Abstract
Exposure to traumatic events or adverse experiences and their consequences have been studied mainly from a posttraumatic stress disorder perspective. Existential psychotherapy focuses on universal human concerns and the anxiety that occurs when a person confronts the conflicts inherent in life and toward death, which include the experience of difficult situations. A systematic review was performed including 56 papers that studied the relations between adverse experiences and existential concerns. The articles were assessed and described in relation to existential domains, type of adverse experience, posttraumatic responses, and existential psychological interventions. Existential concerns appeared in different degrees and categories in studied samples. Outcomes suggest that from an existential psychotherapy perspective, reactions to traumatic events can be both negative and positive for a person. In addition, the passing of time turned out to be an important factor, especially in finding meaning from traumatic experiences, the reduction of negative symptoms, and the achieving of posttraumatic growth. Existential-related interventions described in this review showed positive outcomes, suggesting that it is an effective trauma treatment approach.
Introduction
Adverse experiences are universal in human kind, even though they affect people differently. Most persons experience at least one violent or life-threatening event in their life and everyone is likely to experience the pain and disorientation of losing a loved one (Mancini & Bonnano, 2006). In fact, trauma is increasingly being recognized not as a specialized area, but as a fundamental part of human experiences (Corbett & Milton, 2011).
The Diagnostic and Statistical Manual of Mental Disorders–Fifth edition defines the posttraumatic stress disorder (PTSD) as the exposure to traumatic or stressful incidents—which includes threatened or actual death, sexual violence serious injury, which lead to a set of distressing symptoms (American Psychiatric Association, 2013). The PTSD is a starting point for understanding trauma, but it may pathologize natural responses to traumatic incidents (Du Toit, 2017) and designate them to a mental disorder that tends to be reduced to organic etiologies (Sherin & Nemeroff, 2011). As well, the definition is limiting because other experiences can be traumatic (Substance Abuse and Mental Health Services Administration, 2016) and there is no situation that is equally traumatic for all human beings. The PTSD is a frequent response to adverse experiences, but there are other associated disorders that may appear like depression and anxiety (American Psychiatric Association, 2013). Moreover, a traumatic experience may climb to posttraumatic growth (PTG) or other psychological benefits (Corbett & Milton, 2011). Oversimplification of trauma may shut down the possibility of a diversity of experiences, stifling the individuals’ ability to emotionally process their experiences in purposive and meaningful ways (Joseph, 2009).
Existential psychotherapy supports a broad understanding of human distress that takes into account the subjective experience and looks at the individuals’ perspective in context (Washa, 2013). “Trauma is existential through its impact on the manner in which the individual experiences the world, their self-understanding, and their sense of place in the world” (Hoffman, Hoffman, & Vallejos, 2013). Existentialism is often misrepresented as a philosophy of negativity because it explores the dark dimensions of existence, but it also aims to face them up and be able to respond as effectively as possible to these challenges (N. Thompson & Walsh, 2010). A “boundary situation” is an urgent experience that propels one into a confrontation with one’s existential “situation in the world”—“the givens of existence, death, isolation, freedom and meaningless” (Yalom, 1980). Thus, to be struck by a crisis is disruptive but also an opportunity to find one’s position in relation to the basic existential dilemmas (Du Toit, 2017). No matter how seriously someone is affected, the situation will always contain both pain and possibility, reaching the positive via the negative: because of the disruption, the individual can look at what life is “really about” (Jacobsen, 2006). This means trauma, pain, and suffering are not only pathological but also an opening for existence.
Many theoretical articles had studied trauma from an existential perspective. In addition, there are some recent systematic reviews that focus on related topics: longitudinal trauma studies (Santiago et al., 2013), measures of existential anxiety (Van Bruggen, Vos, Westerhof, Bohlmeijer, & Glas, 2014), early PTSD interventions efficacy (Roberts, Kitchiner, Kenardy, & Bisson, 2009), interventions for PTSD in refugees and asylum seekers (C. T. Thompson, Vidgen, & Roberts, 2018), and religion and spirituality in PTG (Shaw, Stephen, & Linley, 2005). However, none of them focused in traumatic experiences and existential concerns. The main objective of this systematic review is to collect relevant and recent literature about existential psychotherapy and its relation with traumatic experiences and mental health. This is to explore existential domains, its related theoretical models, and if or how existential concerns mediate trauma responses and traumatic experiences affect existential domains.
