Running head: EXISTENTIAL COUNSELLING IN PSYCHIATRIC NURSING
Existential Counselling in Psychiatric Nursing Practice
Dayle Lauren
Stenberg College
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EXISTENTIAL COUNSELLING IN PSYCHIATRIC NURSING
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Existential Counselling in Psychiatric Nursing Practice
Understanding the human psyche; why people do what they do, and where these
behaviours come from when working with mental health patients is a prerequisite for any
psychiatric nurse. In consideration of the various counselling therapies available to the
psychiatric nurse, the use of existential counselling and psychotherapy holds much value.
Existentialism offers a deeper, philosophical understanding of human existence, what it means to
be human, and how our paths and who we ‘are’ becomes shaped by the choices we make. When
considering psychiatric nursing practice, implementation of an existential approach to
counselling would bear witness to a refreshing and valuable attitude of wonder to all we
encounter in the field of mental health, allowing the nurse to “discover something of what life is
like for the client, to gain an approximation of the client’s experience” (Palmer, 2011, p. 78).
This paper then explores the history and the irrefutable value of incorporating the existential
assumptions into psychiatric nursing practice, particularly as value to a real-life client
experience.
Existentialism as a modality of therapy is rooted in existential philosophy, which covers a
broad base of varying schools of thought (Palmer, 2011). According to Palmer (2011), some of
the earliest Greek philosophers who were existentialists include Socrates and Stoics, and a more
modern list, the likes of Sartre, Kierkegaard, Nietzsche, Heidegger, Binswanger, Boss, Laing,
van Deurzen, Cohn, and of course, Rollo May and Yalom. Palmer (2011) posits that Emmy van
Deurzen was likely the most influential psychotherapist to make contribution to the development
of existentialism in our country, and at the same time, was responsible for the development of the
Society for Existential Analysis (Palmer, 2011).
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The underlying theory and concepts of existential thinking exist as “several basic
assumptions about what is true for all of us as human beings, assumptions about what it means to
exist” (Palmer, 2011, p. 71). The handful of assumptions is known as the ‘givens’ of existence
(Palmer, 2011). These assumptions are human nature; choice; freedom; anxiety and guilt;
being-in-the-world; with-world; interpreted world; death; acquiring and perpetuating
psychological disturbances; and the move to psychological health (Palmer, 2011). By
understanding each assumption fully, the existential therapist or existentially trained psychiatric
nurse is placed in a position of deeper understanding of the mentally ill patient under their care.
The foundation of human nature, according to Sartre (1905-1980), is that there really is no such
thing as human nature, as he argued that at the core of our very being was nothingness, and that
we become something through the choices that we make as we travel through our lives; in a
perpetually dynamic state, never static, but rather, always changing and in process (Palmer,
2011). Sartre also explained the second assumption, choice, as being something that we have in
response to our limitations, and that this is, in fact, our freedom (Palmer, 2011). It is through this
freedom that we allow ourselves to experience change and growth; a concept that is difficult for
most of us to grasp, as we like to believe that we are the same person we were yesterday, last
year, or even twenty years ago (Palmer, 2011). By adopting this way of thinking as Sartre did, a
prudent psychiatric nurse would be able to help the patient see new ways of perceiving situations
that may have become obstacles in their mental health. Freedom, as Palmer cites Sartre to argue,
is a burden of responsibility that we all bear; acknowledging that there are no absolutes, no
certainties outside of death and that we ultimately have the control to lead our lives in any way
we desire, make our own rules and discover our own meaning (2011). With this realization
comes enormous stress for some, or for others, extreme liberation. For the mentally ill patient
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who already suffers from a possibly altered reality, assisting their recovery through existential
therapy, on a path of self-realization could be highly beneficial. This method of therapy would
open up the opportunity to adopt a more passionate and exhilarating experience of living. The
existentialist also believes that because we have freedom to make choice, this leads to the
development of anxiety, and when we ultimately fall short in some regard or another, we then are
further perplexed by ensuing guilt (Palmer, 2011). Much of the guilt and anxiety faced daily by
those with mental illness comes from their inability to function at a level that they perceive or
that society perceives they should function at. This then creates a vicious cycle of which some
illnesses are managed by other means such as self-medication, avoidance, denial and isolation.
Another set of assumptions of existentialism are being in-the-world; with-world; and the
interpreted world. As Palmer states, existential philosophers view our existence in our world as
‘being in-the-world’ in which we have an innate connection to the world around us, and to which
we are part (2011). Secondary to this is the ability to relate to others, and the subsequent
development of individual relationship-personalities unique to each relationship we encounter,
through which we are able to gain a sense of self; this is known as ‘with-world’ (Palmer, 2011).
