Existential Therapy, Culture, and Therapist Factors in Evidence- Based Practice 1

Transcription

1 Existential Therapy & EBPP 1 Existential Therapy, Culture, and Therapist Factors in Evidence- Based Practice 1 Heatherlyn Cleare- Hoffman Argosy University, San Francisco Campus Louis Hoffman Saybrook University Sivan Wilson Saybrook University Although there is a solid basis for existential therapy as an Evidence- Based Practice in Psychotherapy (EBPP), this has not been adequately articulated in the scholarly literature (Hoffman, Dias, & Soholm, 2012). This paper advances two important aspects of the evidence- based foundation of existential therapy: therapist factors and implications for diversity/individual differences. The three pillars of EBPP include 1) research, 2) experience/expert opinion, and 3) individual differences and diversity. Wampold (2001) has successfully advocated that therapist factors are one of the most important contributions to successful outcomes in psychotherapy. Furthermore, Wampold (2008) maintained that existential- integrative psychotherapy could form the basis of all effective treatments (p. 6). In large part, Wampold can make this argument about existential therapy due to its foundation in the relational factors of therapy, and these relational factors are strongly supported in psychotherapy research. Existential therapy has well articulated the relational factors, particularly those connected to the person of the therapist. However, an area that requires further development is the cultural variations of the therapy relationship in existential practice. Although relational factors in psychotherapy may be important regardless of the individual or culture, these must always be interpreted within the context of culture. For example, authenticity may be experienced differently in varied cultural contexts, such as individualistic and collectivistic cultures. Similarly, the conveying of concern and empathy may be quite different in high context versus low context cultural communication styles. Drawing upon the research literature and clinical experience, this presentation addresses ways in which relational factors in existential practice can be adapted and applied in a culturally sensitive manner. 1 Paper presented at the 121 st Annual Convention of the American Psychological Association held in Honolulu, HI, July/August 2013.

2 Existential Therapy & EBPP 2 All therapists, regardless of theoretical orientation or therapeutic approach, should be committed to assuring the therapy they provide is effective. Too often existential and humanistic therapists have resisted this. Although there are many legitimate concerns about many of the approaches to assessing therapy outcomes that have been popular in recent years, this does not necessitate rejecting all approaches to evaluating therapy. Evidence- Based Practice in Psychology (EBPP), the current zeitgeist in evaluating therapies, is a more flexible approach that can be a good fit for existential and humanistic psychotherapies (Hoffman, Dias, & Soholm, 2012). While EBPP is an approach that could be considered a good fit with existential therapy, Wampold, Goodheart, and Levant (2007) warn that if there are not intentional efforts to keep a broad, inclusive understanding of EBPP that it could easily gravitate toward being understood in a more narrow, restrictive manner consistent with previous approaches to evaluating therapy modalities. Thus, Hoffman et al. (2012) argued that it is important for existential and humanistic therapists to be active in the discussions about how EBPP is understood and defined, as well as working to demonstrate that existential and humanistic therapy meets the criteria for being EBPP in psychology. This paper builds upon previous arguments that assert that existential therapy can rightly be considered an evidence- based practice (Hoffman, 2009a, Hoffman, et al., 2012). However, it should be cautioned that EBPP is not about establishing specific therapy modalities as evidence- based, but rather conceives of evidence- based practice as something that extends beyond a particular therapeutic approach to also consider factors about the individual therapist and their competencies. Thus, when saying that existential therapy can rightly be considered an evidence- based practice we are stating this within the provision that the therapist implementing this approach must have established a number of basic competencies relevant across therapy modalities. Brief Overview of Evidence- Based Practice 2 The American Psychological Associations (APA) Task Force on Evidence- Based Practice (EBPP) (2006) identified three cornerstones of EBPP: 1) Research, 2) Expertise (i.e., established expertise or competency), and 3) consideration of individual differences. How each of these is conceived, however, is still being debated. It is important for existential psychology to be involved in this debate. If this is done from solely a critical or defensive posture, it is not as likely that it will be taken seriously or influence the broader field. 2 For a more detailed history and overview from an existential and humanistic perspective, see Hoffman, Dias, and Soholm (2012), Existential- Humanistic Therapy as a Model for Evidence- Based Practice. This article is available at: Humanistic_Therapy_as_a_Model_for_Evidence- Based_Practice.

