The end in sight: engaging with an existential understanding of time when working in time-limited practice.
This paper reflects upon working as an existential practitioner
within a time-limited setting, and explores using this limitation to the
benefit of the therapeutic endeavour. I offer a brief overview of some
key existential thinking on time and temporality, and a review of key
definitions of time-limited practice. A case illustration is included in
which I seek to demonstrate the inherent potential in an existentially
informed exploration of a definitive ending as a lever for facilitating
an authentic engagement to being. I suggest that existential therapy is
uniquely placed and suited to utilise the frame of the increasingly
prevalent time-limited contract to the advantage of the client.
Temporality, existential practice, time-limited, brief therapy, ending Introduction
Philosophy of mind (Research)
|Publication:||Name: Existential Analysis Publisher: Society for Existential Analysis Audience: Academic Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2012 Society for Existential Analysis ISSN: 1752-5616|
|Issue:||Date: Jan, 2012 Source Volume: 23 Source Issue: 1|
|Topic:||Event Code: 310 Science & research|
|Geographic:||Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom|
Much has been written about what time-limited counselling is, what
it is not, and what we can practicably hope to achieve in such a limited
number of sessions (De Shazer, 1985; Hoyt, 1995; Strasser &.
Strasser, 1997; Bor et al, 2004; O'Connell, 2005). Proposed key
benefits common to each of these definitions are the sense of urgency
and agency that can be imbued by working briefly. Certainly supporters
assert the therapeutic viability of the work and argue that it need not
be considered an inferior imitation of longer-term contracts, a point
declared as far back as 1925 by Ferenczi and Rank.
In the seminal book on existential time-limited therapy (Strasser & Strasser, 1997), the authors also emphasise the importance of time, temporality and ending to the time-limited therapeutic endeavour. However, they propose a modular approach to the counselling in which additional blocks of sessions can be offered determined by need. While recognising the significant value and, in certain circumstances, ethical necessity of this flexibility, for me this nonetheless somewhat dilutes the therapeutic opportunity afforded by utilising the time limitation and the certainty of ending.
Since perhaps the vast majority of counselling services available today follow a time-limited framework (principally on account of economic necessity and often without the option of modular working), highlighting the inherent potential of working with the client's experience of time and ending seems useful, particularly from an existential perspective. In this paper, by way of a case illustration, I seek to demonstrate how a client's relationship with time became the central focus of our work, aided and facilitated by the rigidity of a time-limited contract.
Understanding time, temporality and ending
Since the primary purpose of this paper is to explore how we can utilise an existential understanding of time within a therapeutic setting that is time-constrained, it is useful to first offer a brief overview of the underpinning philosophical understanding of the concept. The conventional scientific idea of time is that it is an entity of itself, measurable, linear and wholly objective. Temporality, however, 'is the name of the way in which Time exists in human existence' (Warnock, 1970: p62). That is, it is about how we engage with and experience time in living and are affected by it. It is by definition a unique and subjective experience for each of us and one that is in large part determined by our mood. Does a seminar feel interminably long, for example, or does it seem to fly past? One's experience will be influenced by factors such as our level of interest in the subject being presented. Does the speaker enthral, stimulate and capture our curiosity? Or does their monotonous tone bore us into restless submission and longing for the break? Underlying this will be our emotional state while sitting in the audience: depressed, distracted, agitated, content, focused, excited, and so forth (as both cause and effect relationships to temporality).
We are inescapably 'thrown' into a finite life for which we exercise no control over our birth or (typically) the timing of our death. Our awareness of the inherent finitude of our possibilities, Heidegger (1927) terms our 'Being-towards-death'. Humans have the unique ability to transcend the present and project towards the future where our possibilities, and our death, reside. Usually we conceal this awareness of death from ourselves by becoming immersed in the distraction of everyday life, which Heidegger terms the 'evasive concealment' that 'dominates everydayness so stubbornly that, in Being with one another, the "neighbours" often still keep talking the "dying person" into the belief that he will escape death and soon return to the tranquillized everydayness of the world of his concern' (ibid: p253). That is, when the possibility of the anxiety of facing death emerges for one (and the potential that this affords), the collective tendency is to seek to dispel this uncomfortable truth the Other is confronting for fear of the bearing it would have on me. But when the awareness does emerge we experience ontological anxiety, the conduit for authentic living. This real engagement with our existence and potential requires a facing of the fact that I am at any time between birth and death, never complete, always becoming, and only complete when I cease to be.
