Using Feminist and Existentialist Therapies to Treat Depression

Sam is a 24 year old heterosexual Caucasian man who has a self-reported history of depression. He is a high achiever, has an engineering degree with honours, a mid-teens golf handicap and has completed three marathons, but doesn’t feel proud of his achievements. He has no girlfriend and has not been in a relationship since his teens. He reports being bullied for several years early in high school mostly, he says, because of his femininity. He says that over the years he has also been labelled or accused of being gay, in derogatory terms, because he does not demonstrate overtly masculine traits. Throughout his bullying period, he had no friends and his family struggled to provide the emotional support he needed. He wants to try feminist therapy (FT) because he feels the therapist may help him come to terms with his femininity. He sees it, or primarily his lack of adjustment to it, as the possible root cause of his ongoing battle with depression. His current dissatisfaction with his personal situation, despite his achievements, has him questioning the meaning of life, so he is also curious about existential therapy (ET). He hopes to find a therapist who will blend the two approaches. This article will describe how these therapies work, how they might be combined, and how they may help Sam.

Sam’s choice to see a feminist therapist is perhaps based in the knowledge that feminist therapists don’t just work with women, although this was originally the case when FT first began (Corey, 2013). Springing from the so-called ‘second wave’ of feminism in the 1960s, FT rejected the notion that biological differences between men and women should decide what roles they played in society (Thomas, 1977). Influenced at the time by discrimination, heterosexism and violence against women (Kahn, 2010), it had its origins in focus groups attended by female psychotherapists and counsellors, who emerged changed by their experience in these sessions (Israeli & Santor, 2000). Originally fuelled by a significant amount of research showing gender bias, FT has also had to deal with a recent political swing to the right, especially in the US, which has seen emotional expression blunted somewhat, as well as a relabelling of psychotherapy as ‘behavioural care’, which has not been helpful (Hill, 2005). As distinct from other therapies, FT has no significant founders, although there have been many influential contributors to its theory, such as Miller, Enns, Espin and Brown in recent decades (Corey, 2013).

A core concept of FT is the recognition given to the psychological disadvantages that women have faced due to societal expectations and prejudices (Sands & Howard-Hamilton, 1995; Thomas, 1977). FT is an eclectic mix of techniques that have common themes around empowerment, gender role awareness and acceptance of the fluid nature of gender, undefined by biology (Kahn, 2014). It has evolved from its original derivation as the antithesis to existing male dominated traditional therapies (Thomas, 1977) to be more inclusive, aiming to transform the norms for male and female health into a singular standard; an androgynous model that does not have masculinity as a norm for behaviour like some older therapies such as psychoanalysis and behaviourism (Ganley, 1991; Porter, 2005). With its more androgynous approach, FT proposes that gender be seen as a spectrum, rather than a dichotomy, where females and males can sit anywhere on a continuum as it suits them (Ganley, 1991).

FT is not deterministic, seeking instead to allow clients to define what their gender identification means to them (Corey, 2013) and in this respect is similar to the Person Centred Therapy created by Carl Rogers and others. FT also strives for equality between therapist and client, as distinct from many contemporary theories where the balance of power in determining a particular course of action is shifted towards either the therapist or the client (Rader & Gilbert, 2005).

In therapy, the goals of FT are to help individuals self disclose (Ganley, 1991), gain more power over their own destiny (Corey, 2013), and to have better self awareness of who they are through their gender identification with respect to societal demands (Kahn, 2010).

The role of the feminist therapist is to understand how the still dominant male paradigm affects their client (Kahn, 2010; Porter, 2005). They are encouraged to share of themselves if they have a relevant but equally poignant story of their own brush with feminine oppression (Thomas, 1977). The client-therapist relationship should be collaborative, where the therapist discloses their own values to the client. In this case, Sam should be valued as a feminine man and given the understanding that he has unique contributions he can make to society as a result (Kahn, 2010).

Given Sam’s present life situation, where he seems to be searching for a form of happiness, his therapist may also wish to employ Existential Therapy (ET). With its acceptance of anxiety as a natural human condition (Varvatsoulias, 2015), ET presents a possible mechanism by which Sam can understand how he has grown through the anxiety generated by his struggles with his gender.

Having a much earlier origin than feminist therapy, ET has also not arisen primarily from the work of one or two individuals (Corey, 2013). Beginning with nineteenth century philosophers Kierkegaard and Nietzsche, existentialism was enhanced by Heidegger, Buber, Binswanger, Boss and Sartre in the twentieth century, becoming a therapeutic technique in the process. Later important contributors such as Frankl, May and Yalom helped solidify the core concepts of ET into a cohesive approach (Corey, 2013).

