**3. Trauma: a humanistic-existential perspective**

#### **3.1. Trauma: taking a different path**

tance of the "*here and now*" knowing that the only moment we directly experience is "*right now*"—as we become aware of ourselves in the world. The humanistic-existential psychologist is concerned with the human experience as a whole, and recognizes the meaning and value of nonhedonist emotions and experiences, such as suffering, conflict, grief, guilt, and death. Inevitable loss, mortality, and absurdity are part of the human condition and are recognized as existential universal realities that all beings have to face and adjust to with their unique, creative, yet complex manner [8]. Those existential challenges and the suffering that comes with it are normal, but are also worthy and may be transforming. As such, suffering may open an opportunity for change and for potential healing and growing. Humanistic-existential psychotherapists have genuine interest and curiosity for every individual potential for

182 A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice

The etymology of the term "*healing*" refers to "*wholeness*" or being "*whole*." From the humanistic-existential point of view, psychotherapy may signify "*to make more whole*." Wholeness may therefore be understood as a sense of completeness, integrity, and coherence. It may as well mean to exist more fully as a human being, including with the condition of being mortal. For May [10], health and healing means "*to experience more fully, deeply, consciously, and authentically one's existence*." The psychotherapy process consequently involves the exploration of barriers people may have, preventing them from experiencing and expressing their freedom in choices and will [11, 12]. Healing may as well be understood as a process that leads to a deeper and fuller engagement with the self, with others, and with the world. As Jager [13] puts it, "*being human means standing in a relationship to others, to things, and to the world*." Healing may therefore occur in a relationship that allows the narration and reflection of one's subjective experience. The other's presence can be understood as a key allowing us to become more aware of

It is within the clinical encounter that the process of healing can occur. The psychotherapeutic relationship involves the validation and value of the individual's unique way of being. It also implies the recognition of the singular contribution of the therapist's subjectivity. Hence, the psychotherapeutic encounter can be understood as a process of shared discovery in which the meaning of the patient's lived experience is explored, understood, and eventually transformed. Repeated events of "*meaning*" and of mutual comprehension of the patient's lived experience may allow a deeper awareness and more freedom of choice and will. New freedom, allowed and supported by the therapeutic relationship, opens up the possibility to seek and cocreate new meanings. The psychotherapist is therefore involved in articulating, comprehending,

The humanistic-existential therapeutic encounter, as a unique and intersubjective space of cocreation, aims at supporting, promoting, or restoring the individual's fundamental sense of self-cohesion [16]. As Quintin [15] puts it, psychological suffering is not something that can be fixed with expertise, opinions, or advices. The humanistic-existential stance rather refers to a

growing and healing.

**2.2. Human potential for growing and healing**

ourselves, of the other, and of the world [14].

**2.3. Healing together: the humanistic-existential encounter**

validating, and contributing to the patient's search of meaning [15].

In this section, we will explore how the humanistic-existential approach may shed a different light on the trauma experience and healing process. To do so, we will see how the humanistic-existential perspective can complement the bio-medical model, as both stem from distinct epistemological roots. Hence, we will review the common definitions of PTSD and will introduce the notions of subjectivity and meaning in trauma comprehension, recognition, and healing.

The humanistic-existential approach is concerned with how the individual experiment himself in the world. Therefore, it relies on the subjective experience and on its idiographic meaning as the starting point of comprehension and healing. From its Greek origin "*idios*," idiographic notably means "*applying to the individual*." Thus, idiographic exploration focuses on understanding the individual as a unique, holistic, and complex entity. It depends on detailed and descriptive explorations such as biography and case study to develop in-depth and intimate comprehension of the unique individual experience. Idiographic understandings are often contrasted with "*nomothetic*" research or assessment that primarily focuses on uncovering general patterns of behavior having a normative basis. For instance, nomothetic research on PTSD may want to develop an objective description of its symptomatology and to identify its risk factors and predictors of recovery. Such knowledge would apply to people generally as patterns, statements, or laws [18].