When we know the value of time, when we acknowledge that we are finite, the more concerned and purposeful our living becomes: 'When Dasein concerns itself with time, then the less time it has to lose, the more "precious" does that time become, and the handier the clock must be.' (ibid: p418). The choice then is how to deal with this most fundamental anxiety, to confront it, to embrace it and so move towards authenticity, or to seek to avoid it. There is much we can take from this to shape how we work as existential practitioners, and specifically when in time-limited practice. By facilitating an explicit engagement with how our clients experience time and, most crucially, the potential (possibilities) and certainty (death) that lie ahead, we can enable the quest for authentic living. Before offering a case illustration of how this might be achieved in existential practice, it is useful to firstly offer an overview of some key definitions of working in a time-limited contract.
Definitions of the time-limited approach
Borne essentially from practical and economic necessities, today the prevalence of time-limited counselling can be seen in most major service providers. For example, many if not all employee assistance programmes (EAPs) follow the brief model (of typically up to around six sessions). One such brief model is solution focused brief therapy (SFBT), developed originally by Steve De Shazer in the 1980s. With a usual duration of up to six sessions, the work is future-focused and aimed at harnessing the client's own abilities by adopting techniques including generic 'skeleton key' interventions. (Incidentally, Langdridge (2006) argued how brief existential practice is not necessarily incompatible with the somewhat a--theoretical solution-focused therapy, and could be used as a means of maximising the efficacy of the brief therapeutic encounter). And of course, there is the overwhelming dominance of the 'evidence-based' interventions, notably cognitive-behavioural therapy (CBT), as the preferred therapeutic treatment in the National Health Service and which also work to a structured and pre-defined limited contract (usually up to around 12 sessions). The reach of time-limited work is therefore wide, with 'long-term' or open-ended contracts becoming increasingly the preserve of private practice.
Bor et al (2004) in their authoritative account of brief therapy seek to distinguish it from open-ended in a number of ways. Most notably, they refer to the importance of the ending and suggest that this should be made explicit early in the work and regularly thereafter. The practitioner should 'positively' challenge from the outset and they consider this to be less likely where time is not so restricted. An agreed contract of between six and 10 sessions is suggested, with a clearly defined and realistic goal set at the outset. Ongoing assessment should be a regular feature for the duration. They deem working briefly to be relevant to all mainstream theoretical frameworks, and to be an approach that is 'ethically driven yet commercially aware' (Bor et al. 2004: p1). Crucially, and as for most proponents of brief work, the authors consider 'small' changes to often be sufficient to instigate a process of change, which the client will continue to develop after the sessions have ended.
The aim is for there to be a 'positive, strong, collaborative working alliance' developed as quickly as possible (ibid: p8). Solutions to problems should be collaborative and the client's resourcefulness should be emphasized and encouraged. They suggest that working briefly is '... more about the creation of a profound connection with the client than simply an awareness of time' (ibid: p1). So the importance and centrality of the therapeutic alliance is emphasised, something often considered to be less achievable in time-limited work.
Hoyt (1995) alludes to perceived shortcomings of brief therapy, by pointing to aspects of counselling that characterise the benefits of longer term working. Namely, that early life trauma takes time to be comprehensively addressed, the therapeutic relationship is one that builds gradually, and that changes tend to require a period of consolidation. Meanwhile, Koss and Butcher (1986) identified principle requirements of brief therapy as the therapist being active and 'openly influential'. Clearly the risk here being that 'openly influential' becomes a form of well-intentioned coercion. Certainly it is essential that by mitigation, supervisors remain particularly alert to this risk from the enthusiastic counsellor. Equally the challenge for the self-supervising practitioner is for him/herself to remain continually reflexive and attentive to their own motivations and agenda in the counselling alliance.
