Discussion: Humanistic and Existential Personality Theories

PERSPECTIVES

Humanistic-experiential therapies in the treatment of generalised anxiety: A perspective Ladislav Timulak*

Trinity College Dublin, Dublin, Ireland

*Corresponding author. Email: [email protected]

Keywords: anxiety, emotion-focused

therapy, generalised anxiety disorder,

humanistic therapy

doi: 10.1002/capr.12172

Abstract

This study discusses the current status of evidence-based psychological

therapies for generalised anxiety disorder (GAD). It points to the

dominance of cognitive-behavioural therapies (CBTs) and compares this

dominance with the position of humanistic-experiential therapies (HEPs)

in this area. The paper hypothesises several reasons for this situation,

including historical developments as well as HEPs’ ambivalence around

embracing mainstream mental health classification systems, and

corresponding types of research. The paper then highlights some recent

developments in HEPs for anxiety disorders (particularly emotion-focused

therapy; EFT); developments that are breaking new conceptual grounds

while also generating new outcome research.

Generalised anxiety disorder (GAD) is a commonly

experienced condition and especially prevalent in

client presentations within primary care services

(Kroenke, Spitzer, Williams, Monahan & L€owe,

2007). Broadly speaking it is a form of emotional

suffering characterised by excessive worry and

omnipresent symptoms of anxiety (American

Psychiatric Association, 2013). However, as with

many other diagnostic categories, there are many

problems in delineating GAD as a condition. Indeed, it

appears that even though the description of GAD in

the International Classification of Diseases of the

World Health Organisation and the Diagnostic and

Statistical Manual of Mental Disorders of the

American Psychiatric Association (the two most

common classification systems) is similar, the two

systems classify partially different populations as

meeting criteria for the condition (Slade & Andrews,

2001). Furthermore, to compound difficulty with

classification, comorbidity, particularly with

depression and other anxiety disorders, is also very

high (Brown, Campbell, Lehman, Grisham & Mancill,

2001), while the aetiology of GAD also appears to be

shared with other conditions (Stevens, Jendrusina,

Sarapas & Behar, 2014).

Research-informed psychotherapeutic approaches

applied in the treatment of generalised anxiety are

almost entirely from the family of cognitive-

behavioural therapies (CBTs) (e.g. National Institute

for Health & Clinical Excellence, 2011). Although as a

family of interventions, CBT approaches to GAD draw

on and contribute to a solid evidence base, they

represent a variety of approaches that also differ in

their theoretical conceptualisation and practical

application (Behar, DiMarco, Hekler, Mohlman &

Staples, 2009). For instance, there exist Borkovec’s

Avoidance Theory of Worry model, Dugas’ Intolerance

of Uncertainty model, Wells’ Metacognitive model,

Mennin’s Emotion Dysregulation model, Roemer and

Orsillo’s Acceptance-based Behavioural model and

Newman’s Contrast Avoidance model. Each of these

models offers its own conceptualisation of GAD and

suggests its own treatment strategy. While some

have been examined in a number of randomised

controlled trials (RCTs), others have been examined

in only one RCT, and some have not yet been tested

in a full RCT. While collectively they present a robust

evidence base, some researchers have cautioned that

there is room for improvement of recovery

rates (Cuijpers et al., 2014; Hanrahan, Field, Jones &

Davey, 2013), and others have called for research

into non-CBT therapies to increase treatment choice

for clients (Hunot, Churchill, Teixeira & de Lima,

2007).

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Counselling and Psychotherapy Research

Humanistic-experiential therapies are particularly

under-represented in the research on GAD. Yet these

are therapies that are attractive not only to significant

groups of practitioners (members of professional

associations of counselling and psychotherapy) but

also to significant subgroups of the public that may

prefer humanistic-experiential therapies over CBT

(King et al., 2000). The under-representation of

humanistic-experiential therapies for GAD and other

anxiety disorders may in part be due to the overall

sparsity of outcome research of humanistic therapies

on mental health conditions. This sparsity may in

turn be partially rooted in the fact that humanistic

theorists tend to be critical of the mainstream

classification systems (see the difficulties with

classification mentioned above) and therefore have

not historically aligned their research activity directly

with the mainstream classification systems (e.g.

studying a manualised therapy for a specific disorder

or condition). Furthermore, researchers working from

a humanistic perspective have historically tended to

be under-represented in disciplines such as clinical

psychology which have traditionally played a leading

role in research developing and studying the efficacy/

effectiveness of psychological therapies per classified

mental health condition.