Palmer suggests that even when one chooses to isolate from others, they do so in relation to
others: we can never be free from relationships of some sort or another (2011). When a
psychiatric nurse is able to understand this and illustrate this understanding through therapy to a
patient, it aids in developing a deeper understanding of the world which we all inhabit, whether
healthy or in illness. The interpreted world is how we perceive the world in which we live
through the experiences we encounter every day. These too are forever changing and dynamic in
nature (Palmer, 2011).
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It is through the relationships between all that we encounter that our world is shaped,
either in reality or in delusion. On this basis, and in consideration of the discussed existential
assumptions, the value of the existential thinking and theory is then evident in consideration of
mental health and wellness.
I had the honor of having an acute MVA patient enter the ward while I was on clinical
rotation; this patient was lucky to have survived the single vehicle rollover that had him and the
driver removed with the Jaws of Life while three other passengers walked away virtually
unscathed. This 40 year old male had a history of heroine and alcohol abuse, had lost his wife to
drugs and was left to raise a young girl on his own. He had managed to recover from his heroine
addiction for a number of years. He was a strong-built but smaller framed man, clean cut with
grey hair. He was relatively healthy with no other medical issues or allergies. He had a C1
fracture and was in a Philadelphia collar, and as well, had a fractured left scapula, multiple facial
and head lacerations that were stapled shut, and a compound dislocation of his left ring finger
that required surgery. His face had multiple fractures, primarily of the maxilla, and his upper
palate was fractured between his teeth and up into his sinuses. The head nurse in charge of the
team that I was on at that time was reticent to take this patient as they were not equipped to
handle the care of a C-spine patient. This concern resulted in numerous calls down to the
Emergency team that had initially seen him, as well as the doctor who treated him. It was finally
decided he would stay as they assured us he was stable.
After cleaning the patient up from copious amounts of dried blood and dirt, I was able to
begin communicating with the patient. Although he was on large doses of pain killer, he was
amazingly lucid and able to communicate clearly. He had full memory of the night’s events, and
remembers the crash and being stuck in the truck for what seemed like hours while they cut him
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out. He was very worried about the young 21 year old driver whom he had just met that evening
at the pub they were drinking at. They had only been in the truck for approximately 3 minutes
before the driver lost control under high speed and rolled numerous times through a residential
property.
The days that I had working with him that followed where basically managing his pain. I
was able to assess during the therapeutic relationship building time that I was granted with this
patient that much of his healing was to come from inner turmoil while he fought with low selfesteem and much self-doubt; although he seemed reluctant to admit to certain faults and
misguided behaviours, he simultaneously expressed a need to acknowledge it. His near-death
experience had moved him somehow. I instantly recognized that the Existential approach to
therapy would be beneficial for him. As Palmer stated, “…existential therapists will encourage
their clients to confront their difficulties and face up to the anxiety this entails” (Palmer, 2011, p.
76). We spoke frequently, he was eager to chat when he saw me, and quickly began asking
questions about why he was ‘feeling’ certain ways, experiencing feelings he had obviously come
to question, and I assured him that he had just been through a traumatic incident and had almost
lost his life; one was sure to come away with some questions, and there must be a reason why he
was still here.. he still had unfinished business to do. He seemed curious and I then took an
existential approach in his care by addressing his most evident nursing issue; Low Self Esteem
and Depression, as evidenced by his expressions of worthlessness and inability to recognize his
own achievements (Townsend, 2011). The treatment plan developed with these nursing
diagnoses in mind included being able to spend time with the patient in order to convey unbiased
acceptance and thus, contribute to new feelings of self-worth, to help this patient recognize his
own strengths and accomplishments by minimizing attention to past failures, and importantly, to
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ensure that the patient was not becoming increasingly dependent on nursing care, but rather that
he was able to accept responsibility for his own behaviours. (Townsend, 2011).
With these three interventions in place, there needed to be some measurable way of
determining a successful outcome. Palmer states that the Existential approach simply takes
nothing for granted and questions everything, and to “drop our prejudices and biases and to show
an attitude of wonder to all that we encounter” (Palmer, 2011, p. 76). Silence is also seen as the
most important intervention, according to Palmer (2011) in using existential therapy. “It is only
when we are silent ourselves that we can hear what others are saying”, states Palmer (2011, p.