From an existential perspective, the literature remains sparse. As stated at the beginning of this paper, currently the Strasser & Strasser book (1997) continues to be the seminal reference for time-limited existential counselling. In an important and distinct contrast to other (non-existential) models, there should be no setting of specific targets or goals in the existential time-limited approach, since all issues are considered to be 'inextricably linked' (1997: p15). The authors affirm that 'the focus centres on temporality, the limit of time, the use of the structural model and the therapists' and clients' expectation of the outcome' (ibid: p16), and go some way in emphasising the importance of time and temporality in the work:
the one important distinguishing feature of time-limited therapy is the limitation of time itself. So, although the goal is to achieve the same kind of awareness as outlined in an open-ended approach, the aspect of time becomes a tool in itself when employing a time-limited therapy model.
It is a 'tool' in that once there is an explicit understanding of the centrality of time (that there is an end to the process and when it is likely to be), a 'pressure' is created for both the client and practitioner since both become aware of the limitations they face and the expectations of outcome that they hope to meet. This in itself, they argue, will fortify the commitment to the work, which offers a more urgent and vital atmosphere that is conducive to change: 'anxieties that may not emerge over a longer period of time are more likely to surface in time-limited therapy, as well as the anxieties surrounding the prospect of ending' (ibid: p14). This anxiety could be associated with the client in time-limited counselling tending to 'emphasize goals more than in an open-ended approach', and so developing an elevated sense of outcome; that they 'must achieve something' (ibid: p40). Therefore a time restriction is explicit and the potency of the work is here since '.the simple fact of knowing that there is an ending tends to evoke stronger emotions. These largely centre on the issue of separation, so for instance emotions such as fear, anger, sadness and the recollection of previous losses and rejections help clients to identify their value and coping strategies' (ibid: p15).
This is a powerful and persuasive argument, but significantly, after the second follow-up session, another module can be contracted. Notably, they suggest that this possibility is explained to the client at the beginning of the initial contract. While I fully accept that rigid time-limited contracts are not suitable for all presenting and emerging issues, this does weaken for me the claim to be working with the limitation and certainty of ending. If the client (and indeed therapist) is aware that in fact there can be a further module, albeit subject to review, the tendency might instead be to open-up or further develop issues, as opposed to seek to 'assiduously' address them, driven by the need to avoid ending at all cost. I stress that for me this is as relevant to the practitioner as it is to the client--if we as practitioners know we can postpone the certain ending, might that not blunt the potency of using time as a tool itself?
In fact the authors acknowledge this but found that the advantages of a modular approach (including clients not feeling rejected should they need further modules, and the therapist retaining credibility in modifying their initial assessment of number of sessions required) outweighed this risk 'by demonstrating flexibility rather than conforming rigidly' (ibid: p49) to a single block. In any case, a central distinguishing feature that Strasser & Strasser identified in the existential time-limited approach, that of time as a tool, seems for me to be somewhat compromised. So perhaps their modular approach is instead more accurately described by their own term for an essential element of all existential therapy--'time-aware' (ibid: p4), or even Budman & Gurman's (1988) term of 'time-sensitive'.
In the following case illustration I refer to a client, Marcus, whom I worked with in an agency offering time-limited contracts of up to 12 sessions. My aim is to show how by bringing the time limitation and certainty of ending directly into view, placing it at the forefront of our dialogue, this became the work. In so doing, the possibility for learning, growth and a more vital and authentic engagement with life was offered.