3 Existential Therapy & EBPP 3 Research Research evidence is broadly conceived in EBPP, and can include both quantitative and qualitative approaches (APA Task Force on EBPP, 2006). Existential therapy, along with many other approaches, have long been critical of the narrow use of quantitative research, or even randomized clinical trials, as the gold standard of therapy research and outcome studies (see Elkins, 2009; Wampold, 2001). These critiques are important and valid critiques; however, not applicable to EBPP, which takes a much broader interpretation of what is constituted as appropriate research. Hoffman et al. (2009) maintained that it was important to move beyond research focusing narrowly on outcomes of therapy modalities. Within most therapeutic approaches, including existential therapy, there are variations between therapists. Additionally, therapist will vary their approach to therapy based upon the client. While there are some foundations to these approaches as well as consistency in how the therapy is implement across client, no two therapies look alike with many approaches. Thus, it may be more appropriate to consider the core components of the therapy approaches. For example, empathy, the therapy alliance, and congruence are important foundations of humanistic and existential psychology that have strong support in the research literature. Clinical Expertise Clinical expertise is where EBPP most clearly goes beyond evaluating therapy effectiveness beyond the theoretical orientation. Instead, the focus is more on competency, which the APA Task Force on EBPP (2006) understands as including, (a) assessment, diagnostic judgment, systematic case formulation, and treatment planning; (b) clinical decision making, treatment implementation, and monitoring patient progress; (c) interpersonal skills; (d) continual self- reflection and acquisition of skills; (e) appropriate evaluation and use of research evidence in both basic and applied psychological science; (f) understanding the influence of individual and cultural differences on treatment; (g) seeking available resources (e.g., consultation, adjunctive or alternative services) as needed; and (h) having a cogent rationale for clinical settings. (p. 276) Many of these are competencies that will be implemented similarly across theoretical orientations. However, many of them will be quite different based upon the therapeutic modality. For instance, diagnostic judgment may vary between approaches that rely heavily upon traditional diagnostic approaches, such as the American Psychiatric Association s Diagnostic and Statistical Manual of Mental Disorders, as compared to approaches that may take different approaches to conceptualizing the individual s problems. Similarly, the cogent rationale for clinical settings necessarily will be dependent upon the therapy approach.

4 Existential Therapy & EBPP 4 Hoffman et al. (2009) that a supplement to the competencies it should be considered whether, (a) there is sufficient demonstration that the various clinical competencies are utilized within the framework of these therapeutic modalities and (b) approaches to existential- humanistic psychology have been appropriate vetted in the peer- reviewed literature by experts in the field. (p. 6) This serves to root the clinical competencies into a particular therapeutic approach, such as existential therapy. With regard to existential therapy, this literature is particularly robust including a number of important publications that provide extensive clinical examples and case formulations (see Bugental, 1990; Hoffman & Granger, 2009; Schneider, 2008; Schneider & Krug, 2009; Yalom, 1989, 1999) Individual and Cultural Differences According to the APA Task Force on EBPP (2006) the individual difference criteria focuses on the ability of the therapist and therapy approach to adapt to work with a variety of individual differences including ethnicity, gender, development, and sexual orientation, among others. This is an area of weakness within existential and humanistic psychology historically; however, this is beginning to change. However, there is an increasingly ample body of literature addressing how existential psychology can be adapted to work with cultural differences (see Hoffman, Cleare- Hoffman, & Jackson, in press; Hoffman, Yang, Kaklauskas, & Chan, 2009; Quinn, 2013; Schneider, 2008). Therapist Factors and Existential Therapy In this section, we review seven important components of psychotherapy that are important factors in change regardless of one s therapy orientation. These factors have been extensively researched and fit well with foundational clinical competencies, which are the first two components of EBPP. Each of these also can be understood as foundational components of existential therapy practice. In the following section, we will discuss the implication of cultural and individual differences when implementing these factors in therapy. The Therapy Alliance Bohart and Greenberg (1997) assert that the therapeutic relationship is the best predictor of success in therapy. This pithy, profound statement pays rightful tribute to the complexity and wonder of the psyche by concluding that there is no single tangible mechanism with which therapeutic change can be accomplished. Further, the psychologist, even with expertise of both scientific and clinical nature, is not capable of conducting