In the case of anxiety, and thus also generalised

anxiety, the dominance of CBT may also be

attributable to other factors. Early behavioural

approaches made anxiety a major focus of study (for

instance the work of Wolpe or Eysenck), giving rise to

early interventions such as (various forms of) exposure

and relaxation. Most of our received knowledge about

the effectiveness of humanistic therapies for GAD (and

other anxiety disorders), thus mainly comes from

CBT research, comparing CBT with a form of

psychotherapeutic placebo to control for nonspecific

relational factors. These placebo therapies were given

various names (e.g. nondirective therapy or supportive

therapy), but were often viewed as synonymous with

client-centred or humanistic psychotherapy. In many

cases, however, these controls were not bona fide

humanistic therapies performed by well-trained

humanistic therapists (for broader discussion of non– bona fide controls see Wampold & Imel, 2015). This

naturally led to thinking among humanistic theorists

and researchers that any potential superiority of CBT

therapies for generalised and other anxiety disorders

could be attributable to the artefact of using non–bona fide therapies in outcome studies (Timulak, 2003).

More recently, however, a meta-analysis conducted

by humanistic researchers (Elliott, Greenberg,

Watson, Timulak & Freire, 2013) has suggested that a

slight superiority of CBT over humanistic-experiential

therapies in the treatment of anxiety disorders may

remain, even after controlling for researcher

allegiance. This finding has led the authors of the

meta-analysis to call for the development of specific

humanistic approaches aimed at tackling specific

anxiety presentations; approaches which should go

beyond the generic humanistic approaches that often

served as a basis for the varied forms of supportive

therapy controls in CBT outcome studies.

Such developments typically stem from focused

programmes of research involving in-depth

examination of the phenomenology of the condition

(e.g. GAD), as well as intensive therapeutic case

studies examining the developed intervention as

applied to the treatment of that condition. Again,

there is a scarcity of programmatic research of this

kind among humanistic psychotherapy researchers.

It appears that humanistic therapies, such as client/

person-centred therapy, do similarly well as CBT in

treating depression (Barkham, Moller & Pybis, 2017),

where the offer of a caring, validating and

empathically attuned relationship can lead to the

mobilisation of inner resources that in turn

counteract the hopelessness and helplessness that

define this condition. In the case of anxiety

symptoms, however, CBTs offer an active approach

that enhances the client’s control over the anxiety-

inducing threat. Clients learn to face anxiety and in

doing so learn that unpleasant symptoms may abate

when they do not avoid situations that are perceived

as threatening or when they do not avoid the anxious

feelings themselves. Clients learn active ways of

coping with their discomfort (e.g. relaxation

techniques), and they learn how their perception of

threat is linked with their thinking and beliefs, thus

learning that this is something they can bring under

control. The development of humanistic therapies for

GAD and other anxiety disorders may therefore

perhaps benefit from a focus on identifying how to

mobilise clients’ efforts to overcome avoidance and

anxiety symptoms.

The latest developments in humanistic-experiential

therapies, particularly in emotion-focused therapy (a

research-informed approach that builds on the

traditions of client-centred and Gestalt therapy;

Greenberg, 2016), share some of this proactive thrust

with CBT, but do so in a genuinely client-centred and

experiential manner. They focus on the needs

implicit in the vulnerable feelings experienced by

clients, and recognising that the anxiety-provoking

threat has to be stood up to by the client, albeit on

the client’s own terms. Furthermore, humanistic-

Counselling and Psychotherapy Research, September 2018; 18(3): 233–236 © 2018 British Association for Counselling and Psychotherapy234

Humanistic-experiential therapies for anxiety L. Timulak

experiential therapies, in contrast to CBT, also

recognise that anxiety symptoms are often superficial

(secondary) expressions of vulnerability that the

client does not want to feel. For instance, emotion-

focused therapy (EFT) for social anxiety (Elliott &

Shahar, 2017) primarily targets an underlying shame

in social situations (e.g. “I will be seen as defective”)

rather than more superficial anxiety symptoms that

just signal the unbearable nature of such shame.