Existential time-limited practice--a case illustration
Marcus* was a 45-year-old man who had been diagnosed with a life threatening illness a year before coming to see me at an agency offering time-limited counselling (up to 12 sessions). His physical health was deteriorating rapidly and his doctors had recently informed him that he had a 'rapid onset' variation of his illness with a poor prognosis. Marcus smiled as he told me this, speaking quickly without pause, and appearing detached from what he was saying throughout. It seemed rehearsed. There was no space for reaction or response from me, nor emotions for either of us. He explained that 'with this bit out of the way', he could now tell me 'what the actual problem is', which was that he had found himself increasingly losing his temper with his partner and friends (outbursts including shouting, smashing furniture, and arguing with his partner, often in a public arena). He said he had come to counselling because his partner and friends had collectively told him he needed to address this as they could no longer tolerate his erratic behaviour. They specifically suggested that he should find himself an anger management course. I explained how I worked and that for me it felt important to try to firstly understand his situation, his place in his life, and as part of this, to see how we might come to understand the roots of the anger he described. I suggested that we therefore work together initially but that if he felt he still wanted to learn specific skills to prevent the outbursts, we could investigate anger management course availability at this and other counselling agencies. Marcus readily agreed, appearing eager to tell his story. We contracted to work together for 12 sessions.
A well-dressed man, habitually smiling, he would burst cheerfully into the room, and rush to his seat. It was typical for him to be still taking his seat and removing his jacket but already telling me about his week, or how he felt after last week's session, or what he thought we should focus on today. I reflected this to him; 'every second counts ... tick-tock!' he explained. From the outset, time permeated Marcus's narrative and as with his life, he was in a rush in the room: 'time is against me', he often complained as the end of our session neared.
He had spent years in a relationship that he found to be unfulfilling and, he felt, 'damaging'. His partner showed him little affection and regularly mocked him in front of their friends, leaving him feeling 'unsafe and rejected'. Friends were almost always former partners, all of whom he felt it important that he maintained contact with. Marcus couldn't fathom how we could be close to someone in our life at one point and then subsequently end all communication with them at another--for him this was 'too cruel and makes no sense'.
Since his diagnosis, his preoccupation with, and aversion to, wasting time had become all the more intense and he found himself persistently feeling frustrated and angry at how his life was, but all the while feeling unable to change any aspect of it. He said he felt 'crippled' by the mere thought of doing anything new or different. He could (and did) readily talk about his frustrations and how unsatisfied he was, but when I explored how life might be another way, he became agitated, shutting down, unwilling to engage in the conversation. He described feeling deep anxiety at just the thought of another way (manifested bodily by sweating, palpitations and an intense sense of dread in his stomach). Even the ending of his current troubled relationship, one in which he invariably felt humiliated and unloved, was an unbearable concept and so to be avoided. He was experiencing a loss of health, of his financial status, and potentially of his relationships. His illness was progressing fast compelling Marcus to contemplate the end of his life. His anger and frustration seemed to be ontic manifestations of his ontological anxiety and guilt. Temporally, his life was moving too fast yet he was wasting the time he had.
Critically, Marcus' apparent inability to accept that things end became pivotal to the work, and as such the counselling itself became emblematic of his struggle with life. As with all my clients in this setting, I regularly reminded Marcus that our time together was limited. I typically do this for the purpose of allowing space to re-assess and re-focus any aims or objectives from the client. With Marcus, it felt especially pertinent to keep the end 'in sight'. In a relatively early session (week four), I wondered aloud about how he felt about our remaining time together, that we had eight sessions left. Incredulous, he laughed and dismissed my comment, 'but surely we'll remain friends in some way afterwards? Good grief. After all of this I've told you, we can't just walk away ...?' This plea encapsulated Marcus' anxiety--his reluctance, even refusal, to accept that relationships, in all their forms, could not last eternally. And that ultimately, nor would he. Faced with death, Marcus's response was evasion.
Any notion of temporariness was too uncomfortable for Marcus and his response to this in life had been to avoid painful endings by maintaining relationships with former lovers, many that were emotionally ambiguous and upsetting, but nonetheless far more bearable than letting go. My answer to Marcus effectively framed our work together going forward. Yes our relationship would end, I told him. Our time together was indeed limited, we could both be certain of that. Nor would we be friends after the work had ended. I chose not to explicitly cite any professional ethical code since this would have felt, for me, like displacing the ownership and some of the potency of what I was telling him, and not to cushion the message. How we use the time that we do have together, however, and how we accept and face up to the end of our relationship would be what might set this experience apart from how he is in relation with others in the rest of his life. This was a head-on challenge to Marcus' worldview, and one that I was concerned may be too difficult for him--this man was emotionally vulnerable and trying desperately hard to avoid the pain and anxiety that his illness was demanding he contemplate. His cheery, jocular persona as he rushed through his narrative served only to confirm this.