5 Existential Therapy & EBPP 5 productive therapy alone. The client s own skills and strengths must be utilized and mobilized to facilitate change (Bohart & Tallman, 2010; Hubble, Duncan, & Miller, 1999). The therapeutic relationship is evolving and changing across time. However, Lambert and Barley (2001) describe three elements of the therapeutic relationship that can be useful in organizing its development. The first element, tasks, constitutes the actual work in therapy while the second element, goals, refers to the objectives of therapy that both the client and therapist endorse. The final element, bonds, encompasses the mutual interpersonal attachment between client and therapist that includes trust, genuineness, and acceptance. The summaries and reviews of the research on the importance of the therapy relationship and therapy alliance consistently demonstrate that the relationship accounts for a significant amount of the change that occurs in psychotherapy (Horvath & Bedi, 2002; Norcross, 2010; Norcross & Lambert, 2006; Wampold, 2001). Furthermore, the therapeutic relationship, in many ways, is the foundational element that is necessary for all the other components of therapy to be effective. Thus, the next several sections are essential a further explication of therapy relationship and alliance. Empathy Empathy is an essential element of existential therapy that provides a further example of its ephemeral and depth- oriented nature (Bohart & Greenberg, 1997). Empathic attunement allows the therapist to vicariously experience the feelings, thoughts, and attitudes of another in order to deeply understand the struggles of the client. This, however, does not capture the full range and weight of empathy, as much of this is an emotional process hard to capture in words. Empathy presents a dilemma for EBPP due to its intangibility. Yet, several research studies have managed to overcome these challenges (Bohart & Greenberg, 1997; Johnson, et al., 2005). In an effort to quantify empathy, studies sometimes use specific empathic phrases provided by the therapist in the Rogerian mold in order to show a causal relationship between these phrases and client therapeutic outcomes. Yet, this is subject to the same scrutiny of research method and design as any other. Some may contest that empathy has been equated to a particular response technique, empathic reflection or empathetic phrasing, which does not fully capture the impact of empathy. In attempting to find legitimacy with respect to the scientific method, the intangibles of empathy may be relegated to mere concrete variables that, while reflecting an aspect of the variable, do not capture the fullness of the relational experience. Further, empathy is not objective in that it exists within the genuine exchange between client and therapist engaged in therapeutic work. This exchange is rooted in each person s subjective experience embedded in the broader context of his or her life experiences (Flaskas, 2009). As the commonalities of living are explored in therapy, the avenues of empathic understanding are opened between two distinct individuals. Yet, their

6 Existential Therapy & EBPP 6 subjective underpinnings make these avenues difficult to define and research. This does not detract from their importance, but rather speaks to the magnitude of personal meaning that can be found. Relationships, individuals, moments, and the ever- changing rhythm of living are necessary to consider when experiencing an empathic exchange. Despite the challenges in measuring empathy, the reviews of the research have consistently found empirical support that empathy does contribute to therapeutic change (Bohart, Elliott, Greenberg, & Watson, 2002; Wampold, 2001; Watson, 2001). This finding seems particularly impressive given the inherent limitations in measuring a relational process such as empathy. Positive Regard Rogers (1951) identified positive regard as the way the therapist feels about a client that helps bring about change in the client during therapy. In 1957, Carl Rogers concluded that positive regard was one of the necessary and sufficient conditions needed for therapeutic change. He believed that this entails caring for the client as a unique individual with no conditions on acceptance and allowing the client to have her or his own feelings and experiences. This allows for the client to be seen as a person of worth (Farber & Lane, 2002). In order for this to be a successful component of therapy, the therapist must not only experience these feelings towards the client, but also share them with his client in a caring and respectful manner (Rogers, 1957/1992). Farber and Dolin (2011) note that positive regard needs to be continually monitored and adjusted to meet the needs of the client. The personalities of both the client and the therapist dictate this adjustment. Just as therapists may vary in the extent to which they can show positive regard to their clients, clients vary in the way they can receive and use it effectively in therapy. This condition has been difficult to study because it cannot be easily defined or quantified. It has been known by many names including but not limited to unconditional positive regard, affirmation, warmth, respect, and acceptance as well as non- possessive warmth. (Farber & Lane 2002; Wilkins, 2000) Despite this, positive regard has been beneficial in other forms of therapy besides client centered therapy For example, Farber and Doolin (2011) indicated that in behavioral therapy positive regards helps the client to become more engaged in the therapeutic process and from a psychodynamic perspective this aids in strengthening the clients ego. Similar to empathy, positive regard is a difficult concept to operationally define, quantify, and measure; however, there is still support that this is an important factor in therapy outcomes. Congruence Rogers saw congruence as the most important of the conditions necessary for personality change (Rogers, 1957/1992). There are two important aspects of congruence.