Method
This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (Moher, Liberati, Tetzlaff, Altman, & The PRISMA Group, 2009) as well as Perestelo-Pérez (2013) standards on reporting systematic reviews. The details about articles search, screening, and selection process are summarized in Figure 1.
Articles selection flowchart.
Search Strategy, Data Sources, and Screening
The keywords for the database search were as follows: “trauma*” or “advers*” and “existential*” and “psychology” so the search could comprehend more related concepts (trauma, traumatic/adverse events/experiences, existentialism, and existential attitudes/concerns/psychotherapy). The search was conducted through three databases that include studies related to the subjects of our study, MEDLINE Complete, PsycARTICLES, and PsycINFO. This search yielded 223 articles, from which 31 were included in the review. In addition, through a citation search, by reviewing the references of the ones already included, 25 more articles were added.
Inclusion/Exclusion Criteria and Studies Overview
The following inclusion criteria were applied: Research journal articles (a) that studied adverse or traumatic experiences, (b) in relation with existential issues, (c) published online with full-text available, (d) since January 2000 to April 2018. Many articles included the word “existential” but its content was not based existential psychotherapy or concerns. The exclusion criteria comprised philosophical, religion, spirituality, psychoanalytical or theoretical articles, reviews, commentaries, and books chapters. Those studies were discarded because they are not relevant for the objectives. A total of 56 studies were included in this review and are described in Table 1 (51 research articles) and Table 2 (5 intervention efficacy papers).
Articles About Existential Concerns in Adverse Experiences.
Note. DA = death anxiety; EWB = existential well-being; FoD = fear of death; MI = moral injury; MiL = meaning in life; MM = meaning making; PTG = posttraumatic growth; PTS = posttraumatic stress; PTSD = posttraumatic stress disorder; RWB = religious well-being; SM = sense making; SPW = spiritual well-being; PSS = perceived social support; STS = secondary traumatic stress.
Articles Based on Existential Interventions for Trauma.
Note. FACIT = Functional Assessment of Chronic Illness Therapy; IES = Impact of Event Scale; JDS = Job Diagnostic Survey; LES = Life Experiences Survey; LOT = Life Orientation Test; MDT = Measurement of Depression Test; MRPT = Marital Relationship Perception Test; NSS = Nursing Stress Scale; PiL = Purpose in Life Scale; RSE = Rosenberg Self-Esteem.
Results
Existential Approach and Domains
Existential domains refer to human thoughts on how to understand the world, the meaning of life, and how one should live it (Wiklund, 2008). In a sample of adults from the general population, 75% had at least one affirmatively recognized existential anxiety concern (Weems, Costa, Dehon, & Berman, 2004). Nevertheless, individuals exposed to traumatic events may be even more prone to these concerns (Fuchs, 2013). The three models that appear in this review are as follows: terror management theory, existential anxiety theory, and moral injury theory. According to terror management theory, humans’ intelligence leads to a costly dilemma: the ability to conceive of the seemingly unimaginable also renders humans aware of their inevitable nonexistence (Cozzolino, 2006). When mortality is salient, individuals become more likely to defend their worldviews, which often takes the form attacks against opposing or threatening worldviews. In front of an overwhelming fear of death, people will seek ways to intellectualize and distance from that reality (Weems, Russell, Neill, Berman, & Scott, 2016). Tillich’s existential anxiety theory comprises three domains of apprehension: fate and death (the threat to one’s being in death and the relative threat to the self in our personal fate), emptiness and meaninglessness (the fear that there is no “ultimate concern” and hence no ultimate importance in life that gives meaning to one’s existence), and guilt and condemnation (the perceived threats to one’s moral and ethical identity (Berman, Weems, & Stickle, 2006). Last, moral injury is a type of trauma from witnessing and or acting in war zones, characterized by intense guilt, shame, spiritual crisis, and existential/spiritual concerns. It can develop when one violates his moral beliefs, is betrayed or witnesses trusted individual committing atrocities (Jinkerson, 2016).