Marcus worked hard in the room throughout and I too worked hard to remain alert for distractive discourse, or idle chatter, which was plentiful in the early weeks. He also became upset, even agitated, as each of our sessions drew to a close, his eyes continually checking the clock. Regularly, in the final minutes of a session, he would introduce something new and significant that invited exploration, and I in turn reflected my observation of this to him (of which he was typically unaware). Throughout our weeks together I ensured a rigorous and steady adherence to the frame.
As we progressed after the fourth session (and the emergence of endings as a rich seam for exploration), he began to offer some striking insights. By remaining close to the limitations that time presented us with, Marcus gradually and steadily engaged with the idea of not losing the now by being so preoccupied by what had been, and being fearful of the future. It seemed he was finding our relationship to be important in his life, but by being continually reminded of the approaching demise of it, he was beginning to experience it in a different way. Gradually, over the remaining weeks, he adopted a new perspective. Even though our work would draw to a close, the relationship we had during our time together was no less important to him.
In a moving session towards the end of our contract, he told me that he would be sad when we ended but also glad that we had met at all. It was this that he now wanted to focus on; that this relationship felt valuable while he had it. Sometimes things 'ran their course' but it was more about what we did 'during the course rather than running away from the end of the course--like running backwards on a conveyor belt--you're gonna lose anyway' he explained. By the end of our work, Marcus had begun a process of change and looking at his life in a new light and, I hope, a process of moving towards a more authentic way of living. Indeed this was only the beginning of a process that would hopefully continue and develop beyond our ending.
The agency provided the option of offering additional sessions (beyond the original contract of 12) in exceptional circumstances, and the nature of my client's illness may well have allowed him such an extension. However, in consultation with my supervisor, I chose not to offer this to Marcus. To do so seemed counter-intuitive, running the risk of reestablishing his belief that endings could be delayed, even avoided, and ultimately endangering the progress Marcus had already made in confronting his finitude.
Pragmatism dictates that we are in a climate of scarce resources that craves efficiency and value for money, and so it seems prudent that we emphasise more the merits and particular viability of an existential approach to time-limited practice. We must seek to develop and enhance our understanding and skills around how to use the time constraint to our advantage, and so to the advantage of the client. In my view, the existential approach is particularly well-placed to effectively engage with time-limited service provision.
With our curtailed possibilities in a finite life, ontological anxiety and guilt fundamentally influence our way of being and connecting with the world, and sometimes bring us to counselling. By leveraging our philosophical understanding of temporality to face the certainty of death in all its formulations, we can work with the client to maximise the time that they have and minimise the time they spend talking about it in the consulting room. For the practitioner, the requirement is to work with a sense of urgency and focus, to be forever attentive, responsive, and challenging.
Most counselling is of course ultimately time-limited, but the direct engagement with the imposed time-constraint explored in this paper in itself changes the work. By declaring it from the outset, bringing time and endings (death) into the room, we can have a powerful lever for change. Of course, this association and correlation will be more blatant and immediately relevant in some people's life stories and dilemmas than for others (as was so in the case of Marcus). However, ultimately, it is present and vital for us all. Our time is limited. We are limited. Reflecting this in the work, being explicit in existential practice about the ending of both individual sessions and of the contract as a whole, and mindful of our relationship to the time we have together, can facilitate a degree of engagement with temporality and death, and the associated freedoms, possibilities and unalterable limitations--for both client and practitioner.
Much has been written on how to 'do' brief therapy and distinguishing it from open-ended work in a number of ways, but for me the distinction is predominantly about temporality and ending and how we can use this. Otherwise we are essentially talking about skills that are relevant to both short and long-term modes of working. A view persists that brief work subscribes to a 'quick fix' culture, and certainly there are potent pressures for 'fixes' and pain alleviation in as short a period as possible, but with questionable capacity for an enduring benefit to the client (of course, how this is measured raises perhaps as many questions as it seeks to answer). Nonetheless, the potential presented by working within a limited or time-defined contract that explicitly engages with limitations is significant. Meaningful work is possible and so the idea that brief work merely 'touches the surface' is there to be challenged.