7 Existential Therapy & EBPP 7 First, the therapist must be fully aware of him or herself while with the client. Second, the therapist must convey this to the client. Rogers believed that the optimal situation is where both the therapist and client embark upon this process together (Cooper, Watson & Holldampf, 2010), meaning that they both acknowledge, label, and discuss the relevant issues in terms of their past experiences and their present. The terms genuineness and authenticity are sometimes likened to congruence (Koldem, Klein, Wang, & Austin, 2011), which they posit as the willingness to be who oneself truly is in the relationship. Being congruent means that the therapist must be authentic in the therapy relationship or in touch with their own experience. Rogers is clear that the therapist does not need to be integrated in the rest of his life, but does need to be congruent in the time that he or she is with the client (Cooper et al 2010). Klein, Kolden, Micheals, and Chisholm- Stockard (2002) indicate that congruence has intrapersonal and interpersonal qualities. The intrapersonal qualities are those of the therapist and the interpersonal qualities are a function of the relationship between the therapist and the client. With regards to the interpersonal facet of congruence, they also believe that this is evident in one of two ways: either by the therapist providing personal information in the form of self- disclosure or by the therapist reflecting thoughts and feelings while in the actual session with the client. Both of these can be used effectively to enhance therapeutic outcome. As with other therapist factors, congruence must be tailored to the client according to Klein et al. (2002). They also indicate that in order to foster congruence, therapists must model congruence for their clients and be aware of when it is being disrupted. Therapists and clients also have different comfort levels and abilities to maintain higher levels of congruence. Therapists should be sensitive to this and adjust as is needed. Research consistently supports that congruence, genuineness, and authenticity do contribute to positive therapy outcomes (Klein, et al., 2002; Koldem, et al., 2011; Sachse & Elliott, 2002). Along with positive regard and empathy, congruence can be considered closely related to or an aspect of the existential concept of presence, which is generally conceived as a cornerstone of existential therapy practice (Hoffman, 2009a; Schneider, 2008; Schneider & Krug, 2009). Working with Resistance Resistance is a given in psychotherapy. All clients demonstrate at least some resistance at times in therapy. Additionally, there are times and degrees to which resistance can be beneficial. For example, resistance can serve to protect clients in situations where they feel vulnerable or unsafe. However, as is self- evident, too much resistance is problematic. Research on resistance demonstrates that the therapist s ability to work with resistance is an important component of positive therapy outcomes (Beutler, Molerio, & Talebi, 2002). However, there are different types of resistance, such as state versus trait

