistent frame. Ideally, strategies are put into place where the short-term
and long-term strategies work together.
In many disaster situations, it is important to address trauma at the indi-
vidual and community levels (Olweean, 2019) as well as considering other
cultural differences. Often, disaster response includes teams that have trav-
eled to locations to provide therapy. It is critical that therapists working with
individuals from different cultural contexts function from a framework of
cultural humility and seek to learn from local experts about how to adapt their
therapy frame (see Hoffman et al., 2019). In international contexts, Yang and
Hoffman (2019) advocate that cross-cultural work should include (a) cultural
critique of approaches developed outside the context where it is being applied,
(b) cultural adaptation, and (c) the incorporation of indigenous strategies. The
critique, adaptation, and, in particular, the incorporation of indigenous
approaches should be led by experts in the culture in which the therapy is
being applied (i.e., when applying Western approaches in China, individuals
from China should lead the critique, adaptation, and incorporation of indig-
enous Chinese approaches).
6 Journal of Humanistic Psychology 00(0)
Short-Term Strategies
The immediate response to crisis situations necessitates short-term interven-
tions, which many existential–humanistic therapists are averse to relying on.
However, it is possible to implement these in a manner that is consistent with
the depth psychology framework of existential–humanistic therapy (see
Schneider, 2008a). The primary objection to many short-term interventions
and techniques is that they focus on the symptoms and quick fixes rather than
engaging the deeper being-level issues, such as learning to stay with one’s
emotions, becoming curious about one’s emotions, and listening to the mes-
sage of these emotions. However, clients who are overwhelmed by a crisis or
trauma often cannot go into the deeper clinical work without some resources
that provide confidence in one’s ability to manage emotions they perceive as
overpowering.
It is important to distinguish between short-term interventions as an end to
therapy versus short-term interventions as part of deeper work. While manag-
ing emotions and other symptoms is the goal of some approaches to therapy,
in an existential–humanistic or existential–integrative framework, this is a
starting point (Wolfe, 2008). Short-term interventions tend to focus on coping
and skill development. While coping is necessary with many forms of psy-
chological distress, to simply learn to cope falls short of the full potential of
existential–humanistic therapy. When short-term interventions are imple-
mented in the context of what Serlin et al. (2019) refer to as a whole-person
approach, they become consistent with an existential–humanistic approach.
The Relational Frame. The relational frame with an existential–humanistic
approach is embedded in presence (Krug, 2009). In describing presence,
Krug (2019) states that, “Presence involves aspects of awareness, acceptance,
availability, and expressiveness in both therapist and client. Presence implies
that the encounter is real and that the client and therapist include each other
in each other’s recognition” (p. 262). In disaster response, it can be easy to
skip the relationship building to move on to crisis intervention techniques;
however, this can be a mistake. The relationship still can provide a sense of
safety and connection as well as serving to contain emotions. Furthermore,
establishing a good relationship can be critical for long-term follow up. Cli-
ents who have a positive relational experience with a therapist or mental
health professional in a crisis situation may be more likely to return to ther-
apy after the crisis has passed.
From an existential–humanistic perspective, relationship can be utilized
as a primary strategy to help clients cope. An individual’s relationship con-
text following a disaster event or trauma plays a significant role in the
Hoffman 7
individual’s experience and recovery (Hoffman & Whitmire, 2002; Stolorow
& Atwood, 1992; Young, 2006). In considering this from a developmental
perspective, infants and young children often turn to their parents or caregiv-
ers to help them calm down in times of distressing emotion. Healthy adults
often continue to utilize these relational strategies by turning to others in
times of emotional distress. In much of Western society, people are indoctri-
nated with individualism from an early age. Individualistic perspectives tend
to emphasize that the individual should be able to manage or control their
emotions on their own without reliance on others.
Many Western psychological approaches, particularly solution-focused
therapies, tend to emphasize skills that a person can utilize on their own
after learning how to use them. While these skills-based approaches can be
valuable, they also can contribute to isolating people if they are interpreted
as telling disaster victims that they should be able to manage their emotions
on their own, or if they are not combined with more relational coping strate-
gies. When working with trauma and disaster clients, my first emphasis is
on using the relationship to help clients cope with emotions. For some cli-
ents, this is sufficient; however, many clients require additional coping
strategies. The additional coping strategies often are more effective when
implemented in the context of a good therapeutic relationship and when
combined with relational strategies that address the feelings of isolation
and being alone.
