Existential Therapy and the Contextual Model: Unified by Presence, Flexibility, and Meaning-Making

The contextual-based paradigm focuses on the following factors of variability in the order of percentage of contributions that each makes in successful therapy outcomes: client and extra-therapeutic features (80% to 87%); alliance and therapeutic relationship (5% to 8%); the therapist (4% to 9%); hope, expectancy, and placebo (including allegiance 4%); and structure or model (1%; ¹). Client variables include motivation, readiness, ability and timing of change, active participation in therapy work, and confidence that change will be helpful ². A genuine therapeutic bond is characterized by connection, trust, understanding, expertise, and co-construction of expectations, goals, and methods ³. Therapist factors include facilitating a therapeutic atmosphere, empathic listening or presence, creativity, relating to the client as a unique human being, affirmation of emotion and experiences, validation of strengths, resources and abilities, and creating hope ^{4, 5, 6}. The field of therapy has been and has remained highly dependent on specific model-and technique-driven knowledge, training, and intervention ⁷. However, this is the least significant variable in determining outcomes––still, there is value in the therapist’s belief and confidence in the methods utilized, particularly if the client believes in the theory of change ⁸.

Wampold (2008) suggested, “it could be argued that an understanding of the principles of existential therapy is needed by all therapists, as it adds a perspective that might form the basis of all effective treatments” (p. 6). This endorsement begs the question, what is it about or in the existential approach that drives or fosters successful therapy outcomes? It is an interesting paradox that existential therapy has long faced criticisms of being difficult to understand because of vague concepts, confusing language, and a lack of structure ^{10, 78, 32}. Yet, developing knowledge and skills of the core principles of existential therapy may form the bedrock of effective therapy ⁸. In addition, the problem with Wampold’s statement is that there are different forms of existential therapy and differences within the approaches.

Existential therapy is not a monolith. Correia et al. (2017) identified the following four forms of existential therapy: Dasein analysis, Existential-humanistic, Existential phenomenological (British school), and Logotherapy. Dasein tends to be more psychoanalytically influenced; Existential-humanistic focuses more on psychological and individual processes; Existential-phenomenological methods are more philosophically oriented; and Logotherapy or meaning-centered therapies (see ¹¹) are often more technique driven ¹². Cooper (2017) noted, “It is widely accepted that it is not possible to define the field of existential therapy in any single way” but rather as a “rich tapestry of intersecting therapeutic practices” (p. 1), unified by a shared concern with human lived existence.

Core features across these schools of existential therapy include centering therapy on client’s real experiences, facilitating a phenomenological method of exploring and understanding, focusing on the ontological study of the client’s way of being in the world, establishing a shared foundation of existential philosophical assumptions, and targeting a more open and authentic connection with others and the world ⁹. Correia et al. (2017) further recognized five principal categories of practice across these four main existential therapies: (a) phenomenological practice, (b) relational focus, (c) existential assumptions, (d) a willingness to use methods from other paradigms, and (e) loyalty to methods used in the specific existential branch. Presence emerges as a common thread, grounding and facilitating phenomenological inquiry, deepening and navigating relational connection, allowing authentic engagement with existential challenges, and providing therapeutic integration or flexibility. As May stated (1961), existentialism centers “upon the existing person,” emphasizing the human being as continually “emerging, becoming” (P. 16).

Phenomenological practice is central to existential therapy, emphasizing the lived experience of both client and therapist ¹⁵. As Adams (2019) explained, “phenomenology aims to arrive at an understanding of individual human experience by returning us to embodied lived experience and opening to the richness and mystery of life by successive description. It stays experience near” (p. 168). Primary experiencing involves immediate emotions, bodily sensations, thoughts, and desires, while secondary experiencing relates to how individuals interpret and judge these experiences ¹². Schneider and May (1995) argued that dysfunction arises from resisting experience rather than fully engaging with it. Accordingly, existential therapy supports clients in exploring their lived experiences in a genuine, open, and holistic manner ¹⁶.

Presence both anchors and facilitates the phenomenological method ¹⁷. Therapeutic presence entails a curious, attuned, expectation-free engagement with the unique human being and the framing of one’s life predicaments ^{16, 18}. Through bracketing assumptions, therapists cultivate an “un-knowing” stance, remaining open to novel understandings of familiar experiences (¹⁹; p. 8). Satre stated, “the existent is a phenomenon; this means it organizes itself as an organized totality of qualities . . . It is being for revealing” (as cited in ²⁰, p. 91).