8 Existential Therapy & EBPP 8 resistance. Trait resistance is a more generalized resistance that can be understood as a client factor that is associated with poorer therapy outcomes. It is important for therapists to be able to distinguish between types of resistance, recognize when they are present, and respond appropriately. Bugental (1999) developed an approach to resistance consistent with the themes in the research literature. He advocated for an empathetic approach to addressing resistance in which the therapist seeks to empathetically understand resistance and the positive role it was serving with the client. Only after understanding the resistance does the therapist begin to address it; however, resistance frequently begins to lower as the therapist works to understand it. Emotional Expression and Processing Emotion Therapists often speak of processing emotion, yet what this means often lacks clarity. There are at least two important components of processing emotion: experiencing emotion and bridging understanding or meaning with the emotion. Watson, Greenberg, and Lietaer (2010), in their review of the research, demonstrate that having the ability to experience moderate or high levels of emotions, or developing this ability, is consistently associated with better treatment outcomes. Bugental (1987) advocated for helping clients move in and out of the depths of emotional experiencing. While some therapists tend to stay on the surface level of emotions, with mild or no emotional arousal, other therapists tend to try to maintain a more intense level of emotional arousal. According to Bugental, both of these are generally mistakes. Moving in and out of the depths of emotional process assists clients in experiencing the emotion and then connecting the emotion with meaning. Although the different humanistic and existential approaches have different approaches to facilitating the emotional processing, there tends to be agreement that this is necessary. Process- experiential therapies tend to focus on techniques to facilitate emotional experiencing (Elliott & Greenberg, 2001; Watson, et al., 2010), while existential approaches tend to more frequently use the therapy relationship to encourage emotional expression (Bugental, 1987, 1999; Hoffman, 2009a, Schneider & Krug, 2009). However, many therapists will draw from various humanistic and existential approaches to encourage clients to experience their emotions. The research evidence does appear particularly strong that the facilitating of experiencing and processing emotions contributes to therapeutic change (Elliott & Greenberg, 2001; Greenberg, Korman, & Paivio, 2001; Watson, et al., 2010). Meaning Existential therapy is a meaning- centered therapy. As alluded to in the previous section, the creation of meaning is often connected with emotion. For example, Clarke (1996) noted that the lack of emotion was often connected with unsuccessful creation of

9 Existential Therapy & EBPP 9 meaning. Similarly, as suggested in the previous section, the experiencing of emotion without creating meaning is less effective in promoting change than when connected with meaning. There is some evidence that meaning making is connected to successful outcomes in therapy. For instance, Boals (2012) found that when engaging in expressive writing process with therapy the inclusion of meaning making was related to positive change. Similarly, meaning has been found an important protective factor for individuals in stressful situations (Breitbart, et al., 2010; Kelley & Chan, 2012; McLennon, Habermann, & Rice, 2011) as well as being a factor that is associated with psychological well- being (Lightsey, 2006; Tavernier & Willoughby, 2012; Thoits, 2012). Cultural Factors, Individual Differences, and Existential Therapy A number of authors have noted that, in general, there is an insignificant amount of research that has explored cultural differences in regard to evidence based treatment and customizing therapy relationships when working with diverse clients (Brown, 2006; Levant & Silverstein, 2006; Olkin & Taliaferro, 2006; Sue & Lam, 2002; Sue & Zane, 2006). Yet, as Morales and Norcross (2010) advocate, evidence- based practice and multiculturalism need each other. In the previous section, we identified seven factors that are generally considered part of the foundation of existential therapy and discussed their evidence- basis for these factors. In this section, we will discuss how to work with these factors from the perspective of individual and cultural differences. The Therapy Alliance Vasquez (2007) maintained that unintentional bias frequently may interfere with the development of a therapeutic alliance. Furthermore, she noted this may play a role in higher psychotherapy dropout rates of some ethnic groups as well as interfering with therapeutic effectiveness with individuals from these groups. Given this, it is important that existential therapists utilize culturally sensitive language, stay appraised of culturally sensitive issues, and continually work to examine their own implicit biases. Cultures often have significantly different norms pertaining to relationships, including family, social, and hierarchical relationships (Dias, Chan, Ungvarsky, Oraker, & Cleare- Hoffman, 2011). While it is not possible to be aware of all cultures relational norms, therapist must develop sufficient knowledge to recognize differences and appropriately adapt their therapeutic approach. For example, with some cultures the therapy alliance extends beyond the individual to also include the family. If therapists working with clients from these cultures do not involve the family, or consider the implications of the family on the therapeutic alliance, they may have difficulty in establishing a good, working relationship with these clients.