Framing Short-Term and Solution-Focused Interventions. Although often
eschewed by existential–humanistic therapists, solution-focused interven-
tions are, at times, essential in disaster and trauma response. However, exis-
tential–humanistic therapists may utilize these differently. For example,
when introducing these techniques, I generally provide a framework for
understanding coping skills and other solution-focused interventions, such as
stating:
There are a variety of strategies we can discuss to help you cope with the
intense emotions. In some approaches to therapy, learning these skills is the
primary focus of therapy. I tend to approach this differently. Learning to
manage and cope with strong emotions can help you gain a sense of control
over them. As you become more confident in your ability to control your
emotions, it becomes easier to be curious about what these emotions may be
telling you and seek out deeper levels of change that address underlying issues.
It is always up to you as to whether you want to focus on managing and coping
with your emotions, or whether you want to continue working with deeper
emotions and possible underlying challenges after you are more confident in
your ability to manage your emotions.
8 Journal of Humanistic Psychology 00(0)
There are several things that I am trying to accomplish in a statement such as
this. First and foremost, I want to help the client recognize their agency. For
the client to experience agency, they need to recognize that they have choices,
which many clients often cannot see in the wake of a traumatic experience.
The recognition of options and choice begin empowering the client. Second,
I want them to be aware of the benefits of strategies that go beyond solution
focused techniques and skill development. In the above statement, I am hon-
est about my bias while highlighting that there are other options. I do not
believe we help our clients by hiding such biases, particularly as they influ-
ence how we approach therapy with them. However, we may cause harm if
we impose our biases on clients. Ideally, therapists help clients recognize
options and empower them to make informed choices. At the outset of ther-
apy, clients often do not have sufficient information to make informed choices
about therapy.
Selecting Short-Term and Solution-Focused Interventions. Schneider’s (2008b,
2008c, 2016) existential–integrative model seeks theoretical and epistemo-
logical consistency. Differentiating from eclectic therapy approaches, most
integrative strategies strive to first have a solid foundation (Hoffman, 2019).
From this foundation, other therapy strategies can be integrated. To maintain
theoretical consistency, it is important to assess whether other strategies fit
with the foundation. When integrating with an existential–humanistic foun-
dation, it is important to consider which strategies are consistent with its
underlying philosophy and values. At times, strategies that are integrated
require modification to fit with the existential–humanistic foundation as in
the illustration above pertaining to integrating solution-focused strategies.
An example can help illustrate the importance of maintaining theoretical
consistency. From an existential–humanistic perspective, anxiety, as well as
other emotions, are essential guides to the therapy process (Hoffman, 2019;
May, 1958, 1977). When focusing too tightly on managing or reducing emo-
tions, the guide is lost. Furthermore, Watson et al. (2010), in their review of
the research, provide evidence that tolerating moderate to high levels of emo-
tions in the therapy room is predictive of better therapy outcomes. Clients
may be able to tolerate these higher levels of emotions if they have some
confidence in their ability to manage them, which provides support for an
integrative approach in which clients are using some solution-focused strate-
gies to build confidence in managing emotions while not seeking to over-
control or eradicate them. Thus, through adapting how the solution-focused
strategies are used they shift from being a poor fit with existential–humanis-
tic therapy to being proficiently integrated in a manner consistent with the
theoretical foundations of existential–humanistic therapy.
Hoffman 9
Short-Term and Solution-Focused Interventions. One approach that previously
was more commonly used in the wake of trauma or disaster is critical incident
stress debriefing; however, there is limited empirical support of its effectives
and some research suggests this may retraumatize some clients (Friedman
et al., 2006). Debriefing and similar strategies, if utilized, may be more effec-
tive as a long-term strategy, if used at all. As many existential–humanistic
therapists have a strong impulse toward processing emotions, it is important
to be aware of the potential harm from prematurely engaging emotional pro-
cessing of the traumatic event. In the immediate aftermath of the disaster, it
is beneficial to rely on other strategies.