Similarly in GAD, generalised fears appear to be

idiosyncratically specific (O’Brien et al., 2017;

Timulak & McElvaney, 2017); hence, a mother’s

worrying about her children when they are away on

a school trip may be linked to an underlying sense of

being a bad mother for not protecting her children,

with this feeling that she is neglectful towards her

children is in turn rooted in painful memories of

what it felt like to be a lonely, unprotected child.

Emotion-focused therapy for GAD (Timulak &

McElvaney, 2017; Watson & Greenberg, 2017) also

targets worrying, the defining feature of GAD, but it

does so through highlighting the client’s agency in

the worrying (e.g. it is often something the client does

to him or herself to prepare him or herself for a

danger) and the impact and cost of the worrying (e.g.

a sense of constant threat and thus constant anxiety

and subsequent tiredness – for an empirical study see Murphy et al., 2017). EFT then, in the context of a

caring therapeutic relationship, accesses the core

chronic feelings (typically feelings of loneliness,

shame and fear), and the corresponding unmet needs

(for connection, validation and protection), that

underlie the anxiety triggered by various situations.

EFT helps the client to feel and bear those vulnerable

feelings, to articulate the needs embedded in them

and to generate transformative emotional experiences

of self-compassion (e.g. I feel protected and cared for)

and healthy, boundary-setting anger (e.g. I deserve to

live freely) in response to those needs. In particular,

healthy boundary-setting, protective anger is viewed

as an antidote to the threat of being, for instance,

traumatised, put down or abandoned. The generation

of protective anger builds emotional resilience in

clients, as well as a sense of strength, efficacy and

empowerment; a sense that in turn contributes

towards more proactive and less anxiety-prone self-

organisations.

The first research programmes examining EFT for

anxiety (e.g. generalised anxiety disorder and social

anxiety disorder) have started to appear. It is hoped

that these islands of enquiry will lead over time to a

critical mass of independent, although cross-

fertilising, research. These research programmes are

not only attempting to develop EFT as a therapy for

anxiety, but also seek to test its efficacy/effectiveness

(e.g. Shahar, Bar-Kalifa & Alon, 2017; L. Timulak, D.

Keogh, C. Chigwedere, C. Wilson, F. Ward, D. Hevey,

P. Griffin, L. Jacobs, B. Irwin, 2017, in review). It is

worth noting that these endeavours are taking place

in various countries (e.g. Canada, UK, Ireland and

Israel), where local political influences regarding the

delivery of mental health interventions may shape

both what is studied and the format of that study. For

instance, our studies on the efficacy of EFT for GAD

are carried out in the context of the Irish public

health service and are thus tailored for this type of

service (e.g. the length of therapy and qualification/

experience of therapists).

Despite such local variations, it is hoped that these

research programmes, carried out by different teams

in different jurisdictions, will yield results that in turn

will contribute on an international level to a

broadening of the options available to individuals

suffering from chronic psychological suffering where

symptoms of anxiety play a part. To fully achieve this,

there will have to be many independent endeavours,

all focused on the development of humanistic

therapies for GAD and other anxiety disorders and/or

their comparative testing against other treatments,

particularly CBT. One important issue that will need

to be addressed is the fact that CBT is relatively

amenable to various forms of delivery, and low-

intensity interventions based on CBT principles, such

as internet-based CBT (iCBT) or psychoeducational

programmes (that can be delivered by people with

less intensive training, e.g. psychological well-being

practitioners). The question remains as to whether it

will be possible to adapt humanistic therapies into

low-intensity formats. However, if humanistic

therapies are to find their way to public health

delivery, it is a question that will have to be

addressed.

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Biography

Ladislav Timulak, PhD is Associate Professor at

Trinity College Dublin, Ireland. He is Course Director

of the Doctorate in Counselling Psychology. His main

research interest is psychotherapy research,

particularly the development of emotion focused

therapy. He has written six books, over 70 peer

reviewed papers and various chapters in both his

native language, Slovak and in English. His most

recent books include Transforming Emotional Pain in

Psychotherapy: An Emotion-Focused Approach

(Routledge, 2015) and Transforming Generalized

Anxiety: An Emotion-Focused Approach (Routledge,

2017). He maintains a part-time private practice.

Counselling and Psychotherapy Research, September 2018; 18(3): 233–236 © 2018 British Association for Counselling and Psychotherapy236

Humanistic-experiential therapies for anxiety L. Timulak

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