According to ET theory, humans mostly choose who and what they want to be, with fate only playing a small part (Corey, 2013). Humans are always evolving through their life choices (Varvatsoulias, 2015), and when they find themselves in an existential vacuum (in other words, feeling empty and alienated from society, without meaning), they may resort to unacceptable behaviour, have relationship problems or suffer addictions. ET provides a way of avoiding these situations by establishing meaning in one’s life (Schulenberg, Hutzell, Nassif and Rogina, 2008). Frankl believed that the search for meaning and purpose in life was a core quest of all humans, even if it was occasionally or even regularly diverted by day-to-day living (Corey, 2013).

Human existence has limits and a certain amount of tragedy, says existential theory, but also provides opportunities and possibilities. Humans have free will to make choices in life, react to those choices, and to establish an identity in relation to others (Corey, 2013). This, says Heidegger, is represented by dasein, a German word which refers to a person’s way of being in the world: their reaction to it (Daitz, 2011). The existential approach prefers to consider human experience in its totality and how it affects the individual, rather than treating a mental condition purely as an illness or dysfunction, as some other therapies do (Rayner & Vitali, 2016).

The goal of a therapist applying an existential approach is to help the client to understand and appreciate their life as it currently is, along with what it might be in the future, rather than dwelling too much on the past (Varvatsoulias, 2015). The individual is brought to an understanding of their place in the world due to their engagement with it (Daitz, 2011). The therapist aims to evaluate what is working or not in the client’s life, in terms of their attitude and approach to their life situation (Madison, 2014).

The role of the existential therapist is to regard the client as a human being, with value, and to help make them aware of their existence and importance in the world (Schulenberg et al., 2008). With the client potentially feeling vulnerable, the therapist can provide a mirror to this, either supporting them or providing an alternative view to the situation. Either way, it helps the client get a sense of how they are responding to their life’s situation (Leroux, Sperlinger, & Worrell, 2007). The therapist needs to be open and respectful, allowing the client to objectively search for their own truth, as well as their passion. This process could be continually evolving (Daitz, 2011). Herein lies a difference with FT, in that FT is more collaborative: more of a partnership. The therapist combining both therapies will need to choose which approach to take.

Will both feminist and existential therapies be useful in dealing with Sam’s life situation? His decision to seek psychological help puts him in a minority of men who do so, relative to women (Wahto & Swift, 2016). Depression is generally characterised by a sad mood, and can include any of the following: loss of interest, lower energy, trouble concentrating, changes in appetite, guilt & self-criticism, feelings of isolation or even suicidal ideation (Coleman, 2012).

Depression is often caused by many factors acting together. It can be caused by poor relationships, a lack of emotional support, or inadequate social integration (Wasserman, 2011). People with depression often take the blame for their condition, when it isn’t their fault (Coleman, 2012).

Power and control in today’s society results from masculinity, and is seen as an ideal for men to strive for (Wahto & Swift, 2016). Men are taught from a young age to be physically tough, self-sufficient and to control their emotions. Outward signs to the contrary can often result in the person being treated somewhat as a pariah, and can contribute to depression (McCusker & Galupo, 2011).

A point of difference between the two approaches occurs here. FT may say that Sam’s femininity wasn’t really amongst his life choices and taking responsibility for it may be contributing to his depression. On the other hand, ET might say that Sam is too focussed on what has happened in the past, and should celebrate who he is now and be proud. Sam’s therapist may choose to encourage one of these views, or to put them both forward for him to think about.

ET has evolved in recent decades from a somewhat male-dominated line of thinking to be more inclusive of the contributions of women (Kass, 2014), while FT has gone the other way, starting out with a female focus, then gradually becoming more applicable to males (Kahn, 2010). Thus, it may be easier to integrate the two theories than it was in the past. ET has a core theme of coming to terms with life choices and ways of being in the present (Daitz, 2011), while FT aims to facilitate control over one’s destiny (Corey, 2013): a point of compatibility between the two approaches.

Clients may find ET somewhat intimidating when they first start (Corey, 2013). This can be due to feeling vulnerable, as they try to explore core themes of where they feel their life is going (Leroux et al., 2007). In this case, Sam’s self-disclosure of depression is a good place to start for the therapist, as self-disclosure is one of the aims of ET. The therapist may also choose to highlight to Sam that his choice to attend therapy means he has overcome the stigmatisation that often goes with such a choice (McCusker & Galupo, 2011).