The most frequent existential domain was meaning (finding or searching for meaning, meaning and sense making, loss of meaning, and meaning reconstruction). Meaning in life is about having a belief in something and experiencing oneself as whole and connected to life (Wiklund, 2008). Parental bereavement is a crisis of meaning and the search for it is central in the process of readjustment after the death of the child (Wheeler, 2001). This process affected reported grief, trauma, and complicated grief symptoms. Search for meaning was pursued by the majority of bereaved parents (89%; Tolstikova et al., 2005) and all perceived changes in reference to identity and meaning (Forinder & Norberg, 2010) or reported other positive gains from the trauma (Wheeler, 2001). Parents who found meaning in their child’s death showed lower mental distress, higher marital satisfaction, and better physical health than those who could not find it (Murphy et al., 2003). Meaning came from connections with people, activities, beliefs and values, personal growth, and connections with the child (Wheeler, 2001), from the belief that the death was God’s will, the idea of an afterlife in which the child was safe or no longer suffering and biological/medical explanations (Lichtenthal et al., 2013). Nonetheless, as a person creates meaning of himself as worthless, the perceived meaning in life might be that it is meaningless (Wiklund, 2008). Individuals who met complicated grief criteria reported that they searched for meaning and did not find it. Some event features may mediate the differences. First, death characteristics may have an impact in meaning related to grief, since a larger percentage of violent loss survivors could not make sense of their loss, as compared to nonviolent survivors (Lichtenthal et al., 2009). In addition, the degree of meaning following the death of a child was mediated to the violence of the death, the age of the children at death and the length of bereavement (Keesee et al., 2008). In the aftermath of the homicide of a child, there were three prototypes of meaning reconstruction: (a) the existential paradox, where participants viewed death and life as interlocked and their life as “in-between”; (b) a bifurcated worldview which lacks of consistency and continuity; and (c) oppression, mortification, and humiliation, which constructed a new and total identity for them, in their own eyes and in the eyes of society (Mahat-Shamir & Leichtentritt, 2016). Meaning appears to be highly related to illnesses. The onset of a serious or painful illness could be an occasion for prioritizing values and goals, seeking answers to existential questions and reflecting on the “story” of one’s life and it may increase general well-being by enhancing the likelihood that patients will actively participate in health promoting behaviors (Russell et al., 2006). Men infected with HIV made frequent and positive changes in both meaningful activities and social roles in the context of five-time periods (before and the diagnosis, resolving the crisis, starting therapies and the future; Heiland et al., 2002). Their most meaningful activities were as follows: career, friends/family, and health focus. Patients commonly described moving through an emotionally and contradictory experience across the trajectory of living with cancer, like a struggle with a paradox that urged to make meaning of their experience. Its resolution happened by meaning making in terms of spirituality, life perspectives, and taking control (Leal et al., 2015). Meaning seems to serve to reestablish the coherence and continuity of the self-reducing the dissonance created by the conflict between present and postrealities (Heiland et al., 2002). During chemotherapy, two dimensions of meanings were crucial: situational and existential (individual’s perception of his place within the world). Existential meaning was present in varying degrees throughout the treatment. In persons with multiple sclerosis, those with a high personal meaning were not significantly different in terms of quality of life or life satisfaction from those with “middle” personal meaning and low personal meaning. This last group was not interested in finding meaning—thought that it was impossible to find and had significantly low scores on well-being and quality of life (Russell et al., 2006).