Another epistemological distinction may be necessary to understand how the humanisticexistential approach can complement the dominant psychopathology-centered model. Within the biomedical approach, PTSD is considered as a disorder, with universal characteristic features known as "*symptoms*." It is understood as an entity that exists "*objectively*" as long as its diagnosis criteria are met, despite contexts, nations, or culture. For instance, we may state that *Hannah*—who is a Holocaust survivor—and *Gloria*—who recently witnessed a major car accident—both suffer from PTSD, as they present with similar symptoms such as nightmares, avoidance, flashbacks, difficulty to concentrate, and mood alteration. Such a statement would refer to an "*etic*" approach to PTSD that is not specific to particular contexts, cultures, or nations. On the other hand, an *emic* perspective may try to develop a singular yet complex comprehension of Hannah's and Gloria's lived experiences of trauma. It would deeply explore their subjective world and the different meaning of their experience. It would inquire: "*How is it like to experience trauma for Hannah*"? *"How is it like for Gloria"?*

Based on its basic premises, the humanistic-existential perspective would necessarily approach trauma with an emic-idiographic perspective, as opposed to the etic-nomothetic stance. It may try to look beyond symptom and diagnosis to approach the unique meaning that trauma takes for a specific individual at this particular moment in his life.

#### **3.2. Beyond symptoms: the invisible wound**

Commonly accepted descriptions of PTSD involve exposure to a traumatic event that meets specific stipulations and symptoms [19]. The Diagnostic and Statistical Manual of Mental Disorder (DSM-5) currently identifies the trigger to PTSD as exposure to actual or threatened death, serious injury, or sexual violation. Different categories of symptoms characterize PTSD symptoms from each of four symptom clusters: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity (p. 271).

By the nature of its definition, DSM-5 identifies a traumatic event as a trigger to the disorder. The resulting disorder may be understood as the indicator of an invisible wound left by the traumatic event. Therefore, the traumatic event is not the pathology, but rather the event that disrupted someone's existence, by revealing major existential threats: finiteness, disintegration, and assaults to integrity and dignity of the self and/or of a fellow human being. As Greening [1] evokes:

"*What happens when we are traumatized? In addition to the physical, neurological and emotional trauma, we experience a fundamental assault on our right to live, on our personal sense of worth, and further, on our sense that the world (including people) basically supports human life. Our relationship with existence itself is shattered. Existence in this sense includes all the meaning structures that tell us we are a valued and viable part of the fabric of life*."

Greening captures the essence of the lived experience of trauma, and points out the deep disruption of existential meaning that it reveals. Surviving trauma is like waking up in a world that does not make sense anymore. In his book "*Shattered Assumptions*," Janoff-Bulman [17] argues how trauma devastates our experience and understanding of the world we live in. Healthy human development throughout childhood is indeed facilitated by a perception of the world as being safe, benevolent, and meaningful, and the self as worthy. However, such beliefs could also contribute to the development of an "*illusion of invulnerability*" or, in existential terms, of avoidance of the part of absurdity of the human condition. Trauma reveals something about existence that cannot be integrated in a coherent and meaningful understanding of the self and the world. Symptoms are often seen as the biological, the psychological, and the existential self who is trying to adjust and integrate the meaning of what happened and, most importantly, the meaning of one's existence given a new existential reality.

As such, trauma survivors cannot heal from trauma unless they are supported as whole beings [6], including their existential self. Striving for health, wholeness, and meaning may be facilitated by the humanistic-existential encounter. This psychotherapeutic process first involves the exploration of the lived experience of trauma, of its meaning, and of past existential assumptions that have been shattered. It also involves building and cultivating new awareness of what is still meaningful for an individual. Increasing existential awareness allows the exploration of new, different, and meaningful ways to connect to self, to others, and to the world. As such, it evokes not only healing, but also existential growing.