In disaster response, therapists may only meet with clients for one brief
intervention or a few sessions, at times without the possibility for follow up.
This may occur via a crisis hotline, at or near the location of the disaster, in a
shelter or other temporary setting, or at one’s office. The short-term nature of
these meetings and varied settings present a challenge for therapists who pre-
fer depth work. When the number of interactions is limited, the therapist’s
primary focus ought to be on providing some stability to the crisis response.
However, this can be done in a manner that also points clients toward future
options. Through offering a compassionate presence, clients can get a brief
taste of the healing power of relationship. Additionally, therapists can discuss
with clients follow up options, such as considering longer-term therapy.
In considering short-term interventions, various interventions fit better
with an existential–humanistic approach. For example, it is common for exis-
tential–humanistic therapists to incorporate various breathing, centering,
mindfulness-based, or somatic interventions that can be effective in manag-
ing emotions. As an alternative to debriefing, defusing is a short-term inter-
vention that typically entails fact finding, identifying thoughts and feelings,
and providing support and reassurance (Friedman et al., 2006). Defusing is
more focused, but experientially can be adapted to utilize a strong relational
context consistent with existential–humanistic therapy, particularly if the
therapist focuses on the utilization of presence as part of defusing process.
Defusing is not trying to accomplish much, but rather focused on providing
some stability in the situation, providing reassurance, and helping clients
connect with resources. Furthermore, this can help clients become aware of
future therapy options and the value of these.
Providing psychoeducation and normalizing the acute reactions to stress is
important in helping clients avoid pathologizing their response (Ruzek, 2006,
Serlin et al., 2019; Sword, 2019). The nonpathologizing aspect of this fits
well with an existential–humanistic approach. Psychoeducation can help cli-
ents understand what to expect. From an existential–humanistic perspective,
psychoeducation may discuss the possibilities in what to expect while also
10 Journal of Humanistic Psychology 00(0)
emphasizing that each person is unique and may respond differently (see
Figley, 2019). The emphasis on the varied individual responses is important
to avoid pathologizing clients for “not grieving right” or “not recovering
right.” It also may serve to help clients begin recognizing choices and options
of which they may not have been aware.
Connecting disaster victims with relational support is critical. Stolorow
and Atwood (1992) note,
traumatic affect states must be understood in terms of the relational system in
which they take form. . . . Painful or frightening affect becomes traumatic, we
contend, when the requisite attuned responsiveness that the child needs from
the surround to assist in its tolerance, containment, modulation, and alleviation
is absent. (p. 53)
Although Stolorow and Atwood are focusing on children in this quote, this is
applicable to adults as well with some adaptations given the additional psy-
chological resources most adults have. Trauma is always best understood in a
relational context and how it develops within the person is necessarily influ-
enced by the interpersonal context during and after the traumatic event. The
relational context and resources influence whether a potentially traumatic
event manifests with long-term traumatic consequences (Shallcross et al.,
2016; Sharp et al., 2017). While the therapist may be an important aspect of
the relational context, their interaction with the individual is more focused
even in the context of ongoing therapy. It is important for the client to connect
with other relational support beyond the therapist.
Short-Term Strategies and COVID-19. Many therapists felt unprepared for the
necessary transitions to keep clients and therapists safe in the midst of the
COVID-19 pandemic. COVID-19 demonstrated that it is important for all
therapists to be prepared to adjust their practice in case of pandemics or
other disasters that may disrupt usual practice. In consideration of pandem-
ics such as COVID-19, it is important that therapists begin by assessing the
current challenges clients are facing in all their complexities. For example,
clients may be dealing with multiple issues, including direct impact of the
virus (i.e., contracting the virus or having friends or family who have con-
tracted the virus), fears of contracting the virus, school or employment dis-
ruptions, financial distress, feelings of isolation, and feelings of existential
guilt. There may be implications at the individual and communal levels as
well (Olweean, 2019). When interaction time is limited, therapists must be
aware of common issues to quickly assess the client’s sources of distress
and current needs.