Meaning making expressed in action was present also in homicide survivors (Armour, 2003). It refers to a way of coping comprised by intentional acts with symbolic meaning, implying the purpose of finding meaning in a changed life through problem solving or striving to attain visionary goals. Meaning making reconstructs a self-identity as homicide survivors both “relearn the self” and “relearn the world” (Attig, 2004). Certain negative conditions (death imagery or shattered worldviews) may impede meanings, but even the negative meanings given to events by the homicide survivors in this study elicited meaning making behaviors like naming truth, problem solving, and revamping life goals (Heiland et al., 2002). Its attributes were as follows: (a) the metameaning of behavior is to reestablish a moral order by deliberately reacting to what matters as a consequence of the murder and (b) the meaning making initiative is generated by intrusive stimuli, which compels reactions that are self-protective or encompassing a survivor mission. Listed manifestations in action were: declarations of truth, fighting for what’s right and living in ways that give purpose to the loved one’s death. Employment and higher levels of education appear to be associated with meaning-making (Russell et al., 2006). Furthermore, women used religion/spirituality to cope and construct meaning in times of adversity and found it helped them: interrogate and accept reality, recognize purpose and destiny, defining subjectively meaningful moral principles, and achieve growth (Mattis, 2002).
Death-related existential concerns were studied mainly as death anxiety and fear of death. Death anxiety is the experience of fear, panic, dread, and other distress associated with the awareness of one’s mortality. It is an inherently human condition in which we are aware at varying levels of our own mortality (Hoelterhoff & Chung, 2017). To help people who suffer from traumatic responses, it is relevant to explore the possibility of death anxiety, even though it not may be apparent to many clinicians (Chung et al., 2000). In a sample of university students, death anxiety predicted PTSD but it was not associated to psychiatric comorbidity (Hoelterhoff & Chung, 2017). Those exposed to an aircraft crash showed some amount of death anxiety, but less than the standardized high death anxiety and no differently than control patients (Chung et al., 2000). Impact of the event, psychological distress, and death anxiety were correlated. Undergraduated students with a history of trauma exposure had higher levels of overall distress, but there were no differences in death anxiety or meaning in life (Floyd et al., 2005). Death anxiety was present in secondary trauma in professionals that work with trauma survivors. Secondary trauma scores were positively related to death anxiety and fear of and resignation toward human evil was associated with all measures of distress (Barr, 2011). In Neel et al.’s (2013) study, 32% of advanced cancer patients showed at least moderated death anxiety. Their least distressing concern was related to dying alone and suddenly and the most distressing one was about the impact of one’s death on others. A swift death may be not feared because it avoids prolonged suffering. In persons with HIV, death anxiety was associated with overall PTSD symptom severity scores in reexperiencing, avoidance, and arousal even when controlling for depression and satisfaction with social support (Safren et al., 2003). Individuals with spinal cord injuries also showed death anxiety: Death awareness and death denial predicted a significant amount of PTSD reactions (Martz, 2004). On the other hand, death denial predicted significantly hyperarousal. Death anxiety correlated with a greater number of physical symptoms, lower self-esteem, increasing age, and having depending children. Regarding bereavement, the type of loss (child, spouse, or other) did not have impact in reported degree of trauma, grief, or complicated grief, but the difference between the loss of a child and other relative was close to significance to complicated grief reaction (Tolstikova et al., 2005). Also, cancer patients with young children had more death anxiety than those without (Neel et al., 2013). Paternity fear may be rooted in realistic concerns for the well-being of the children who are in a vulnerable stage of development. In parents with hospitalized children fear of death correlated with PTG, suggesting that an unconscious fear of death can be related to psychopathology, but an awareness of one’s finitude may warrant a thoughtful inquiry toward what is important in life (Barr, 2011). Three major themes allowed individuals to develop resilience against death anxiety: self-efficacy, religious coping, and existential attitude (finding meaning in traumatic events and feeling responsibility to others) (Hoelterhoff & Chung, 2017).
