An Existential–Integrative Treatment of Anxious and Depressed Adolescents

Introduction

I just got accepted into my top college this week. I also just realized I don’t really care.

A sense of meaninglessness, identity concerns, a fear of death, devastating feelings of loneliness, and/or an inner struggle to make peace with the overwhelming responsibilities of impending adulthood are all too common worries expressed by anxious and depressed adolescents in the context of individual outpatient psychotherapy (Hacker, 1994). This is not surprising. There is considerable empirical data to suggest that not only are adolescents thinking about existential concerns (Berman, Weems, & Petkus, 2009; Berman, Weems, & Stickle, 2006; Damon, 2008), but they also possess the cognitive capacities and interest in processing these concepts at a relatively sophisticated level (Kuhn, 2009). Chessick (1996), for example, has noted a readiness on the part of “certain rather cerebral adolescents” to contemplate Heidegger’s concept of “resoluteness” in therapy and benefit from existential treatment approaches while Yalom (1980) proposed an existential paradigm that explains considerable adolescent behavior as directly related to concerns regarding meaning, isolation, death, and choice. Yet, as has been noted (Fitzgerald, 2005), very little has been written on how existential concepts and therapeutic approaches might be used with this age group. Somewhat surprisingly it appears that more attention has been paid to incorporating existential theory in therapy with children (Kitano & LeVine, 1987; Quinn, 2010; Scalzo, 2010).

There are well-documented reasons for the relative lack of research focus regarding the use of existential concepts in therapy with adolescents. In an educational and professional landscape that in recent years has placed a premium on the development and utilization of empirically supported treatments for children and adolescents (Kelley, Bickman, & Norwood, 2010; Ollendick & Jarrett, 2009; Roberts & James, 2008), the earnest clinician working with a young person experiencing these concerns may hesitate to embrace existential treatment approaches because of a relative lack of strong empirical support and well-established treatment guidelines (Keshen, 2006; Schneider, 2008). Existential therapists most certainly do not view their role as the deliverers of a specific set of techniques (Deurzen-Smith, 1997; Fernando, 2007). The approach has been referred to more as “a philosophical discussion about life customized to a client’s issue” (Epps, 1998) with a chief aim being to “set clients free” (May, 1981), but even here there exists a notable lack of cohesiveness regarding how to define the therapeutic process from an existential perspective (Cooper, 2003). Similarly the role of existential anxiety in human development and experience remains less well understood (Weems, Costa, Dehon, & Berman, 2004). Finally, there may be an underlying assumption that adolescents are too young to seriously contemplate existential concerns (Fitzgerald, 2005). Most would agree existentialism does not fit easily into a therapist’s tool box.

There may, however, be a trend reversal taking place—driven first in part by an enhanced appreciation for psychology’s cultural and theoretical diversity—that is increasing the openness of both trainees and training institutions to consider existential thinking (Bassett-Short & Hammel, 2008). Furthermore, the ties that bind existential theorists and therapists are continuously evolving and expertly reported. For example, in a landmark work titled Existential–Integrative Psychotherapy: Guideposts to the Core of Practice, Schneider (2008) recently outlined not only existential–integrative therapy’s theoretical basis but also its implications for short- and long-term therapeutic applications. Thus, existential–integrative therapy is becoming increasingly accessible to those willing to learn. This increase in message clarity coincides with a growing appreciation for the potential to research the efficacy of existential therapeutic applications. Specifically, Wampold (2008) argues, “the principles of change in EI are as scientific as those of any other psychological treatment” and that research on contextual factors in therapy (e.g., empathy, alliance, personal factors, etc.) and their therapeutic effectiveness fits eminently with existential therapy. As common factors research evolves, a logical extension of these efforts can and should be the empirical analysis of key existential therapy applications. This combination of increased audience receptivity and material accessibility creates ideal circumstances to more closely explore the use of existential concepts with adolescents.