Presence implies that the encounter between therapist and patient is taken as a real one in its total meaning. Existentially, truth always involves the relation of the person to something or someone. One can think of this as a field-the therapist is part of the patient’s relationship field. This participating in the field which the patient creates (or the “world” which he builds) is our best avenue for understanding the patient; indeed, we cannot really see the patient unless we participate in this field. (as cited in ²⁰, p. 452)

Meaning-making, a central existential concern is rooted in presence ²². The meanings an individual makes from lived experiences creates a set of self and world constructs––in essence, a set of beliefs regarding self, others, and the world ¹⁸. Individuals make meaning out of a dialectical process with the personal and objective poles of existence ²³. This “passion for form” captures the creative forming and reforming of the interrelationship between self and world that is constantly present in our lives (²⁴, p. 134). Schneider and Krug (2017) proclaimed, “existential meaning making is an intrinsically human process related to identity formation. It is the act of making sense of an experience” (p. 23).

Individuals create their private worlds through a meaning-making lens derived from personal agency ¹⁵. Human beings create meaning about self, others, and the world and have the freedom to elect how to explain observations and experiences, as well as the responsibility for choices that are made ²⁶. A freeing factor in therapy occurs when an individual recognizes one can alter meanings that are ascribed to self, others, and the world ¹⁵. Intrapersonal presence refers to an ability to be present with one’s internal experiences and structure, emotions, memories, and thoughts as a person engages in the “here and now” of therapy ²¹. Bugental (1987) advocated for a self as process approach and highlighted initiating and activating presence through listening, guiding, instructing, and requiring. The existential therapist facilitates an inner searching process, focusing on what is most alive for the client during moment-to-moment experiencing and identifying blockages, self-protective patterns or avoidance, and distortions to their subjective awareness ²⁷.

The process of sedimentation entails the client’s fixed and rigid self and world views, as well as the behaviors that keep the client stuck to maintain security and certainty ¹⁸. Bugental (1999) compared protective patterns to wearing a spacesuit in outer space. The spacesuit provides safety and allows functioning, but it does not allow any freedom on the outside, often constricting many areas of life. Presence involves the therapist’s ability to “invoke the actual” (²⁶; p. 81) or sensitively uncover the client’s deep inner experiences, illuminate what is meaningful from that moment, and assist the client to face these blockages effectively. Schneider (2008) referred to intrapersonal isolation as a “reoccupation project,” asserting that clients need help to reconnect and recover the parts of themselves that have been blocked or lost (p. 38). As clients progress through therapy, facing challenges and overcoming self-protective and life-restricting patterns, they create and co-create new meanings and life stances toward self, others, and the world ¹⁵. Schneider and Krug (2017) asserted, Meaning is wrought out of struggle, deep presence to the rivaling sides of oneself, and embodied choice about the aspect of oneself that one intends to live out. The overcoming of resistance, in other words, is preparatory to the unfolding of meaning, and the unfolding of meaning is preparatory to revitalization. (p. 71).

Presence simultaneously allows for defining and broadening life stances ²⁹. Clients move toward intentionality to illuminate a new way of being, which is evidenced by a person turning one’s complete attention and effort toward an identified direction (life stance) or a prioritized goal (life meaning) ³⁰. May (1983) also discussed the importance of “I am” experiences, conveying one’s own feelings of aliveness and the strengthening of self. Individuals may experience a sense of “awe,” or “wonder,” allowing new vibrant pathways for living and a reverence for existence itself (²⁶, p. 71).

The client is the main contributive stimulus toward therapy outcomes, meaning the resources, strengths, skills, or life developments that the client brings to therapy and how these aspects motivate, lessen, or play out in the client’s life outside of therapy, are the main elements that facilitate change ³⁴. Craig (1986) explained that when therapy ends and he obtains feedback from his clients on what helped them, the answers regarding his contributions are quite varied and individualized. Yalom (1980) used the analogy of an expert cook throwing in spices that make all the difference and compared these unique “throw ins” to what the therapist does in a session with clients (p. 4). Norcross (2011) concluded that the following six characteristics were pertinent in tailoring therapy to the individual: reactance, stages of change, preferences, culture, coping style, and religion or spirituality. The existential therapist is open to constructing and co-creating a new therapy for each individual client (Yalom, 1998).