“Existential” and “spiritual” concepts are debated in recent literature: some use existential as a wider concept and some prefer to avoid its religious associations (Wiklund, 2008). Existential and religious well-being were conceptually and statistically distinct from one other and affected persons differently (Edmondson et al., 2008). Existential well-being mediated religion well-being’s effect on health-related quality of life (Edmondson et al., 2008), religion appeared as meaning frameworks in coping with adversity (Park, 2005) and assisted individuals to incorporate life changes and find meaning in their suffering (De Castella & Simmonds, 2013). Childhood adversity had a stronger relationship with existential than with religious well-being (Santoro et al., 2016). Papers that aimed to study spiritual well-being agreed that in the Spiritual Well-Being Scale, existential well-being is related with better coping with adversity (Arnette et al., 2007; Stevens-Watkins, Sharma, Knighton, Oser, & Leukefeld, 2014). Spiritually allowed a crucial set of existential questions, answers, and life lessons (Mattis, 2002) and was a significant moderator between traumatic life events and cocaine use (Staton-Tindall et al., 2013). “Existential spirituality” predicted satisfaction with life, general health, and social integration (Peirano & Franz, 2012). Associations between religion and adjustment vary across time since loss and were mediated by meaning-making coping (Park, 2005). Veterans with a greater loss of meaning were more likely to seek mental health and clergy help, indicating an attempt for a restoration of meaning to their loss which sustains a continued pursuit of mental health treatment (Fontana & Rosenheck, 2005). Regarding other existential concerns, a few articles included guilt, blame, and responsibility. Existential guilt and blame were common in midwives and obstetricians involved in traumatic births (Schroder et al., 2016). Living with addictions implies challenges which arise from the existential themes in two directions: using drugs helps the person deal with life, but in the long term, it does not relieve feelings of chaos, loneliness, guilt, and shame and being cut off from life (Wiklund, 2008). Personality predisposition to maladaptive shame and guilt may increase conscious personal death anxiety and thereby increase acute traumatic stress symptoms severity (Barr, 2010).
Type of Adverse Event
In this review, the most frequent adverse events were medical conditions, grief, war-related events, child abuse, professionals’ exposure to difficult situations, natural disasters, and terrorist attacks. Physical conditions were the most repeated. A systematic review about PTG in life-threatening physical illness, found 42 studies that reported some form of existential revaluation following the diagnosis and discovering new meaning or purpose in life (Hefferon, Grealy, & Mutrie, 2009). Most studies focused on reflection of mortality, spirituality, meaning, purpose, and found that “greater the trauma, greater the growth.” In the present review, the most frequent physical condition was cancer. Existential meaning was an essential part of the chemotherapy experience (Richer & Ezer, 2002) such as death anxiety (Neel et al., 2013). Also, death anxiety was positively related to depression, negatively to emotional and physical well-being, and it was commonly and high in cancer—45% scored in the upper reaches (Lo et al., 2011). However, the most prominent feature was to be afraid of the death of the loved ones (Lo et al., 2011; Neel et al., 2013). Individuals closer to death exhibited increased existential distress and physical symptom burden, terminal illness acknowledgment, and were more likely to report an increased wish to die (Lichtenthal et al., 2009). Persons infected with HIV showed frequent and positive changes in meaningful activities and in the resolution of the disease crisis (Heiland et al., 2002; Safren et al., 2003).
Professionals exposed to difficult situations also showed consequences related to existential concerns. There were three forms of reactions in therapists working trauma patients: traumatic (anxiety and shock), interactional (helplessness or provocation), and existential (feeling extreme responsibility for the therapeutic process; Smith et al., 2007). Also, counselors and psychotherapists showed burn out and trauma and existential well-being was the main factor that accounted the variance in burnout scores (Hardiman & Simmons, 2013). In fact, professionals with a higher level of existential well-being were able to cope with emotional exhaustion when working with severely traumatized clients. In helpers working with war and torture survivors, PTG was related to secondary trauma and fear of and resignation toward human evil, which was associated with all the measures of distress (Kjellenberg et al., 2014). Obstetricians and midwives involved in traumatic childbirths showed blame and guilt, but inner struggles with guilt and existential considerations were dominant in front of blame (Schroder et al., 2016). However, 50% agreed that such experience had made them think more about meaning in life and 65% felt that they became better professionals from it.