The chief aim of this article is to take an additional step toward bridging the gap between the sometimes slippery remoteness of existential therapeutic perspectives and the strong yet often underserved and unrecognized need for adolescents to benefit from this these concepts. To be clear, this article will most assuredly not argue for the substitution of empirically supported treatments and evidence-based practice approaches. Cognitive–behavioral therapy, interpersonal therapy, and antidepressant treatments for adolescent internalizing disorders have all clearly demonstrated efficacy (for a review, please refer to Graber & Sontag, 2009). Rather the case is made for clinicians to consider integrating existential concepts with these well-established, empirically supported treatments for internalizing disorders. Schneider’s (2008) explanation of existential–integrative therapy provides the framework for this discussion. In addition, much can be learned from the attempts at integrating existential therapy with cognitive and cognitive–behavioral approaches in the treatment of adults (Bunting & Hayes, 2008; Corrie & Milton, 2000; Ottens & Hanna, 1998; Schneider & Krug, 2010; Wolfe, 2008). Examples of core existential concepts that can be effectively conveyed to this age group in treatment are provided as a starting point for therapists seeking to more systematically incorporate this approach into their treatment arsenal. Key similarities and differences with existing cognitive–behavioral concepts and treatment techniques are noted in this discussion as well. Prior to offering specific recommendations, however, a brief overview of Otto Rank’s, Paul Tillich’s, and Rollo May’s conceptualization of existential anxiety and associated therapeutic implications is offered, followed by a discussion of the limited research on adolescent experience of existential anxiety and concerns.

Otto Rank’s Conceptualization of Existential Anxiety

Otto Rank, a former protégé of Freud, has been referred to as one of the brightest minds of 20th century psychology (Becker, 1973; Jones, 1960). Rollo May (1983) and Irvin Yalom (1980), two of the most widely cited existential theorists, believe that Rank’s views on personality formation, neurosis, and therapy are critical precursors to the development of modern existential thinking. Rank is also thought to have exerted a strong influence on Carl Rogers and the Humanistic Therapy Movement (Kramer, 1995b). For these reasons Rank is a compelling person to begin a discussion of existential anxiety. As will be the case with the forthcoming overviews of Tillich and May, a thorough review of Rank’s beliefs regarding anxiety and therapy is not possible here.

Rank believed that Freud’s conceptualization of neurosis as resulting primarily from the psychosexual crises and more specifically, the Oedipal complex, was incomplete (Rank, 1936/1978a, 1936/1978b). In The Trauma of Birth (1924/1994), Rank identified the child’s pre-Oedipal relationship with one’s mother as having a greater impact on development (Kramer, 1995a). As his thinking evolved he also criticized Freud for failing to recognize creative will, a spontaneous, life-affirming product of human consciousness that could only be understood from a phenomenological perspective (Rank, 1936/1978b). Within this framework the subjective experience of consciousness ¹ and, by extension, of will and the ability to make choices, was seen as dynamic and in a constant state of tension. Neurosis was not primarily caused by problematic sexual development but was “a failure in creativity: a refusal to affirm oneself as an individual” (Kramer, 1995b). Overwhelmed with the responsibilities of life, separation, and individuation, as well as the inevitability of death, individuals suffering from neurosis were engaged in a failed attempt to avoid both by refusing to live life to the fullest. As Kramer (1995b) eloquently summarizes, “Rank concluded that the neurotic ‘bribes’ life itself–for which we all have to ‘pay’ with death. Because of extreme guilt and anxiety, the neurotic hurls a Big No at living” (p. 63). Here one had two opposing polarities—a fear of life and a fear of death—pushing and pulling the individual in a perpetual pinball-like existence. Referred to by Rank as “ultimate” anxieties, these two fears were seen as having no final solution, but instead required constant analysis and titrating throughout life (Kramer, 1995b). The idea that one could eradicate all anxiety or guilt was simply not seen as possible or even advisable.

Rank firmly believed, however, in the power of artistic creativity and a therapeutic relationship to help ease the burdens attached to the fear of life and fear of death. In Art and Artist: Creative Urge and Personality Development (Rank, 1932/1989), he argued that individuals who direct their creative will into various forms of artistic expression stood the best chance of more successfully mediating life’s ultimate anxieties. Even artistic pursuits, however, were thought to generate guilt. At their core, this form of creativity was an attempt by the individual to express uniqueness and freedom which, in turn, represents a futile effort to deny (even if for a fleeting moment) biological limitations and the fundamental dependence one has on nature (Rank, 1932/1989).