10 Existential Therapy & EBPP 10 Empathy Empathy can be challenged when the therapist and client are from different cultural backgrounds. In part, this is because it is very difficult to fully put oneself in the shoes of a person from another culture. For example, therapists from a privileged culture will often talk about experiences where they were in the role of being a minority for a brief period of time. However, it is very different to have a transitory experience in the role of a minority as opposed to the daily, pervasive experience of encountering prejudice and discrimination. Riley (1995, as cited in Chung & Bemak, 2002), noted that to communicate empathy across cultures it is important to acknowledge one s lack of awareness of the client s culture and/or cultural experience, show an interest in learning about the client s culture, and affirm the client s cultural experience. When therapists try to present themselves as knowledgeable or experts in the client culture, this may inadvertently interfere with the client being able to experience empathy as it does not communicate an interest to learn from the client about their culture and experiences. Therapists also ought to be cautious in helping clients cope with their experiences of prejudice and discrimination. For example, in contemporary culture, prejudice and racism often come in the form of microaggressions, which are subtle and often unintentional forms of racism (Sue, 2010). Microaggressions are often ambiguous, leaving it unclear as to whether the behavior really was reflective of prejudice. It is important for therapists to be cautious in helping clients process through these experiences. If the therapist is quick to suggest that the experience was unintentional or not really the result of prejudice, the client could experience this as invalidating even if the therapist was correct. It is important prioritize validating the client s experience and to be sensitive when addressing potential misperceptions of racism. Positive Regard Comparable to the therapy relationship, with positive regard it is important for therapists to regularly engage in a self- reflective process in order to increase one s awareness of potential biases or prejudices that may reside at the unconscious level. Therapists often express positive regard, as well as disapproval or rejection, through nonverbal behaviors, which may at times be outside of their awareness. Doolin and Farber (2011) note that therapists may be more inclined to convey positive regard to clients who demonstrate strong motivation for therapy, take risks, and show courage in facing their challenges. What is interpreted as risk taking may vary across cultural groups. For instance, individuals from traditionally oppressed groups may perceive just coming to therapy to be a significant risk. Similarly, they may not have much of a frame of reference as to what to expect from therapy, including the ongoing, emergent risks often part of existential and other depth psychotherapy approaches. Thus, after the risk of coming to therapy, these clients may be more cautious as they try to ascertain what is expected of them and whether they can trust the therapist, who, regardless of the

11 Existential Therapy & EBPP 11 therapist s culture, often symbolically represents privilege and power. This is comparable to what individuals from collectivist cultures may experience coming to therapy. For these clients, stepping away from the typical structures from which they seek assistance in order to seek help from outside of the family may be experienced as a significant risk. It is common for some degree of mistrust to be present when clients from traditionally oppressed cultures see therapists who represent the privileged culture. According to Sue and Sue (2003), some research suggests that the intentional use of positive regard may help overcome this mistrust therefore solidifying the therapeutic alliance and enhancing therapy. For example, therapists may be more intentional in expressing their positive regard for certain clients if they are aware of some mistrust that may be present due to cultural differences. However, cultural variations also exist in regard to the comfort level of direct, verbal expression of positive regard. Some cultures, such as individuals from Chinese backgrounds, may be uncomfortable with the direct verbal expression of positive regard and may respond better to intentional, but more subtle and nonverbal forms. Congruence Heery (2009), in discussing global authenticity, states, What we experience as an essential quality of authenticity is humility, of allowing ourselves to not know and be humbled by the not knowing for others and ourselves (p. 215). Consistent with what was discussed earlier in regards to empathy, congruence calls for therapist to be honest about their limited cultural knowledge. Therapists, in developing cultural competency, are often encouraged to develop and be able to demonstrate some cultural knowledge when working with clients representing a different cultural background than their own. While this can be beneficial, therapists must be cautious as their attempts to demonstrate some knowledge of the client s culture may be experienced as disingenuous by the client. Even for therapists who share a similar cultural background, they can never fully know the cultural experience of the client. Therefore, the acknowledgement of not knowing is often more congruent than the experience of knowing. Working with Resistance It can be easy for therapists to misidentify cultural differences as resistance. For instance, clients who tend to be quiet, deferring to authority, and express little emotion may be perceived as being resistant; however, within their cultural context this is quite normal. Similarly, existential perspectives are often quick to pathologize conformity or deferring to group pressures or perspectives. However, within collectivist cultures, some of these behaviors might be experienced very differently. Additionally, clients may be resistant to particular suggestions of the therapist as well as conceptualizations the therapist brings at times because of cultural differences. It is quite easy for therapists, often without any intentions of doing so, to impose certain beliefs,