In individuals exposed to hurricanes, existential concerns were prevalent and each facet of existential anxiety was differentially associated with psychological symptoms (Scott & Weems, 2013). Also, disaster exposure in adolescents moderated the association between facets of existential anxiety and health symptoms (Weems et al., 2016). In relation to adult survivors of childhood abuse, all three papers highlighted gender as an important factor. Baljon’s (2011) study focused on males, proposes that there is a “wounded masculinity” conformed by gender-specific consequences of abuse. Meaning, abuse, gender, and coping have a complex interrelation: Power and isolation are main concepts in sexually traumatized men, which are intrinsically linked with gender messages. In addition, PTG correlated with emotional expression and women reported more PTG than men. The association between childhood maltreatment and adult PTSD symptoms in African American women was mediated by existential well-being—not by religion and physical intimate partner violence—(Zhang et al., 2015). Participants with severe sexual abuse had lower existential well-being scores than those in every other category of abuse (Feinauer et al., 2003). Nevertheless, they were able to make meaning of their lives beyond the traumatic experience. Those with a higher sense of purpose experienced significantly less disturbance in terms of symptomatology than those who did not have one.
Regarding war related events, papers mainly focused on the concept of Moral Injury. It is an existential concept that has been found to affect PTSD and depression (Yan, 2016) and to have impact in mental and physical health (Currier et al., 2015). Morally injurious events were indirectly linked with mental health outcomes via the extent in which veterans were able to make meaning of their stressors (Currier et al., 2015). In addition, soldiers stress perception and PTSD symptoms were associated particularly with existential an inner peace needs (Bussing & Recchia, 2016). From a clinical perspective, moral injury is characterized by intense shame and spiritual/existential concerns (Currier et al., 2015). The combat ambit provides situations that would be unethical as a civilian, which violates its personal moral values and causes them a cognitive dissonance (Jinkerson, 2016) and highlights the importance of attending to loss of meaning in this population (Currier et al., 2015). If it is not resolved, guilt, shame, alienation, and demoralization may appear (Jinkerson, 2016). Exacerbation of shame and guilt may contribute to veteran’s posttraumatic maladjustment and impede treatment in significant ways (Currier et al., 2015). In contrast, loneliness in veterans was primarily characterized as experiential isolation, rather than social, emotional, or existential (Stein & Tuval-Mashiach, 2015).
From nine studies, eight agreed on the fact that the development and process of grief was related to sense or meaning making (Armour, 2003; Barr & Cacciotore, 2008; Currier et al., 2006; Keesee et al., 2008; Lichtenthal et al., 2013; Mahat-Shamir & Leichtentritt, 2016; Murphy et al., 2003; Tolstikova et al., 2005; Wheeler, 2001). Sense making emerged as an explanatory mechanism for the association between violent loss and complicated grief (Currier et al., 2006). In a child’s violent death, predictors of parents finding meaning were religious coping and support attendance (Murphy et al., 2003). Healing time may be an important variable: None of the parents reported meaning in early bereavement but by the time of the fifth-year postdeath, over half of them found meaning. Failure to find meaning in a loss is a crucial pathway to complicated grief (Currier et al., 2006). Individuals who met complicated grief criteria reported that they searched for meaning and did not find it. Also, the failure to find meaning in the death of a loved one impaired self-reference (Tolstikova et al., 2005). Death anxiety correlated with both trauma, grief and complicated grief (Barr & Cacciotore, 2008; Tolstikova et al., 2005). In bereaved mothers, fear of death correlated with maternal grief, fear of the unknown, fear of premature death, and fear of conscious death (Barr & Cacciotore, 2008). Parents thoughts and feelings had an existential nature and were related to the threat of losing their child, the uncertainty regarding the present state, and the future perspectives and feelings of loss (Forinder & Norberg, 2010). For most parents, the child’s death precipitated a severe crisis of meaning, but also initiated a search for one that involved cognitive mastery and renewed purpose (Wheeler, 2001). Social support availability may signify a part of a personals existential outlook (Forinder & Norberg, 2010). Women who experienced stillbirth during their first pregnancy but gave birth to a living child after a further pregnancy, stated a changed view of the world, questioning why that happened to them and the enduring relationship with the deceased child (Ustundag-Budak et al., 2015).