As for the impact of a positive therapeutic relationship, Rank (1936/1978b) believed that the dilemma of living and suffering could not be most successfully contemplated in isolation. Rather, the experience of being heard and unconditionally accepted by another was thought to lead to increased self-acceptance and reductions of anxiety and guilt. Client acts of will in therapy were not to be interpreted as resistance. The therapist was seen as more of an “assistant I” or collaborator and the purpose of therapy was to help clients “make deeper contact with themselves and their ambivalences, anxieties and guilt feelings” and to “[allow] clients to own unacknowledged parts of their suffering, letting the pain sit in their laps, rather than displacing or projecting it onto others” (Kramer, 1995b, p. 72). The client–therapist relationship, as opposed to psychoanalytic interpretation, was the key mechanism for positive change. To merge briefly with another (i.e., the therapist) and then separate was seen as a healthy microcosmic experience of one’s life journey—the inherently unobtainable, simultaneous pursuit of isolation and union (Kramer, 1995b).

Paul Tillich’s Conceptualization of Existential Anxiety

Paul Tillich, a German-born theologian who taught at New York’s Union Theological Seminary and Harvard University, spoke at length about existential anxiety in a series of lectures that formed the basis of his highly influential work, The Courage to Be (1952). His conceptualization of existential anxiety, neurosis, and healthy personality formation is similar in many respects to Rank’s views. Drawing heavily from the works of Nietzsche (1878/1996, 1886/1990) and Kierkegaard (1843/1954a, 1849/1954b), Tillich separated existential anxiety into three domains: (a) Fate and Death, (b) Meaninglessness and Emptiness, and (c) Guilt and Condemnation. Like Rank, he believed that awareness of life’s finitude and the contemplation of nonbeing form the basis of anxiety. Pathological anxiety was seen as “the consequence of the failure of the self to take the anxiety upon oneself” through the use of avoidant defense mechanisms and self-affirmation of a “limited, fixed, and unrealistic basis” (Tillich, 1952, p. 77). A neurotic was seen as “more sensitive than the average man to the threat of nonbeing” (Tillich, 1952, p. 67), who unsuccessfully built a metaphorical “castle of certitude” against the threat based on an unrealistic appraisal of life and death. One can see the obvious parallels between Tillich’s discussion of “unrealistic” formulations of reality with classic cognitive–behavioral references to “dysfunctional,” “maladaptive,” and “irrational” thinking (Beck, 1979; Ellis & Harper, 1975). Helplessness, a lack of intentionality, and inadequate reactions to the world were thought to be symptoms of existential anxiety overload, occurring when individuals could not maintain an adequate buffer between their daily life experience and the awareness of impending death and nonbeing (Weems et al., 2004). At the most extreme limits of intensity and chronicity, existential anxiety could morph into psychosis (Becker, 1973).

Tillich took pains to differentiate fear from anxiety, arguing that the former “has a definite object . . . which can be faced, analyzed, attacked, endured,” whereas “anxiety has no object, or rather, in a paradoxical phrase, its object is the negation of every object” (Tillich, 1952, p. 36). Within this framework, Tillich believed that individuals strive to convert anxiety into fear because, at the very least, fear can be met with courage. In the end, however, he concluded that the “anxiety of a finite being about the threat of nonbeing cannot be eliminated” (Tillich, 1952, p. 39), because death is unavoidable. As a result, he too believed that some amount of existential anxiety or tension will be experienced by the individual throughout life.

Tillich (1952), like Rank, offered a healthier alternative to living with the ultimate threats than that which the neurotic pursues. He believed that an individual’s ability to summon courage in two key areas provided the best prescription for managing existential anxiety. First, individuals were encouraged to have the courage to despair. Despair, defined by Tillich as simply “without hope,” was felt when awareness of nonbeing was contemplated head on. Tillich described the painful experience of despair in relation to the threat of nonbeing in the following manner:

No way out into the future appears. Nonbeing is felt as absolutely victorious. But there is a limit to its victory; nonbeing is felt as victorious, and feeling presupposes being. Enough being is left to feel the irresistible power of nonbeing, and this is the despair within the despair. (Tillich, 1952, pp. 55-56)

In essence, the experience of feeling despair affirmed one’s being. To feel, one had to be. Here we see another fundamental proposition of existential thinking: The experience of negative emotions such as anxiety, guilt, and despair was seen as a necessary and beautiful part of the human existence. Rather than deny the existence of the threats of nonbeing and meaninglessness, one first had to acknowledge their existence, feel the doubts and anxieties associated with these threats, and ultimately despair. ² This position stands in stark contrast to classic cognitive–behavioral theory which argues that anxiety results from maladaptive or irrational cognitions derived from inaccurate cognitive schemas (Beck, 1979; Ellis, 1973).