Hoffman 11
For existential–humanistic therapists, it is important to recognize one’s
own human and temporal limitations. In crisis situations, trying to do too
much can cause harm to oneself and to the client. Recognizing one’s limita-
tions and focusing on what can be realistically accomplished with the limited
time available is vital to effective care. Therapists may need to shift to a more
active and directive role in a crisis situation, which moves away from the
phenomenological approach generally relied on as primary. While this may
not be comfortable for some therapists, it is necessary in addressing the
immediate need within the temporal limitations. If it is assessed that the client
would benefit from follow-up care, providing a good relational and therapeu-
tic experience can be critical in helping clients feel comfortable seeking out
therapy after the immediate crisis situation is mitigated.
Long-Term Strategies
For many disaster situations, the recovery process takes many months or
years. The word recovery can even be seen as suspect in this context. If
recovery is taken to mean being fully restored to the state of existence prior
to the disaster, then this is an inappropriate term. It even can be harmful as it
creates unrealistic expectations and neglects the valuable lessons that can be
learned from the tragedy. Instead, I am using recovery to mean transitioning
to a new state in which most aspects of well-being have been restored, even
if looking and feeling different than the predisaster state. Furthermore, recov-
ery can be understood as inclusive of integrating new knowledge and wisdom
resulting from honestly facing and working through the crisis situation,
which could be viewed as posttraumatic growth.
The aftermath of COVID-19 will leave a tremendous impact on the lives
of many people for years to come. Sadly, it is likely that the most vulnerable
will experience the most sustained negative impacts. There will be a long
period of recovery at the individual, social, and cultural levels. It is important
for therapists to be aware of the layers of impact that may influence clients.
Existential–humanistic therapy is well suited for the postcrisis work with
clients who have experienced disaster situations or pandemics. There are
trauma models, such as whole-person approaches to integrated care, that
have strong roots in existential and humanistic psychology (Serlin et al.,
2019). Existential therapists tend to be attuned to the tragic elements of
human existence and open to exploring these within the therapy context. The
influence of Frankl’s (1984) experience in the concentration camps on his
therapeutic approach is just one of many examples. In this section, I address
a few concepts from existential psychology that are particularly relevant to
disaster response.
12 Journal of Humanistic Psychology 00(0)
Existential Guilt. Through labeling a form of guilt as existential, it is claiming
that it is ontological (Hoffman, 2018; May, 1958). In other words, this is
rooted in human existence as a universal experience. While the experience of
existential guilt may be universal, it is experienced uniquely within each indi-
vidual. Rollo May (1958) argued that existential guilt is rooted in self-aware-
ness and includes a constructive potential. Three different types of existential
guilt were identified by May, each connecting to a different mode of being-
in-the-world. Existential guilt in the eigenwelt refers to forfeiting or not liv-
ing up to one’s potential. Umwelt existential guilt connects with the
environment or one’s physical world, and may be connected to issues such as
one’s role in global climate change.
Existential guilt in the mitwelt mode is rooted in one’s connection with
other human beings and the most relevant to disaster situations. Hoffman
(2018) states,
This form of existential guilt calls all people toward social responsibility to
others, even though the person may not have control over the outcome. This
guilt, too, may be connected with complacency or inaction in the face of harm
or evil, or the participation in a system in which harms are being perpetuated
without recognizing what one ought to recognize or voice concern about what
one recognizes but may not be able to change.
This form of existential guilt can be closely connected with survivor guilt. As
people reflect on what they did or did not do after the crisis has passed, guilt
may become more prominent. This guilt is rooted in human finitude—the
limitations that are part of being human.
The helplessness faced by many in the midst of a crisis or pandemic can
easily become existential guilt. One may feel they can never do enough.
Many who minimized COVID-19 or claimed it to be an overreaction or a
hoax may experience guilt as the impact of the virus becomes more evident.
Individuals who worry that they may have inadvertently passed the virus to
others or believe that they did not do enough to prevent spreading the virus
similarly may experience existential guilt. This guilt emerges from believing
that one did not do enough to help those who are suffering or through recog-
nition that their privilege protected them while others without that same priv-
ilege suffered greater than they did.