The professional therapist draws a sense of personal identity from work, exhibits motivation and commitment to ongoing improvement, self-reflects on the meaning of the work, and understands that one’s own being is the principal pathway toward reaching one’s potential as a therapist ²⁷. The therapist’s most prized and useful instrument is that of oneself ⁴⁰. Therapist personhood is inseparable from presence. The personal growth of the therapist can positively have impact on different settings that they occupy and engage in, such as therapy ³⁵. The therapist’s personal self-influences the professional self, and vice versa ³⁶. Therefore, an emphasis should be placed on the personal context and the ongoing development of the personhood of the therapist, which are principal features of existential therapy training and work ¹⁷.

Therapists are unique human beings that develop a way of being in their lives and practice therapy in a way that has a definitive bearing in successful therapy outcomes. As Miller et al. (2020) stated, “decades of research confirm who the therapist is matters” (p. 119). The principles of therapy practice are rooted in personal experiences of being and therapists must “walk the talk” in terms of exploring their own lived experiences as it pertains to a set of beliefs the therapist has about oneself, others, and the world based on the meanings the therapist has created (¹⁷, p. 26). The therapist needs to be able to reflect on one’s self and world-other constructs to identify biases, historical backgrounds, cultural influences, and relational patterns and styles that may hinder the work ¹⁷.

Countertransference does not occasionally show up and then go away; rather countertransference is actually “a fact of limited presence, to a greater or lesser extent” (¹⁷; p. 36). Thus, supervision, consultation, or training may be enhanced by focusing on the personal context of the therapist, spotlighting protective patterns of limiting factors ¹⁷. Inner attending focuses on viewing the self of the therapist as an instrument in healing and encompasses spontaneity, creativity, trusting in the process, authenticity, and refocusing on the “here and now” ³⁷. Extending and contacting revolves around being accessible, developing congruence, and intuitively responding during an encounter with a client ³⁷.

Rollo May (1992) likened the therapeutic relationship to Dante and Virgil, in The Divine Comedy, where the therapist accompanies a client through their personal “Hell” toward healing. He emphasized that therapy demands profound responsibility and courage, rooted in centeredness within one’s being ²³. Centering is the ability to be aware of, and authentically adjust and direct, one’s constrictive or expansive options and polarities ²⁶. The therapeutic relationship may look quite different from one client to the next, but the key feature is the therapist’s ability to form the bond based on the client’s individual and relational needs and to navigate the alliance over the course of the work ²⁹.

According to a task force developed through the American Psychological Association on evidenced-based therapy relationships, “the therapy relationship makes substantial and consistent contributions to therapy outcome independent of the specific type of treatment” (³⁹, p. 98). In addition, the therapeutic alliance may produce the most significant therapeutic outcome if the therapist makes it the chief emphasis of treatment ³. The therapeutic partnership serves as the “agent of change” (⁴⁰, p. 32). The relational focus is on two individual human beings genuinely interacting in service of the one––i.e., the client ⁴¹.

Therapeutic relationship factors center on the quality of the alliance from the client’s perspective, highlighting empathy, positive regard/affirmation, congruence/genuineness, collaboration/goal consensus, expectations or theory of change, and cultural adjustments ³. Rankings of therapist empathy are among the most constant predictors of therapy outcomes ⁴³. Geller and Greenberg (2023) asserted, “presence could be seen as the larger condition by which empathy, congruence, and unconditional positive regard came to be expressed” (p. 31). In an interview with Baldwin (2000), Rogers stated, “I recognize when I am intensely focused on a client, just my presence seems to be healing” (p. 29).