Once true despair has been felt and endured, Tillich (1952) believed that it was incumbent on the individual to still summon the courage to be. Tillich defined this courage as “the self-affirmation of being in spite of the fact of nonbeing . . . the act of the individual self in taking the anxiety of nonbeing upon itself by affirming itself as a part of an embracing whole or in its individual selfhood” (1952, p. 155). Approaching life with vitality and “life power” was achieved through balancing self-affirmation with the awareness of nonbeing. Having the courage to live with intentionality, create beyond oneself without losing oneself, and accept responsibility for the choices one makes—all achieved in the face of nonbeing—was seen as the ultimate level of being. Here a close parallel is drawn between Rank’s belief in the therapeutic effects of artistic creativity and Tillich’s courage to participate in life vis-à-vis artistic and technical pursuits.

Rollo May’s Conceptualization of Existential Anxiety

Rollo May, a world-renowned existential theorist and therapist, was heavily influenced by Rank and Tillich’s views on anxiety. Similar to these predecessors, he defined anxiety as “the apprehension cued off by a threat to some value that the individual holds essential to his existence as a personality” (May, 1977, p. 205). The threat could be physical (e.g., threat of death), psychological (e.g., the loss of freedom, meaninglessness), or the potential loss of a cherished value (e.g., patriotism, love of another). The purpose of anxiety, therefore, was to alert and protect the individual from critical danger. May also took considerable pains to differentiate anxiety and fear, noting that fear is based on objects but anxiety cannot be objectified because it threatens an individual’s most basic “security pattern” and “attacks the foundation (core, essence) of the personality.” Furthermore, he accepted that anxiety was inherent to human existence and believed that when “the goal in all life is a total absence of anxiety, the judgment becomes delusive and even dangerous” (p. 375). The danger, he argued, lay in overlooking the potential for normative anxiety to be constructively accepted by the individual and incorporated into a zest for life and the given day. To this end he believed that anxiety was a key motivating emotion in successful therapy (Schneider, Galvin, & Serlin, 2009).

May (1977) outlined the differences between “normal” and “neurotic” anxiety. His definitions of both reflect not only classic existential theory but also echo modern cognitive–behavioral thinking. He defined normal anxiety as comprising the following four parts: (a) it is proportionate to the objective threat, (b) it does not involve repression, (c) it does not require neurotic defense mechanisms for management, and (d) it can be confronted constructively. In contrast, neurotic anxiety was seen as disproportionate to the threat at hand, involves repression, and is managed by various neurotic defense mechanisms. He even incorporated learning theory into the discussion, stating, “I here suggest that the capacity for anxiety is not learned, but the quantities and forms of anxiety in a given individual are learned” (May, 1977, p. 218).

Like Rank and Tillich, May (1977) held out great hope for the capacity of psychotherapy to assist an individual in managing anxiety. He identified two specific methods that he believed were helpful in this regard. The first was the process whereby therapeutic discourse involves an expansion of awareness. Here the client experiences an “opening” or “unlocking” of their self-awareness, an awakening of sorts. Specifically, he argued, “the person sees what value is threatened, and becomes aware of the conflicts between his goals and how these conflicts developed” (May 1977, p. 374). What followed was re-education, the second therapeutic method for managing anxiety. Therapy in this case consisted of assisting the client in restructuring their life goals, clarifying their choice of values, and developing a realistic and responsible plan for obtaining these goals. ³ Like Rank, May placed a high value on the power of the therapeutic relationship to promote positive change as opposed to interpretation. No fan of “gimmicks” in therapy, May emphasized the process of “making the unconscious conscious” and helping individuals “become more sensitive to life, to beauty, and . . . to love” (Schneider et al., 2009, p. 425). This was not conceived as an easy process for the therapist or client, and included risk and contact with feelings historically characterized as negative that May referred to as the daimonic. He defined this term as “any natural function that has the power to take over the whole person” and believed that it could either be creative, destructive, or both (May, 1969/2007, p. 123). The risk clients took in pursuing therapy was to trust and remain open to developing a deeper understanding of themselves, potential warts and all. Therapists supported this risk by allowing clients the freedom to experience their choices and assume responsibility for their actions (Pitchford, 2009).