12 Existential Therapy & EBPP 12 ideas, and even behaviors upon clients. When encountering resistance, it is often helpful to return to Bugental s (1999) approach of working with the resistance while considering the cultural implications of what the therapist perceives to be resistance. As the therapist develops empathy and greater understanding of what they perceive as resistance, they may find that it is not resistance at all. Emotional Expression and Processing Emotion Significant cultural differences exist pertaining to the outward expression of emotion and even the way individuals experience emotions internally. Therapists often hold assumptions or biases pertaining to emotions and emotional expression. For instance, many southwest Asian cultures express their emotions very subtly, whereas much of American culture is more expressive with their emotions (Hoffman & Cleare- Hoffman, 2011). Previously, it was discussed that moderate and high levels of experiencing emotions was associated with better therapy outcomes. However, how clients hold and experience moderate and high levels of emotions may greatly very. In some cultures, the individual s emotions may be very evident in body posture, voice tone, and other aspects of nonverbal behavior; however, in other cultures, there may be very little change in the nonverbal expression of emotion across different emotional states. If therapists are not aware of these differences, it could lead to misinterpreting client s emotional expression as being overly dramatic or repressed. While experiencing and expressing emotion may be a beneficial aspect of therapy for most clients, how this looks and what it entails may be very different from culture to culture. When encouraging clients to experience and express their emotions, it is important that therapists not impose particular ways of doing this upon clients. As Hoffman and Cleare- Hoffman (2011) advocate, what constitutes a healthy way to experience and express emotions for clients may be partially culturally determined. Thus, imposing upon clients a particular way to experience and express emotions may cause a rupture in the therapeutic alliance and potentially even be harmful to the client. Meaning Hoffman (2009b), building upon the ideas of Rollo May, advocated that myths often serve as primary systems through which individual and cultural meaning is organized. As such, myths are not something that are false, but rather myths are unable to be proven to be true (May, 1991). Furthermore, myths often stand in relation to the existential givens, or facts of existence that everyone must face, such as death, freedom, isolation, emotions, and meaning. Myths can be operationalized as stories, songs, and movies as well as in rituals, traditions, and beliefs. According to Hoffman (2009b), the existential givens are universal challenges that require a personally and culturally specific response. For instance, everyone must

13 Existential Therapy & EBPP 13 eventually face death. Yet, no universal answer to the challenge of how death and loss are understood and experienced can be provided. Different cultures have different beliefs and rituals surrounding death. Therapists can help clients explore meaning, in part, by helping them explore their personal, familial, and cultural myths. At times, clients may work to deepen their connection with cultural myth and meaning; at other times they may become aware of how these have influenced them and choose to pursue meaning in a different direction. It is important for therapists to remain aware of the client s values and meaning system in order to avoid imposing one s own meaning system upon the client. Often, this will begin by working to become familiar with the client s individual meaning and cultural meaning as understood by the client. As both the client and the therapist come to understand the client s meaning and its impact upon the client, then therapist is able to empower the client to make more informed choices. Conclusion In this paper, we have advocated that existential therapy can rightly be considered an appropriate treatment approach within the standards of EBPP. After a brief overview of EBPP, we identified seven aspects of existential therapy that can rightly be considered as part of EBPP. For each of these, we began with discussing their foundation in research and clinical expertise. In the last section of the paper, we discussed how these several aspects of existential therapy and evidence- based practice could be adapted with consideration of individual and cultural differences. Through this process, we have demonstrated that these seven factors fit well with the criteria of EBPP. This, in itself, does not assure that existential therapy is an evidence- based practice as it is necessary that the therapist is able to implement this therapeutic approach in a manner consistent with basic therapeutic competencies while making the adaptations for the particular client in regard to individual and cultural differences. References American Psychological Association (APA) Task Force on Evidence- Based Practice. (2006). Evidence- based practice in psychology. American Psychologist, 61, Beutler, L. E., Moleiro, C. M., & Talebi, H. (2002). Resistance. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients (pp ). New York, NY: Oxford University Press. Boals, A. (2012). The use of meaning making in expressive writing: When meaning is beneficial. Journal of Social and Clinical Psychology, 31,

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