Seeking psychological help and talking about one’s feelings is still considered a feminine activity, and not associated with strength of character (Wahto & Swift, 2016). However, one of the core concepts of FT is to promote femininity as having just as much strength as masculinity, and overturning sexism and socialisations of sex roles (Ganley, 1991). This promotion of femininity as a strength can be empowering, and highlighting of one’s strengths has been shown to be effective in dealing with depression (Johnson, 2003).

Characterised by a relative absence of specific techniques, ET instead aims to allow the person to feel and experience the current emotions in their life situation, rather than moving too quickly through them (Madison, 2014). A technique known as Socratic questioning may be used, whereby the client is questioned so as to facilitate internal exploration aimed at uncovering life meanings, with appropriate action to follow (Schulenberg et al., 2008). Socratic dialogues can be valuable for the client in finding truth in their lives (Kass, 2014).

Another more recent ET technique known as Existential Experimentation has recently shown promise. It is a short term integrative therapy with a series of questionnaires forming part of a phenomenological therapeutic approach. It has been shown to be very successful in dealing with depression and anxiety (Rayner & Vitali, 2016). There is relatively little research on this approach however, so Sam’s therapist may not yet be comfortable in using it.

An FT technique known as reframing (Corey, 2013) may help Sam to consider social factors in his life, such as his bullies, rather than blaming himself for his supposed weakness in being feminine. Relabelling is a similar technique which may help him to not consider himself in negative terms, but to express a characteristic positively instead (Corey, 2013). In Sam’s case, he is not “soft”, and is instead more “caring and thoughtful” than most.

The therapist can also use the FT technique of gender-role analysis (Israeli & Santor, 2000), analysing the effect of social expectations at the time of Sam’s bullying in a closed school environment, and social expectations now that he is older and can choose the people around him. Consciousness-raising can also be employed, making Sam aware that others (celebrities, perhaps) are in similar situations to him, and that he is not alone (Israeli & Santor, 2000). Empowering the individual to be strong in their identity and not accept the passive role dictated by society has been shown to be an effective therapeutic approach (Sands & Howard-Hamilton, 1995).

The two therapies (FT and ET) should work well together. FT has its focus on empowerment, acceptance of self and the individual gaining awareness of their place in society in terms of their femininity (Corey, 2013). ET is focussed on ways of being in the world (dasein), which allows the FT concept of empowerment to change the way the individual reacts with their world – bringing about a healthier dasein. ET says that humans can deny or evade their existence and be inauthentic, or they can see potentials and be open, or authentic; the preferred option (Daitz, 2011). With this in mind, the FT concept of self-awareness can mesh with the authentic dasein of ET and provide a stronger identity for the patient.

Both therapies have made significant contributions to Psychology. ET has provided a philosophical context that moves beyond medical models and diagnoses of conditions (Madison, 2014). It can be integrated with almost any therapy as a result.

FT has been influential in understanding the important of gender within a psychotherapy context (Kahn, 2010). As such, there is now an increased emphasis in society to accept femininity as having strength and, to Sam’s benefit, to allow males to be accepted if they adopt more ‘traditional’ feminine traits such as expressiveness, nurturing and empathy. Indeed, the aim of FT is to eschew defining these traits as especially feminine (Ganley, 1991).

FT still has to overcome its limitations, however, as does ET. Both are still considered to be in the domain of white folk, especially males in the case of ET, although this situation is improving (Kass, 2014). FT is also taking steps to address the cultural imbalance, with some writers pushing for inclusiveness of all genders, races and cultures (Porter, 2005).

Another potential limitation is that a client visiting a practitioner of ET may be expected to overcome or deal with environmental circumstances when in reality, after they leave the therapist’s office, this is hard to do (Corey, 2013). Similarly, a client may feel safe and supported in the collaborative equality of the FT office, but isn’t able to reproduce that environment when they return home (Rader & Gilbert, 2005).

Nonetheless, Sam has chosen a good mix of therapies for his situation. He wants to find meaning in life now that he is older, his career is established and he has achieved some life goals and worked hard. With acceptance of his feminine nature now a priority, and with feminine therapists increasingly allowing for male clients, he may find an understanding and sympathetic therapist who can help him embrace his femininity and find meaning and dasein in his life that brings him the happiness he seeks.

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