Humanistic and existential psychology has the premise that the human being has an inner tendency and potential for healing, but also for growing [5]. Hence, we can ask how people grow from trauma. Tedeschi and Calhoun [20] coined the term *posttraumatic growth* to capture the positive psychological changes they had witnessed as clinical psychologists among their patients who were coming to terms with highly stressful and challenging life events. "*Posttraumatic growth*" refers to the transformative process that can lead to positive changes after trauma. It has been a fertile notion to capture the transformation that may occur from gaining more existential awareness, and how it can transform one's relationship to self, to others, and to the world.

Of course, as trauma itself, posttraumatic growth is complex [21]. Its relationship with the trauma itself may be multifaceted. Here, we do not aim at reviewing the concept exhaustively, but explore the type of transformations that may be experienced by individuals who experience trauma. Our synthesis of diverse writings reveals indeed that there are new ways of relating and connecting to self, to others, and the world. Well-known transformation resulting from trauma reported by patients include: "*changes in the self*" or in the "*relationship to the self*." Such changes may take the form of an increased perception of personal strength, maturity, and spirituality [22]. An increased sense of personal worth and acceptance of one's vulnerability, sensibility, and humanity have also been reported by trauma survivors.

Such personal transformation with the relationship to self may also be mirrored in the experience of relating to others. Patients who survived trauma and healed from it are often moved by the compassion, sensibility, and care of others; feeling better connected to the people surrounding them, and experiencing more deeply or more consciously the preciousness of existing bonds.

Greater awareness and gratitude spread out and contribute to "*a greater appreciation for life*" in general [20, 23]. In fact, in a study examining the role of gratitude in PTSD in a sample of Vietnam War veterans, it is suggested that the experience of gratitude may be integral to this process of healing from trauma. For survivors, more gratitude may mean more pleasure in the small things in life, identification of new possibilities for one's life [22]. Enhanced appreciation of life itself has also been reported. For many, trauma was a trigger to reflect on life's meaning and absurdity. Despite distress, getting more awareness to the suffering aspects of life may also mean more awareness of its humanity and beauty. Existential awareness may allow clarity of life priorities, and more freedom to see "*new opportunities*." In short, for some people, healing and growing from trauma transformed their experience of the world itself.

#### **3.3. Growing from adversity**

Based on its basic premises, the humanistic-existential perspective would necessarily approach trauma with an emic-idiographic perspective, as opposed to the etic-nomothetic stance. It may try to look beyond symptom and diagnosis to approach the unique meaning that trauma takes

Commonly accepted descriptions of PTSD involve exposure to a traumatic event that meets specific stipulations and symptoms [19]. The Diagnostic and Statistical Manual of Mental Disorder (DSM-5) currently identifies the trigger to PTSD as exposure to actual or threatened death, serious injury, or sexual violation. Different categories of symptoms characterize PTSD symptoms from each of four symptom clusters: intrusion, avoidance, negative alterations in

By the nature of its definition, DSM-5 identifies a traumatic event as a trigger to the disorder. The resulting disorder may be understood as the indicator of an invisible wound left by the traumatic event. Therefore, the traumatic event is not the pathology, but rather the event that disrupted someone's existence, by revealing major existential threats: finiteness, disintegration, and assaults to integrity and dignity of the self and/or of a fellow human being. As

"*What happens when we are traumatized? In addition to the physical, neurological and emotional trauma, we experience a fundamental assault on our right to live, on our personal sense of worth, and further, on our sense that the world (including people) basically supports human life. Our relationship with existence itself is shattered. Existence in this sense includes all the meaning structures that tell us we are a valued and viable part of the*

Greening captures the essence of the lived experience of trauma, and points out the deep disruption of existential meaning that it reveals. Surviving trauma is like waking up in a world that does not make sense anymore. In his book "*Shattered Assumptions*," Janoff-Bulman [17] argues how trauma devastates our experience and understanding of the world we live in. Healthy human development throughout childhood is indeed facilitated by a perception of the world as being safe, benevolent, and meaningful, and the self as worthy. However, such beliefs could also contribute to the development of an "*illusion of invulnerability*" or, in existential terms, of avoidance of the part of absurdity of the human condition. Trauma reveals something about existence that cannot be integrated in a coherent and meaningful understanding of the self and the world. Symptoms are often seen as the biological, the psychological, and the existential self who is trying to adjust and integrate the meaning of what happened

and, most importantly, the meaning of one's existence given a new existential reality.