From an existential perspective, the Strasser book offers a significant contribution (and the first) to our understanding of the value and relevance of working in a time-limited existential manner. For me, the modular aspect of their model seems to somewhat dilute that since the limitation is less definite. However, they comprehensively highlight how the very basis of existential thinking on authenticity (our embracing of our limitations, possibilities and death) can be fundamental to the approach, and in so doing stake a claim for the existential orientation in this domain.
In this paper I have sought to demonstrate, by offering a case illustration, how the limitation of time and specifically the unequivocal ending of our time together provided an opportunity for a meaningful engagement with how my client lived his life. What was initially presented in the room as an issue of anger management, by exploration was more meaningfully understood to be about his experience of time and the lack there of. By exploring the ontological anxiety, we understand the ontic fear, frustration and indeed so the anger. And by doing so, Marcus uncovered new horizons.
If we accept that our lives are shaped by the possibilities and limitations inherent in lived time, and within which we are inextricably bound, it surely follows that existentially informed practice in a time-limited setting can create the conditions to confront this anxiety and fundamental of authentic living. Reflecting life, the counselling contract is limited. Inviting the client to explore their relationship to this offers a potentially rich seam of exploration.
Heidegger (1927) tells us that we are forever projecting towards future possibilities and that fundamental to the quest for authentic living is Being-towards-death, by confronting our deepest ontological concern. The opportunity for engaging with this is abundant in a counselling setting shaped by time limitations and the certainty of an end date. Hoyt (1995: p144) tells us that in therapy, 'More is not necessarily better. Better is better.' From an existential counselling perspective, I would add that less, sometimes, can indeed be more.
Bor, R., Gill, S., Miller, R., & Parrott, C. (2004). Doing Therapy Briefly. London: Palgrave.
Budman, S.H. & Gurman, A.S. (1988). Theory and Practice of Brief Therapy. New York: Guilford Press.
De Shazer, S. (1985). Keys to Solutions in Brief Therapy. New York: W.W. Norton.
Ferenczi, S. & Rank, O. (1925). The Development of Psychoanalysis. New York: Dover.
Heidegger, M. (1927/1962). Being and Time. Trans. Macquarrie, J. & Robinson, E.S. Oxford: Blackwell.
Hoyt, M. (1995). Brief Therapy and Managed Care. San Francisco: Jossey-Bass.
Husserl, E. (1913/1931). Ideas: General Introduction to Pure Phenomenology. Trans. Boyce Gibson, W.R. London: George Allen & Unwin Ltd.
Husserl, E. (1991). On the Phenomenology of Internal Time Consciousness Vol. 4. Collected Works. Trans. Brough, J. The Hague: Nijhoff.
Koss, M.P. & Butcher, J.N. (1986). Research on brief psychotherapy. In Garfield, S.L. & Bergin, A.E. (eds) Handbook of Psychotherapy and Behavior Change. 3rd ed. New York: Wiley.
Langdridge, D. (2006). Solution Focused Therapy: A way forward for brief existential therapy? In Existential Analysis, 17(2): 359-370.
O'Connell, B. (1998/2005). Solution-Focused Therapy. London: Sage Publications.
Strasser, F. & Strasser, A. (1997). Existential Time-limited Therapy: The Wheel of Existence. Chichester: John Wiley & Sons.
Warnock, M. (1970). Existentialism. Oxford: Oxford University Press.
* 'Marcus' consented to this material being written and his identity has been sufficiently disguised to protect his anonymity.
Neil Lamont As well as working privately, Neil works for a large counselling agency with people affected by HIV, and as a group facilitator for people living with addictions.
Contact: 79 Rouel Road, London SE16 3SL
Email: londonbridgewellbeing@gmail. com
|Gale Copyright:||Copyright 2012 Gale, Cengage Learning. All rights reserved.|