Trauma Responses and Existential Interventions
A total of 11 articles explored specifically PTSD symptoms. Over a half of individuals with HIV met the criteria for PTSD (Safren et al., 2003). The results suggest again that death anxiety predicted various aspects of PTSD reactions (Martz, 2004) and symptoms (Hoelterhoff & Chung, 2017; Safren et al., 2003; Weems et al., 2016). Also, the PTSD group was seven times more likely to have attempted suicide than the no PTDS group (Hoelterhoff & Chung, 2017). Existential well-being mediated the association between childhood maltreatment and adult PTSD symptoms (Zhang et al., 2015). The most common problems for clinicians include vicarious and secondary traumatization and burnout (Hardiman & Simmons, 2013). The confrontation with traumatic material could result in secondary traumatization and the accumulation of confrontations with interpersonal violence could lead to distortions of a therapist’s cognitive schemas (Smith et al., 2007). Results also indicated positive posttraumatic outcomes. Apparently, PTG occurs in a wide range of people that face a variety of traumatic circumstances (Tedeschi & Calhoun, 2004). Trauma prompted a process of questioning and meaning making that facilitated growth, such as finding meaning, perceiving benefits from suffering and traumatic experiences influence in their perception of purpose in life (De Castella & Simmonds, 2013). Terrorism victims showed evident existential concerns, quoting: “ . . . I wonder if what I am doing is really important and really matters” (Thomas, 2003, p. 864). Previous traumatic events served to temper their responses to 9/11 attack, confirming that confrontation with death is potentially a growth enhancing experience. Existential emotions and coping strategies explained the variance in PTG (Barr, 2011).
It might be beneficial to enhance a sense of purpose in trauma-affected persons with a humanistic–existential approach: prioritizing an enhancement in existential well-being, encouraging patients to strive for meaning in their lives and strengthen their coping and reduce negative outcomes risk (Zhang et al., 2015). Hopelessness—linked to existential well-being—can be addressed through therapeutic work design to find individuals to find meaning in their lives (Arnette et al., 2007). In this review, four interventions for trauma came were described. The meaning-making intervention, uniquely addresses the existential impact of cancer through coping strategies and has a positive impact on psychological adjustment (Lee et al., 2006). It is characterized by a distressing, but necessary confrontation with loss which can lead to improved psychological well-being, if followed by a plan to fulfill purpose in life and can be facilitated and lead to positive psychological outcomes following cancer diagnosis. The meaning-centered intervention applies didactic and process-oriented strategies, including guided reflections, experiential exercises, and education based on themes of Viktor Frankl’s logotherapy (Fillion et al., 2009): the will to meaning, the meaning of life, and the freedom of will (Frankl, 1978). Palliative care nurses benefited from it by changing their perception about their job and realizing that it is a source of personal growth in their lives. “Holding, telling, mastering, and honoring” therapy was useful for both heart attack recovery (Lantz & Gregoire, 2003) and marital treatment in veteran couples (Lantz & Gregoire, 2000). The “expressive writing treatment” is not presented explicitly as existential psychotherapy but it addresses existential issues and reported benefits in this area. Women that were sexually abused as children, went through five sessions and all showed a reduction of the prominence of the abuse, suggesting this treatment may aid to process their abuse story (Pulverman et al., 2017). In general, existential psychotherapy showed positive outcomes from the clinician’s perspective, from clients’ self-reports, and from clinical measures.