77). By employing this method of therapeutic communication with this patient, I was quickly
able to gain acceptance and most importantly, trust from him. During moments of deep
introspection on the part of the patient, I was able to enter the patient’s world and understand,
through the lens of his eye, what his life experiences were up to that point, and therefore glean a
better understanding of who he was as a patient. He would consistently state, however, that live
was lousy for him, always a struggle, and likely wouldn’t ever be any better than it was, and he
could see no hope for improvement, but rather had just accepted the fact that he was and always
would be, how he was. Palmer further posits to this regard: “ By simply staying with whatever
the client presents, with the phenomena, and not looking for causes or explanations, the therapist
and client will gradually gain a better understanding of the client’s experience” (2011, p. 76). I
recall vividly when in conversation with the patient, he made a statement and I responded with a
simple “I know” or a small nod of acknowledgement. He paused and looked at me for some
time before stating: “You do know, don’t you? I really feel like you understand me.” It was
stated with the utmost respect and dignity and I was happy to have made a difference for this
person in some way. I remember Palmer stating “…what we are at any given moment does not
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reside in either individual but in the ‘in-between’ between us and the other, this is where the
relationship occurs” (Palmer, 2011, p. 77).
I continued to simply gain an approximation of the patient’s experience and slowly but
surely, the patient began to question his own assumptions and beliefs. I remember wishing I had
more time to spend with this patient as I only had two days, but was sure to pop in on him when
time permitted around my new patients. I was surprised when he walked up to me in the hallway
a week after our time together; I barely recognized him as he was significantly more healed. He
had tears in his eyes as he told me that the woman and her child whose yard they had ended up in
after the crash, had come to visit him. The young boy and his mother were awoken by the crash
and rushed to the window just in time to see the truck come to a rest against a large tree in their
backyard, upside down. The mother had told the patient that the boy had asked “Mommy, why
are all those angels flying around above the truck?” The boy would not stop talking about the
angels and repeatedly asked his mother to come and visit the man that the angels saved. She
finally was able to track down who he was and where he was and together they came in to see
him.
I was dumbstruck and deeply moved as I knew that this knowledge was to move this
man into a new direction. He gripped my arm and looked away from me in tears and said “I
don’t know what it means, but I believe you now when you said there are reasons I’m still here.
I’m just gonna let life take me where it wants me to go. Thank you for all your care. I can’t thank
you enough” (F.L., personal conversation, 2013, NRGH).
Although I feel that there were many events surrounding the plight of this patient that
resulted in the perceived successes of his care, I would like to think that adopting an Existential
approach to my therapeutic time with him was impactful and resounded on his new-found
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thinking as evidenced by his change in thought patterns and connection to something ‘spiritual’.
I think I was successful in providing this patient with the space and time to do some self-work in
exploring his own experiences and where this latest event would leave him (Palmer, 2011). One
truth for all is impossible, as stated by Kociunas (2009), as every truth bears the mark of
subjectivity. As Kociunas quotes Heidegger, “the core of truthfulness is in opening of Being and
connected to authentic way of existence” (Kociunas, 2009, p. 244).
I can see the evidence of the power of Existential therapy in nursing and look forward to
a career in which I can build on these experiences and spend more time with and marvelling at
the results of this powerful form of therapy.
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References
Kociunas, R. (2009). Truth and psychotherapy. Existential Analysis, 20, 240-247. Retrieved from
http://search.ebscohost.com/login.aspx?direct=true&db=pbh&AN=44007246&site=ehost
-live
Palmer, S. (2011). Existential. In Introduction to counselling and psychotherapy: the essential
guide (pp. 70-82). London, UK: SAGE Publications Ltd.
Townsend, M. C. (2011). Alterations in psychosocial adaptation. In Nursing diagnoses in
psychiatric nursing: care plans and psychotropic medications (8thpp. 125-144).
Philadelphia: F.A. Davis Company.
Grade
Graded on
Graded by
33.00 / 35.00
Monday, 20 May 2013, 9:32 AM
Vicki Hammond
Part Two of your paper is graded with the following considerations:
-Provide a clinical synopsis or case study from your own experience (or an
imaginary one) in which you match one client's assessed needs your selected
counseling approach
Feedback
comments
-Provide a background history/description of client’s current problem, one NANDA
nursing diagnosis and treatment plan (in paragraph form), utilizing the counselling
concepts and theory you have chosen.
-Provide clear clinical justification for your choice, evidence based research
support, and articulate what outcome you would see, in using this approach with
your client (and perhaps their family).
-Provide some discussion of what outcomes you would look for in evaluating your
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success with this approach.
-Part Two should include a conclusion paragraph that summarizes the entire paper
(parts one and two).
As noted for part one, your marks is also based on adherence to APA (style and
mechanics), evidence of critical thinking, appropriate use and reference to the
literature, and ability to organize your thoughts and ideas into a logical format
which demonstrates flow.
Thank you Dayle for this submission. I like how you have identified a client who
suffered a MVA for you case study, and you clearly had an investment in his care.
You have provided an overview of his complex challenges and a NANDA
diagnosis. You could have included more specific examples how often would one
engage in the interventions. The conclusion paragraph clearly tied in part A and part
B. Overall you have done a nice job with this paper, including style, mechanics and
flow. The personal examples really made this an interesting paper for me, take care!
Good luck next semester, Vicki