The therapeutic alliance is foundational in existential therapy’s conceptualization and approach ¹⁰. The existential therapist strives to consistently embody human qualities: warmness, kindness, sincerity, acceptance, and responsiveness ¹⁷. Therapy is an expression of human connection and social engagement ⁴⁶. Yalom (2002) depicted the therapeutic alliance as one of “fellow travelers,” meaning, “we are all in this together,” and the therapist is not exempt from the innate challenges of life (p. 8). Buber (1970) espoused an I-thou relationship as being transcendent and indicated by confirming each other openly, sincerely, nonjudgmentally, and without objectification. This occurs in contrast to Buber’s (1970) interpretation of an I-it relationship, which is when one person relates to another as an object, in a dehumanizing way. Friedman (2009) built on Buber’s stance in therapeutic meetings and specified that client and therapist growth is produced from constructing the ability to be present and affirm oneself, as well as remaining available and open to the affirmation of another.

Existential therapy emphasizes co-creating a solid in-depth therapeutic relationship through co-presence and dialogue ¹². Presence has two completely interconnected features: receptivity, an openness to be influenced by a situation, and expressivity, an openness to share oneself in a situation ²⁵. Cooper stressed the exchanging feature of dialogue and the potential for one to take in the information of the other and to risk being transformed in some way, while Spinelli explained, “dialogue is about talking through some issue, it is about working one’s way across something with words” (as cited in ⁴⁷, p. 197). This process of “merging” happens through a joint venture in which both therapist and client experience a real connection and learn from one another ⁴⁸.

Developing and navigating the therapeutic alliance offers a pathway for change through its foundational security and allows the therapist to address self-protection, life limiting patterns, and interpersonal difficulties ²⁹. Experiential engagement in existential therapy focuses on the immediate, kinesthetic, affective, and cosmic or reflective ²⁶. Craig (1986) referred to presence as “sanctuary,” or a sense of safety in which vulnerability can be accepted, cared for, and sensitively addressed. Yalom (2002) stressed the importance of “here and now” engagement, with an emphasis on working in the interpersonal domain or “in-betweenness” of therapist and client (p. 46). Interpersonal presence is defined by emotions, memories, and thoughts, as they ensue in the “here and now” experiential engagement between therapist and client ²¹.

Schneider (2015) defined presence as “a complex mix of appreciative openness, concerted engagement, support, and expressiveness, and it both holds and illuminates that which is palpably significant within the client, and between client and therapist” (p. 304).There is immense value in being able to notice and engage with what is not being said or with any undercurrents to the dialogue that is occurring ²⁶. Thus, the therapist consistently returns to what is happening for the client internally and relationally by checking in and processing the process ²¹. The therapist and client need to revisit the client’s experience of being stuck repeatedly because, “the path to greater freedom is paradoxically found through an encounter with the ways in which we are bound” (²¹, p. 17).

The client and therapist may assess the sessions in a unique way and may have differing perceptions on what is helpful for the client ⁵⁰. Therefore, therapists need to regularly obtain client feedback regarding the therapeutic alliance and treatment options to direct and navigate the therapeutic process (Lambert, 2010). The therapist must prioritize the client’s reflections and employ congruent feedback, because the client is the principal influencer of change.

Yalom (1998) hypothesized that the reason a client will come to therapy is often because of relationship challenges; therefore, therapy can center on the client’s inability to build and maintain healthy relationships. Therapy also represents a social microcosm, where the interpersonal difficulty of the client can play-out in the proceedings of the therapeutic relationship and be addressed between client and therapist, which is practice for real life ⁵¹. Responsiveness and mutuality are key factors in effective therapy ⁷.

The therapeutic relationship from the client’s perspective is the main forecaster of successful outcomes in therapy ⁵². Hope for one’s life to improve, expecting to get better or heal through therapy, and a belief in the therapist’s credibility and reasoning for interventions are key elements in efficacious therapy outcomes ^{53, 8, 3}. The therapeutic relationship is dynamic and progressive, not static, or fixed ⁵⁴. Strains or misunderstandings may happen and the therapist’s ability to repair the relationship when harmed is a primary factor in facilitating effective therapy ⁵⁵. Recognizing the uniqueness of the client, remaining flexible, and building and returning to the therapeutic connection can help reduce defensiveness and reactance in the client ^{56, 57, 58}. If the therapist does not remain focused on client needs, preferences, and multi-pluralistic change options, then the client and therapist will be at a disadvantage ¹².