Conclusions
The present study offers a broader perspective on existential concerns and its relation with traumatic experiences. Features about existential concerns, types of adverse experiences, traumatic responses, and interventions were described. In general terms, existential concerns are related to diverse adverse experiences and are evocated by difficult situations in different intensities. Even with methods inconsistencies, the majority of the studies agreed in the fact that there is a high prevalence of existential concerns in different samples, and that these concerns affect general well-being and psychological health. Likewise, an adverse experience can impact existential concerns positively and in a negatively. Existential anxiety might be necessary for achieving existential well-being, which facilitates a better coping with adversities. Parents’ bereavement and cancer were frequently associated with meaning in life and death anxiety. Death anxiety was prevalent in medical conditions, and it was related to complicated grief and secondary traumatization. The experience of illness was associated to meaning making and PTG. Living with illnesses and physical pain, initiates thinking about death, reconsidering life aspects, and experiencing thankfulness. Time appeared as a relevant growth factor, both in meaning and PTG, and in reducing negative symptoms. Meaning changes appear to be gradual. Substantial meaning shifts and meaningful activities occurred during the crisis period as compared with before the diagnosis and showed more positive changes years after the diagnosis. Similarly, length of bereavement was related to finding meaning, since more parents were able to find it years later comparing to a more recent death. Meaning-making process is common in parents experiencing the loss of a child and its complications are related to the level of violence in the children’s death. Most violent deaths are sudden, which may impede processing the death compared with natural anticipated causes (Lichtenthal et al., 2013). Cancer was related to the process of meaning and also with PTG. Death anxiety had a particular relation with cancer: the majority of the sample showed it but toward the death of the loved ones. Professionals that work with trauma victims are exposed to existential distress and decreased existential well-being. Likewise, professionals involved in traumatic events showed guilt and existential concerns, questioned about meaning in life, and felt they became better professionals. Extreme conditions in war-related events result in a particular trauma associated to the violation of ones and others moral beliefs, a cognitive dissonance very difficult to solve. Correspondingly, adverse experiences facilitate PTG in war survivor’s workers and PTG was related to secondary trauma. Existential anxiety was associated to different psychological symptoms and natural disasters exposure moderated the association between existential anxiety and health symptoms. Survivors of childhood abuse showed different types of consequences related to gender. In women, childhood maltreatment and PTSD were mediated by existential well-being. PTSD symptoms are present in many of the studied samples and are associated with death anxiety and confrontations about evil and violence. Nonetheless, PTG is another common trauma response: an ongoing distress may be a necessary component for it to happen. Outcomes of existential-related interventions suggest that this approach may be for treating this type of patients. Generally, existential distress opens the possibility of growth and meaningful. These results suggest that more research is needed in differing physical illness and other types of grief or loss. The way existential concerns predict posttraumatic reactions has not been studied, a further investigation may be helpful in terms of prevention. To enhance a sense of purpose in trauma-affected individuals a humanistic–existential approach is desirable (Zhang et al., 2015). Few articles studied different existential concerns at once or compared cultural features. These features may help develop a more wide-ranging approach for trauma treatment. Furthermore, it highlights the utility of exploring the relation between age (or pass of time since trauma). A relevant finding is the presence of different existential concerns in similar samples that seem to go in different lines, as a few studies explain as an “existential paradox.” For example, in grief, the presence of fear of death and meaning making. This review shows the importance of studying this both lines of impact in existential concerns and how they interact or correlate. Are they lineal or parallel? Do they influence each other or are they independent? Also, for studying these aspects more deeply in relation to clinical psychology, it would be interesting for future researchers to observe the relation between existential concerns and other mental disorders, since traumatic or adverse experiences do no constitute the only reason for emotional and mental health problems.
Some limitations might influence current findings. First, because of the inclusion criteria, some relevant papers might have been left out. Second, concepts that were analyzed were related in a semantic way but are not necessarily equal or comparable. There was a lack of agreement on existential terms and its assessment and measurements differed highly even among the same domain. In addition, inconsistencies among papers methodology hampered the comparison of data. Nonetheless, in general terms, the present work suggests that existential psychotherapy approach is useful for understanding the impact of adverse experiences and for trauma intervention, not only focusing on the negative consequences but also on the possibility of positive gains following adversity.
Footnotes
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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Arantxa Y. Arredondo is supported by a PhD scholarship awarded by CONACyT (Consejo Nacional de Ciencia y Tecnología, Mexico).