Existential guilt easily becomes neurotic if not faced, but when individu-
als directly face their existential guilt it can become productive (Hoffman,
2018). Existential–humanistic therapists help clients compassionately
explore their choices and actions during the time of crisis. When engaging
in this process, clients may recognize their moral or other failures. As this
Hoffman 13
existential guilt comes to light, it provides opportunities for clients to
decide what they will do with this guilt. Through creatively engaging exis-
tential guilt, clients can find healing while being empowered to live more
consistently with their values in their life in general and in the face of future
times of crisis.
Existential Shattering and Meaning. The concept of existential shattering was
developed by Tom Greening; however, Greening never published on the
topic (Hoffman & Vallejos, 2018). Instead, the concept was developed by his
students and colleagues who recognized the importance of this topic (see
Hoxie, 2013; Vallejos, 2015). Hoffman and Vallejos (2018) define existential
shattering as, “the sudden and unexpected dismantling, or shattering, of one’s
self-conception and worldview as a consequence of an event or process that
the individual has experienced.” Similarly, Vallejos (2015) described the
experience of existential shattering as a “devastating, unexpected, irrevers-
ible event, a trauma, in which one’s fundamental systems of meaning and
relating are irreparably shattered” (p. 6).
COVID-19 has been an existential shattering experience for many people.
It prompted them to question their basic feeling of security in the world.
Watching people fight over toilet paper, water, and other essentials can lead
to people questioning their faith in humanity. Increasing awareness of the
governmental failures may transition into increased anxiety and questioning.
Individuals more directly affected by COVID-19 through the loss of loved
ones, loss of employment, or other consequences may be thrown into various
forms of existential questioning and struggle.
Clients experiencing an existential shattering need a therapist able to sit
with them in their places of despair while helping them find the light of hope
in the midst of the darkness. In the midst of an existential shattering, clients
often struggle to find hope. If the therapist embodies hope that there is some-
thing on the other side of the darkness, this relationally can help sustain the
client until they find their own hope. Therapists experienced with working
with existential shattering have walked the path through the darkness enough
to have confidence that there is something better. Hope, then, can be shared.
As LuXun (1921/1959) noted, “ . . . hope cannot be said to exist, nor can it be
said not to exist. It is just like the roads across the earth. For actually the earth
had no roads to begin with, but when many men pass one way, a road is
made” (p. 101).
Existential Anxiety. Van Deurzen and Kenward (2005) note that existential
anxiety is different than everyday worrying or neurotic anxiety. Rather, exis-
tential anxiety is akin to angst, which they describe as “a natural reaction to
14 Journal of Humanistic Psychology 00(0)
the vastness of choice and isolation, a predictable response to the loneliness
of individual life and the choice the individual must make” (p. 7). In other
words, existential anxiety is rooted in the human condition and a response to
the givens of existence. Tillich (1952) states, “The basic [or existential] anxi-
ety, the anxiety of a finite being about the threat of nonbeing, cannot be elimi-
nated. It belongs to existence itself” (p. 19). Threats to one’s existence, or the
existence of others, may elicit existential anxiety.
Similar to existential guilt, May (1977) notes that, “Anxiety has meaning.
Though part of this meaning can be destructive, another part can be construc-
tive” (p. xiv). Existential anxiety emergent from threats to one’s existence,
such as is the case with COVID-19, may prompt reflection that leads to
growth. However, when existential anxiety is not dealt with, it easily becomes
neurotic anxiety, which is more likely to be destructive. Because it is onto-
logical in nature, existential anxiety cannot be effectively managed through
mainstream approaches to control and reduce the discomfort of anxiety.
While these strategies may decrease the discomfort, they serve to suppress
and avoid the deeper existential questions that are beckoned by the nature of
existential anxiety. Rather, existential anxiety must be invited into one’s con-
sciousness and, in therapy, invited into the therapy room. This allows for
existential anxiety to be faced directly.
Yalom (2008) noted, “though the physicality of death destroys us, the idea
of death saves us” (p. 7). COVID-19 brings opportunities for reflection at the
individual, familial, and cultural levels. It encourages people to consider val-
ues and priorities, the risks that one is willing to take, and how one’s freedom
and way of living impacts others. When the focus is on defending against
existential anxiety, one may be drawn toward hoarding toilet paper and other
“essentials,” fighting with others over resources, or blaming others for the
challenges being faced. However, when existential anxiety is faced directly,
it allows one to consider how they want to face the existential challenges sur-
rounding them with integrity.