Existential therapy explores four major dimensions: the physical world (Umwelt), the social world (Mitwelt), the inner world (Eigenwelt), and the spiritual world ^{24, 81}. Anxiety is at the epicenter of existential therapy ¹⁸ and Heidegger (1962) referred to anxiety as “uncanniness” or “not-being-at-home” (p. 233). Human beings are anxious about exploring self, developing self, losing a sense of self, and through alienation with one’s world ²⁵. May (1979) specifically defined anxiety as, “the apprehension cued off by a threat to some value which the individual holds essential to his existence as a self” (p. 72). The threat may be toward physical existence (death or illness) or toward psychological existence (e.g., loss of freedom, love, achievement, meaning, spirituality, etc.) ³⁸. Therapeutic work entails facing anxiety, but it offers clients opportunities to find inner and relational homelands.

Central to the practice of existential therapy is the paradox of human freedom––acknowledging that while we are all constrained by cosmic, genetic, cultural, and circumstantial forces ⁶¹, we retain the capacity for action and attitudinal change ²². At the center of freedom is choice, which dictates navigating human possibilities and limitations ⁶². Presence creates a “pause,” ––a space for clients to slow down, explore possibilities and limitations, and consciously choose their path (⁶¹; p. 164). Clients also need an opportunity to trace out possibilities and deliberate the ramifications of change and not changing ²⁶. May (1969) proposed that clients need to engage in “wishing” or playfully imagining possibilities to be able to move towards willing or acting. Cooper et al. (2019) asserted, “Existential therapy aims to illuminate the way in which each unique person––within certain inevitable limits and constraining factors comes to choose, create, and perpetuate his or her own way of being in the world” (p. 2).

Yalom (1980) proposed that a confrontation with the following ultimate concerns of existence is essential in existential therapy: death, freedom, isolation, and meaninglessness. Greening (1992) elaborated on these givens of existence through paradoxical dialectics: life and death, meaning and absurdity, freedom and determinism, and community and aloneness. He contended from an existential point of view that it is important to acknowledge, accept, and resourcefully react to these paradoxical dimensions. Georganda (2016) spoke to response-ability and declared, “although we are not free of conditions and given’s we are free to take a stance, to respond to life in the best possible way we can under the specific circumstances” (p. 9). Research has found that one to two thirds of people that meet with a therapist grapple with existential issues and that therapists outside of humanistic and existential practices often do not feel comfortable and trained to deal with existential concerns ⁷¹.

Meaning-seeking and meaning-making are at the core of existential therapy ^{65, 66, 11}. Human beings are primarily driven by purpose and meaning and experience psychological suffering if purpose and meaning are missing in life ¹⁰. This existential premise is highly backed by a broad body of evidence ⁶⁷. Existential theorists have disagreed whether life is inherently meaningful or meaningless and existential thinking here seems to diverge through a spiritual lens or atheistic lens, differentiating whether meaning is either discovered or invented ¹².

Frankl (1984) proclaimed a will to meaning through the following main pathways: experiencing others through love, purposeful work, or tasks, and through one’s attitude toward suffering. Research by Tedeschi (2018) identified posttraumatic growth often shows up in the following areas: personal strength, relating to others, new possibilities, appreciation of life, and spiritual and existential change. Wong (2012) built on Frankl’s logotherapy and advocated for meaning-making therapy through the PURE model, emphasizing purpose (prioritizing values, motivation, and direction), understanding (cognition-making sense of oneself and the world), responsibility (behavior), and evaluation (affective-assessing effectiveness). In this approach there is acceptance of life, belief in positive change, commitment to identifiable actions, discovering meaning, and evaluation of actions ¹¹. Not only are pursuing meaning and meaning-making essential, but also experiential learning is the crucial element in therapy ⁶⁶.

Existential-integrative therapy provides a foundational framework upon which various congruent theories and techniques can be organically assimilated through experiential encounters ^{26, 14}. The fluidity and adaptability of the existential therapy style lends itself to addressing different individual and cultural needs, as well as incorporating pointed technical aspects from other mental health models ⁶⁹. May (1983) advocated, “technique follows understanding” and therapists may use a technique from any schools of therapy if it is in the best interest of the client (p. 151). The existential therapy approach may be seen in a pluralistic way, allowing many perceptions and processes for change to emerge, and entailing that clients can be helped in numerous ways based on what the client wants ¹². With over 400 models of therapy and not one of them being more effective than any other, it does not make sense for therapists to remain strictly loyal to methods used in a specific model, existential or otherwise ^{12, 3}. It is also important to recognize that what this author refers to as existential therapy does not mean that therapists from other models do not employ many of these same methods.