In summation, several commonalities emerge across Rank, Tillich, and May’s conceptualization of personality formation and psychosocial development that have bearing on the present discussion. These include the following: (a) anxiety is seen as an unavoidable, objectless source of tension that is based on an individual’s awareness of impending nonbeing, a sense of meaninglessness, and feelings of isolation and guilt; (b) anxiety can be both normative and pathological—the individual can use anxiety as a source of motivation to assume the responsibility of living life to the fullest or make a futile attempt to avoid nonbeing by pursuing a limited existence; (c) fear is seen as objectless anxiety converted into object form and allows for individuals to summon courage to face the challenges of life in a positive, self-affirming manner; (d) creative pursuits, an appreciation for all that is beautiful, and love are positive means through which individuals affirm their inherent uniqueness in the face of biological limitations and finite being; and (e) a positive therapeutic relationship can help an individual mediate anxiety by increasing awareness, clarifying goals, and momentarily bridging the fundamental isolation felt by all within a collegial atmosphere of unconditional positive regard. With these core themes in mind, the following section argues that (a) adolescents possess the capacity to contemplate existential concerns and (b) existential concerns are a common feature of their conscious experience.

Evidence for Adolescent Experience of Existential Concerns

Adolescence has long been identified as a distinct period of development from evolutionary (Hall, 1904), psychosocial (Erikson, 1968), psychosexual (Freud, 1905/2000), and cognitive (Piaget, 1951) perspectives. In recent years, with the advancement of medical science, this stage has also been identified as a critical period of brain development (Paus, 2009) and hormonal changes (Susman & Dorn, 2009). Hacker (1994), in an insightful analysis that expands on Yalom’s (1980) thinking, has even conceptualized a multitude of adolescent behaviors as defense mechanisms against existential concerns of isolation, death, meaninglessness, and choice. All these paradigms to varying degrees cite dramatic increases in self-awareness, information processing, and abstract thinking as defining characteristics of adolescence, while select efforts have made a direct linkage between these cognitive advances and the development of existential awareness and concern (e.g., Fitzgerald, 2005; Hacker, 1994). On what specific basis are these connections being made?

To begin, there is a growing body of evidence indicating that adolescents experience notable advances in their “executive functioning skills” which are defined by Kuhn (2009) as “monitoring, organizing, planning, and strategizing–indeed any mental activity that entails managing one’s own mental processes–as is also associated with increased impulse control” (p. 153). Previously identified by Inhelder and Piaget (1958) as the formal operations or “thinking about thinking” stage of development, it has become increasingly apparent that a narrow window of months or years in early adolescence when this capacity develops does not exist (Keating, 2004). Rather there is great intraindividual and interindividual variability in the age of onset and sophistication of these considerably wide-ranging formal operations and executive functioning skills (Kuhn, 2009). Yet when these advances in cognition occur they lay a critical foundation on which existential questions and concerns can germinate.

Two additional areas of cognitive development during adolescence merit brief consideration. Harter and colleagues (Harter, 2006; Harter, Bresnick, Bouchey, & Whitesell, 1997) argue that increased introspective abilities allow for a more nuanced understanding of the world at large and inconsistencies in particular. This enhanced capacity to recognize contradictions is thought to increase both intrapsychic distress and concerns regarding inauthenticity. In addition, specific advances in intentional thinking capacities may lay the groundwork for the development of the “existential domain” of thinking, whose primary function is to better understand the meaning of events that happen to oneself (Bering, 2003). Not surprisingly developmental models of anxiety are increasingly adopting the stance that adolescents possess the capacity for insight into one’s mortality and other existential concerns (Warren & Sroufe, 2004; Westenberg, Siebelink, & Treffers, 2001).