Existential–humanistic therapists are called to sit with clients in the midst
of the existential anxiety and help them confront it. If the therapist focuses
solely on comforting the client’s anxiety, they miss the opportunity to delve
into the deeper meanings that may be brought into focus when existential
threats are present. This is not intended to glorify tragedy or crisis, but rather
it is focusing on the opportunities that are present when such crises emerge.
In order to do this effectively, therapists must be willing to do their own
work. Sitting with such existential anxiety can prompt one’s own angst.
Therapists must be willing to look within to find the courage to face their own
existential anxiety and be with others as they face theirs. This is not easily
accomplished, particularly if the therapist has not done their own work in
Hoffman 15
advance. Therefore, part of the existential–humanistic therapist’s preparation
for disaster work must be rooted in doing their own existential work.
Recovering From Isolation. COVID-19 has thrown many into an experience of
feeling isolated and fearful of others. As clients reengage their normal rou-
tines and relationships, these relationships may feel different. It may not be
easy to return to their normal routine and way of engaging others. Although
the importance of connecting with social support following a crisis is often
emphasized (Olweean, 2019; Young, 2006), the challenges with reengaging
are missed. The here-and-now focus of existential–humanistic therapy with a
relational emphasis (Hoffman, 2019; Krug, 2009; Schneider & Krug, 2017;
Yalom, 1980) allows for clients to work on reengaging through their relation-
ship with the therapist. If therapists are not attuned to ways that crisis, trauma,
and isolation can affect relationships, they may miss the deeper work of help-
ing clients reengage in relationships in a meaningful way.
The Necessity of Self-Care
Therapist self-care is a popular topic in the field of psychology (Bush, 2015;
Norcross & VandenBos, 2018). In this section, I focus on self-care with
Telepsychology as well as some unique existential perspectives on self-care.
Telepsychology and Self-Care
Telepsychology affects therapists physically and emotionally in different
ways than face-to-face therapy. For example, staring at a computer for long
days can lead to eye strain. It is may be important for therapists to consider
glasses that decrease harmful blue light, looking away from the screen for
periods of time, and reducing screen time outside of therapy. As noted previ-
ously, many therapists experience higher fatigue from Telepsychology. It
may be valuable to have additional breaks throughout the day.
Working from home may further isolate therapists from colleagues who
provide social support and opportunities for consultation. When working
remotely, it may be beneficial to schedule time for video or phone consulta-
tion with colleagues. Spending quality time with family members or others
who live in the same home may become more important when working long
hours of Telepsychology. For therapists who live alone, it is important to find
safe ways to spend time with friends, family, and colleagues to avoid feeling
isolated and depleted.
As Telepsychology is relatively new, there needs to be more exploration—
research as well as more informal exploration—of the impact of this modality
16 Journal of Humanistic Psychology 00(0)
on the person of the therapist. As the person of the therapist is a central aspect
of existential–humanistic therapy, this is even more vital within this approach.
Clarifying the impact of Telepsychology is important to recognize the unique
self-care needs not being met through other forms of self-care.
Meaning and Self-Care
Existential–humanistic therapy advocates that meaning is an essential com-
ponent of helping individuals cope with and transform suffering (Hoffman,
2019; Hoffman et al., 2015). Wong (2012) notes that meaning also is impor-
tant in promoting well-being. Meaning, therefore, should be a natural source
of self-care for existential–humanistic therapists. In times of crisis and
change, it is easy for therapists to lose track of important sources of meaning
in their own life and work. Meaning can be enhanced through mindful con-
nection of the meaning inherent in helping people and communities who are
suffering as well as engaging in meaningful activities during time away for
work. Pardess (2019), for example, emphasizes the importance of engage-
ment with pleasurable activities, utilizing the creative arts, and engagement
with nature, all of which can be sources of meaning.
COVID-19 hit during a busy period in my own life. When a colleague and
friend in China asked if I would do some additional trainings and supervision
for therapists in China, I could feel the tension pulling me two directions. I
recognized the need for boundaries as part of my own self-care, but also the
importance of this work. Despite recognizing the internal tension, I also
immediately knew that I would agree to this additional commitment. Although
the additional time was tiring, the meaning associated with the work that I
was doing was rejuvenating. Yet, I also recognize that the rejuvenating aspect
of meaning can only go so far.