Existential therapy is grounded in authenticity: helping clients develop personal meaning and live congruently with their values, beliefs, and experiences ^{10, 71}. Therapists focus on real-life experiences, viewing clients as being free, creative, responsible beings, capable of growth, even through negative emotions, and existential challenges ⁶¹. Clients are invited to explore their past and present experiences with an emphasis on the present as well as future possibilities ¹². Therapists explore feelings, beliefs, actions, and physiological states with clients because these aspects are essentially interrelated ²¹. Therapists are mainly authentic and direct with clients as opposed to being aloof and hierarchical; and therapist flexibility is stressed over rigidity ¹⁰. Lambert (1992) determined that virtually all therapeutic philosophies consider therapist authenticity as instrumental in co-creating the therapeutic relationship and a significant factor in the client making substantive progress in treatment (Table 1).

Tailoring interventions to individual clients, rather than rigidly adhering to a model, is essential ²⁴. Rigid standardization and set engagement with clients at its worst can produce objectification, pressure, and isolation. Also, such strict intervention may have a limiting, sterile, or negative effect on the client, the therapist, and the therapeutic relationship. As Yalom (2002) asserted, “standardization renders the therapy less real and less effective” (p. 33). Bugental (1999) used the term “pou sto” to determine where the therapist needs to stand with a client, demonstrating the need for situational presence and flexibility (p. 85). It is important to highlight that the therapist’s stance toward the client encompasses moment-to-moment experience with centering both the client’s inner and interpersonal short-and long-term needs, as well as the agreed-upon goals ²⁹.

Therapeutic presence dictates the stance and decisions the therapist makes in collaborating with the client. The therapist’s tasks are to attune, attend, and translate meaning alongside the client. This begins by honoring and highlighting the client’s view of the challenge(s) and theory of change towards agreed upon goals and methods ²⁹. The “who” of the client is a top priority and dictates focusing on the “what” of the therapy (goals), as well as the “who” of the therapist (role) and the “how” (means or method; ⁷, p. 133). According to the Merriam Webster College Dictionary (2019b), attune means “to bring into harmony” and “to make aware or responsive” (p. 80), while attend means “to look after, to be present at, to be present with, to apply oneself, to pay attention, to direct one’s attention” (2019a, p. 31). The Webster’s New World Dictionary (2016) defines translate as “to move from one place of condition to another” and “to put into different words” (p. 672).

Wampold (2008, 2012) theorized that the meaning-making aspect of the existential approach was powerful in terms of offering client’s alternative narratives and explanations to ponder and act on. People conceive of themselves and derive meaning through narrative and self-stories ⁷³. All therapies may be viewed through a narrative lens and entail the telling and re-telling of stories to find and develop meaning ⁷⁹. Narrative meaning is the “primary scheme by means of which human experience is rendered meaningful” (⁸⁰; p.11). At the most fundamental level, therapy is about supporting clients in illuminating and reassessing the life stories that clients tell themselves to create or retain meaning in their lives ¹⁹. The therapist supports the client in developing monologue (intrapersonal presence), engaging in dialogue (interpersonal presence), and facilitates a meaning-making process through serving as a kind and helpful editor ²⁹.

Cultivating and activating intrapersonal and interpersonal presence provide pathways for enhancing the main elements of the therapeutic relationship: client, therapist, connection, objective(s), and task(s) ²⁹. Krug (2009a) argued that intrapersonal and interpersonal presence are the “therapeutic juice” driving change (p. 3). Presence fosters responsibility and action, supports clients in connecting with their wound(s) or problem(s), and helps clients engage in meaning-making and transforming their wound(s) or problem(s) ⁷². Krug (2009b) pointed out that both inner and relational routes of presence may be utilized and although a therapist may be more intra-personally inclined, or more interpersonally leaning in style, the therapist needs to have the ability to cultivate and activate presence with different people at different times, based on modifying their approach toward the specific needs of the unique client they are working with. Presence is transtheoretical and can enhance therapist, client, and relational functioning across different therapeutic theories and approaches ³⁷. It is not a technique, but a way of being––anchoring existential therapy in dynamic responsiveness, authenticity, and co-created meaning.