In addition to qualitatively different experiences of isolation, loneliness, and death concerns (Hacker, 1994), advances in adolescent thinking give rise to dramatic changes in self-concept (Damon & Hart, 1982) and identity formation (Erikson, 1980). Identity is defined as “the sameness and continuity of the person’s psychological functioning, interpersonal behavior, and commitments to roles, values, and beliefs” (Cote, 2009, p. 267) and is predicated on a level of self-awareness that is thought to fully develop in the second decade of life. There are strong suggestions that Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) identity problems are a relatively common occurrence in adolescence (Berman et al., 2009; Hernandez, Montgomery, & Kurtines, 2006). The search for identity takes the form of present-oriented questions posed by the adolescent such as “who am I?” as well as “who am I to become?” (Erikson, 1968; Hacker, 1994). Advances in perspective taking allow the adolescent to try on different roles and internalize different values as they search for a self-identity that fits (Peterson, 1987; Sartre, 1975). Waterman (1984) has cogently noted that identity formation is an act of creation on the part of the individual, requiring the individual to assume responsibility for the choices they make within almost a limitless sea of possibilities. Waterman’s analysis speaks directly to Tillich’s courage to be in the face of nonbeing and Rank’s fear of life dilemmas, and can also be conceptualized as a logical extension of a positive creative process that individuals pursue in an effort to affirm their being. A search for one’s identity presupposes a sense of being.

Marcia’s (1980; Marcia, Waterman, Matteson, Archer, & Orlofsky, 1993) impressive body of research based on Erikson’s formulation of identity development has yielded four identity statuses that adolescents and young adults may achieve. These include identity diffusion, identity foreclosure, identity moratorium, and identity achievement, and are based on the cross-tabulation of the two dimensions of choice and commitment. Identity diffusion (low choice, low commitment) and identity foreclosure (low choice, high commitment) are thought to represent relatively less mature stages of identity development, whereas identity moratorium (high crisis—making choices, low commitment) is thought to be more complex but also anxiety-laden (Cote, 2009; Kidwell, Dunham, Bacho, Pastorino, & Portes, 1995) and filled with uncertainty (Meeus, 1996; Meeus Iedema, Helsen, & Vollebergh, 1999). Identity achievement (postcrisis producing choices, high commitment) is seen as the most complex and mature. Not surprisingly, this condition correlates with more mature interpersonal relationships (Dyk & Adams, 1990; Kroger, 2003), balanced thinking (Boyes & Chandler, 1992), and higher levels of personal agency (Cote, 1996). Although here, too, there exists considerable variability in the age of onset and extent of incorporation for each of Marcia’s conditions (Cote, 2009), a maturation process toward increasingly unified self-identity is thought to take place as the adolescent’s cognitive capacities increase (Meeus, van de Schoot, Keijsers, Schwartz, & Branje, 2010). This expanding body of identity formation research provides additional support for the contention that many adolescents possess the cognitive capacity to process existential concerns at a relatively sophisticated level.

Though the empirical evidence is limited there are also strong suggestions that existential concerns and anxiety are a common experience in adolescence. Here the focus shifts from evidence suggesting a capacity for existential thought to indications of actual existential concern. In perhaps the most in-depth and methodologically rigorous analysis to date, Berman et al. (2006) investigated the presence of existential concerns, identity development, and psychological symptoms in a sample of 139 high school–aged youth. The participants completed the Existential Anxiety Questionnaire (Weems et al., 2004) and Ego Identity Process Questionnaire (Balistreri, Busch-Rossnagel, & Geisinger, 1995) as part of the study, both of which have demonstrated adequate reliability and validity. The Existential Anxiety Questionnaire is a true–false rating scale designed to measure the critical domains of anxiety outlined by Tillich (1952; i.e., Fate/Death, Meaninglessness/Emptiness, Guilt/Condemnation). The Ego Identity Process Questionnaire contains two subscales designed to reflect identity exploration and identity commitment. Results indicated a high prevalence of existential anxiety in the sample. Specifically, nearly half the youth surveyed expressed death apprehension, while concerns regarding fate (64%), meaninglessness (30%), emptiness (70%), condemnation (53%), and guilt (59%) were also endorsed with high frequency. Ninety-six percent of the sample endorsed at least one significant area of existential anxiety, leading the study authors to conclude that “it may be reasonable to consider [existential anxiety] a normative phenomenon” (Berman et al., 2006, p. 308).