Balancing self-care strategies is important. As Pardess (2019) notes,
Traditionally, self-care strategies have emphasized the value of “good
professional boundaries” and effective self-care strategies outside the
workplace. These alone, however, can lead to emotional detachment by the
caregiver. Over-reliance on strategies of avoidance can result in diminished
compassion satisfaction. (p. 192)
In my own experience, I have consistently found that when I am detached
from my clients, therapy becomes more draining without the benefits of
the rejuvenation that is part of a caring, empathetic relationship. Empathy,
warmth, concern, and compassion are not just therapy techniques—they
are personal and relational qualities that are healing in and of themselves.
Hoffman 17
These can be healing for both the therapist and the client, particularly
when combined with a belief in the power of the therapy process. Belief in
the healing potential of therapy helps empower therapy through the hope
that on the other side of the suffering is something better. Suffering, then,
is no longer mere suffering, but suffering for a purpose and suffering with
potential.
Yet boundaries remain necessary for balance. Therapists need different
types of restoration, including more active and restful forms of self-care.
Setting appropriate boundaries can be a way of affirming another source of
meaning: the value of oneself. For me, the deepest meaning in life is rooted
in compassionately serving others. Yet, I also recognize that when I am over-
worked my compassion and empathy for others can become depleted, which
leads to compassion fatigue (Pardess, 2019). Compassion fatigue negatively
affects the restorative qualities of relationships, including relationships with
clients. If we do not take care of ourselves, the therapy services we offer will
be negatively affected.
Relationship and Self-Care
The importance of relationships in self-care already has been addressed in the
context of other forms of self-care; however, it deserves additional attention
given its importance. Existential–humanistic psychology is a relationally
focused therapy; therefore, it is valuable to draw from the wisdom of this
approach for self-care as well. As already discussed, the need for relational
support can be heightened when shifting to Telepsychology work. However,
in general, relational needs may shift when working with disaster situations.
When the need is great, therapists may give more of their time to support oth-
ers, including clients, colleagues, family, and friends. It is vital that therapists
do not neglect their own relational needs.
Time apart from others is an essential part of being with people
(O’Donohue, 1998). Therefore, we must balance the interrelated relational
needs of time for oneself and time with others. Individuals have different
needs in regard to solitude and time with others. This balance may shift
when working with disaster response. Therapists must be aware of their
changing needs so that they can adapt to the particular situation. It also may
be important to give greater consideration to what relationships are engaged
with outside of therapy. Personal relationships that are challenging or con-
sume more emotional energy may need additional temporary boundaries. It
may be more important to spend time with individuals who are supportive
and who understand the strain you are experiencing. For others, it may be
important to engage more with relationships that help shift one’s focus to
18 Journal of Humanistic Psychology 00(0)
more pleasurable or less stressful activities. While, at times, these may not
be as deep of relationships, they serve an important purpose in helping dis-
engage from the stressful work environment and possible rumination about
the related challenges.
Conclusion
While COVID-19 is undoubtedly a tragedy, it is a tragedy that can be
learned from as a field and society so that we are better prepared for
future pandemics, should they occur. While existential–humanistic ther-
apy is often neglected in disaster response, it has much to offer in these
contexts. It is important for existential–humanistic therapists to be pre-
pared to adapt their therapeutic approaches to meet the needs of the many
who are suffering in times of crisis, which may include being prepared for
the use of Telepsychology. As illustrated in this article, this can be done
in a manner that stays true to the foundations and values of existential–
humanistic therapy.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publi-
cation of this article.
ORCID iD
Louis Hoffman https://orcid.org/0000-0002-4288-0072
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Author Biography
Louis Hoffman, PhD, is psychologist in private
practice in Colorado Springs, Colorado. He is
the executive director of the Rocky Mountain
Humanistic Counseling and Psychological
Association and assistant director of the IIEHP.
An avid writer, he has published 17 books,
including Humanistic Approaches to
Multiculturalism and Diversity and Existential
Psychology East-West (Volumes 1 & 2) as well
as over 100 journal articles and book chapters.