There are other strong indications that adolescents are thinking about existential concerns. Damon, Menon, and Cotton-Bronk (2003), for example, closely reviewed the development of purpose during adolescence which has important implications for Frankl’s (1959) discussion of the existential question of meaning and the positive psychology movement as a whole (Seligman & Csikszentmihalyi, 2000). Citing clinical observations and studies of youth purpose conducted by Erikson (1968), Inhelder and Piaget (1958), Loevinger (1976) and others, Damon et al. (2003) conclude that a search for meaning and purpose is a central task of adolescence with important positive prognostic implications. They do not argue that all adolescents experience the development of a sense of purpose to the same degree. Those youth who do however “show high degrees of religiosity, consolidated identities, and deeper senses of meaning than those who do not experience purpose” (Damon et al., 2003, p. 126). In addition to the experience of identity concerns and a search for purpose, adolescents commonly report a fear of death in normative studies of adolescent fears (Ollendick, Matson, & Helsel, 1985). This finding has been replicated across a wide range of American (Ollendick et al., 1985, Ollendick, Langley, Jones, & Kephart, 2001), European (Ollendick, Yule, & Ollier, 1991), Asian (Dong, Yang, & Ollendick, 1994; Ollendick, Yang, Dong, Xia, & Lin, 1995), and African (Ingman, Ollendick, & Akande, 1999) samples, suggesting a universality of this fear in adolescence. Though clearly more research is needed to assess the presence of specific existential concerns during adolescence, the limited research to date strongly supports the assumption that adolescents can and do contemplate existential concerns.

Specific Recommendations for Incorporating Existential Concepts in Therapy

When working with anxious and depressed adolescents the clinician operating from an existential–integrative perspective should always conduct a thorough assessment to determine symptom etiology as well as a client’s desire and capacity for change. Although conventional assessment methodologies are recognized as often beneficial, “supreme consideration is accorded to the therapists’ lived engagement with the client and to the latent possibilities therein” (Schneider, 2008, pp. 50-51). A similar parallel emerges in the treatment phase. Specifically, a readiness to incorporate empirically validated treatments is recommended given that there may be presenting concerns, internalizing symptoms, and specific client characteristics that will most benefit from these interventions and only minimally benefit from the existential concepts introduced below. These efforts should be delivered within an offering of experiential liberation, a term Schneider (2008) uses to describe the process whereby clients, through increased self-awareness, reoccupy parts of themselves that they have denied. Existential–integrative therapists can promote the rediscovery of meaning by remaining an authentic presence, by invoking the actual and attending to the clients immediately felt experience, and by vivifying and confronting resistance (Schneider, 2008).

There are several scenarios where a clinician may choose to integrate existential concepts. These include (but may not be limited to) the following: (a) an adolescent identifies clear existential concerns regarding identity, meaninglessness, isolation/loneliness, and/or death, as part of or the entirety of the presenting concern, (b) existential concerns are raised in the course of treatment that were not identified initially, (c) the adolescent is facing a life transition, loss, or significant change (e.g., death of a friend or relative, move, graduation, significant illness or accident) that may sensitize the individual to existential themes and questions, and/or (d) the client fails to respond in a satisfactory manner to the empirically validated approaches alone. ⁴ Drawing on the recommendations of Rank, Tillich, May, and Schneider, the clinician treating an adolescent struggling with existential themes may consider integrating the following.

Concluding Remarks

This article opened with a quote from a depressed adolescent recently seen in treatment. The client was struggling to find meaning in the achievement she had so long identified as the ultimate validation of her existence. She was experiencing the cataclysmic dismantling of her fictional final goal. She was profoundly scared. Many of her fears appeared normative and without easy solutions. To do anything but sit with her in her pain, validate her sense of despair and hopelessness, allow her the space and safety to contemplate a will to create new meaning, and to try and foster in her the courage and patience to continue her profoundly disorientating struggle with her sudden sense of uncertainty, seemed not only contraindicated but on a deeper level unconscionable. By summoning within herself the courage to come into closer contact with these difficult feelings, thoughts, and questions—both “irrational” and “rational”—the client increased her self-awareness and forged for herself new meanings, resulting in a present and future oriented focus that she owned and embraced. On setting off on a new life course her depression had lifted, her close relations had improved, and in her own words, “I know I’m going to be okay either way.” Ultimately, her external world in terms of college choice and career goals changed little from before. Her internal experience of why she was pursuing what she was pursuing underwent the most profound changes.

It appears possible, likely even probable, that psychotherapists can find a way to simultaneously increase an adolescent’s awareness of distorted cognitions while acknowledging that some core anxiety and despair may continue to remain when all the rational analysis has been completed. Life is complicated in this regard. Approaching adolescents like Virgil approached Dante, however, can be precisely what is indicated (Schneider, 2008). The courage to incorporate existential concepts with empirically supported treatments for adolescent internalizing disorders is all that is needed.