He teaches at the University of Denver, the
University of Colorado, Colorado Springs, and
Saybrook. In addition to his university teaching, he is an affiliate instructor with the
Existential-Humanistic Institute and regularly provides training and supervision in
China through the IIEHP.
... First, effective physician-patient communication is of the utmost importance during the pandemic. Therefore, it is important to teach medical students the humanistic ideal of presence, which refers to "aspects of awareness, acceptance, availability, and expressiveness" (Hoffman, 2020). Presence involves the physician and patient recognizing the role of one another and building a trusting relationship. ...
... During times of uncertainty, such as a pandemic, it is crucial that this step not be diminished. Establishing a meaningful relationship is significant because it gives the patient a sense of safety and commitment for long-term follow-up care (Hoffman, 2020). Additionally, the physical presence of healthcare workers, much like gloves, masks, hand sanitizers, and ventilators, was of increased value and demand, as healthcare worker shortages were pronounced during the pandemic (Adams and Walls, 2020). ...
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The current global pandemic due to COVID-19 has resulted in widespread lockdowns, social distancing, and other protective guidelines; these infectious control and mitigation measures challenge the medical system and create anxiety among all populations. In hospitals and healthcare facilities, patient interaction and shared decision making are sacrificed for fear of COVID-19 nosocomial spread. The intangible effects of human interaction with COVID-19 patients, whether of a physician or a patient’s family, are replaced with isolation amid ventilators. Medical professionals must find a way to practice life-saving medical care while maintaining humanistic and professional interactions. This article provides insight into the necessity and challenges of humanistic communication during COVID-19 across various institutions and offers both short- and long-term solutions and reforms through medical education.
... Due to the physiological and psychological abnormalities in the recovered COVID-19 patients, the researchers have insisted on the support and intensive care of these individuals to reduce the perplexities related to death by changing the meaning of life. One of the interventions that have a good history in improving the psychological state in critical conditions is Existential Therapy (13). This treatment has a desirable structure to work on the existential problems of the clients. ...
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Background & Aims: Due to the high physiological and psychological damage of COVID-19 patients after discharge from the hospital and the need for interventional approaches, the present study was conducted to evaluate the effectiveness of existential therapy on death anxiety and the meaning of life in recovered COVID-19 patients. Materials & Methods: The research was a quasi-experimental design with pre-test and post-test and control group. The statistical population in this study included all recovered patients of COVID-19 in 2020 in Urmia, Iran. To select the sample, the patients' files were checked in the counseling center of Taleghani Hospital. After that, 30 of the recovered patients that had the inclusion criteria were randomly assigned to either experimental or control groups, each group consisting of 15 individuals. The experimental group received ten sessions of online existential therapy whereas the control group received no intervention. For the collection of data, the Meaning of Life (MLQ) and Death Anxiety Questionnaire (DAQ) were used. The collected data were analyzed using single-factor analysis of covariance (ANCOVA). Results: The results of the comparison of the post-tests of the groups indicated that scores of death anxiety (p<0.01) and meaning of life (p<0.01) of experimental and control groups differed significantly. The analysis of data showed that existential therapy reduced death anxiety and increased the meaning of life among recovered patients of COVID-19. Conclusion: Existential therapy is an effective approach in dealing with critical situations. The results of the present study can be used to improve the perplexities related to death and the meaning of life during the COVID-19 pandemic. Keywords: Existential Therapy, Meaning of Life, Death Anxiety, Recovered Patients of COVID-19
... Due to the physiological and psychological abnormalities in the recovered COVID-19 patients, the researchers have insisted on the support and intensive care of these individuals to reduce the perplexities related to death by changing the meaning of life. One of the interventions that have a good history in improving the psychological state in critical conditions is Existential Therapy (13). This treatment has a desirable structure to work on the existential problems of the clients. ...
... However, mental health professionals working remotely may also have a great burden. Hence, self-care practices that psychotherapists can adopt are essential (Hoffman, 2020). ...
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... Robson & Robson, 1998;Williams et al., 2009) and ethical concerns related to managing risk appropriately (e.g. Hanley, 2006;Hoffman, 2020). ...
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This chapter provides history on the early development of existential-humanistic therapy in China, including a discussion of challenges and opportunities.
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