As such, trauma survivors cannot heal from trauma unless they are supported as whole beings [6], including their existential self. Striving for health, wholeness, and meaning may be facilitated by the humanistic-existential encounter. This psychotherapeutic process first involves the exploration of the lived experience of trauma, of its meaning, and of past existential assumptions that have been shattered. It also involves building and cultivating new

for a specific individual at this particular moment in his life.

184 A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice

cognitions and mood, and alterations in arousal and reactivity (p. 271).

**3.2. Beyond symptoms: the invisible wound**

Greening [1] evokes:

*fabric of life*."

A recent review of posttraumatic growth among individuals who had suffered severe physical injuries particularly caught our attention to understand the essential meaning of posttraumatic growth. Based on the meta-synthesis of qualitative research conducted with physically injured trauma survivors, Kampman et al. [24] tried to capture the meaning of such an experience. The analysis highlights essential themes to describe the significance posttraumatic growth may take for physically impaired individuals following trauma.

First, the analysis suggests that the trauma experience forced individuals to question the very basis of their existence. It deeply moved them from their essential core. The findings of Kampman et al. highlight how traumatic injury may trigger existential awareness and force individuals to deeply reflect on the meaning and purpose of their lives. Posttraumatic growth also involves the contemplation and acknowledgment of the unchanged aspects of life, as well as the recognition of the changed aspects of life that are positive. Such an increase in existential awareness may lead to greater sense of meaning and purpose in life. Kampman et al. also noted in individuals a new awareness for physiological and psychological potential despite limitations, and gratitude for the fulfilling meaningful aspects of life that remain unchanged and that can still be part of life (e.g., physical activity, arts, travel). In other terms, it allowed people to experiment their world more fully and more consciously.

Finally, Kampman et al. insist on the deep personal qualities that can be developed from the experience of suffering. In fact, this is reflected in the statement of a participant in Salick and Auerbach (2006) study [cited by 24, p. 289]: "*I guess suffering makes you feel more human. You relate to other people*." Kampman et al.'s essential theme "*humanity*" tries to capture the increased sense of humanity developed among trauma participants. The authors define this new sense of humanity by altruism, kindness, and act of love toward fellow human beings.

#### **3.4. Posttraumatic growth and existential awareness: making the invisible more visible**

Posttraumatic growth can be comprehended as the increased existential awareness that is triggered by the traumatic event. Of course, the experience of trauma is not sufficient in itself to facilitate existential growth [20]. However, one of the recurrent themes in understanding the meaning of posttraumatic growth is the enlargement of existential awareness. Such awareness accounts for fuller appreciation of life and gratitude for the different sources of meaning in life remaining unchanged. Existential awareness may trigger an existential wound, but also reveal existential meaning.

Existential meaning in life was notably introduced in clinical psychology by Viktor E. Frankl (1905–1997). One cannot fully appreciate Frankl's work without considering his exceptional life's story. Austrian and born in Vienna from a Jewish family, psychiatrist and neurologist, Frankl lived for 3 years in different concentration camps during World War II. This period of suffering helped him to pursue the development of the existential approach.

Alongside with the premises of humanistic-existential psychology, the psychotherapeutic approach of Victor E. Frankl is based on meaning and responsibility. It is also based on the premise that human beings need to find a meaning to their life. Like the humanistic-existential movement, Frankl's approach is characterized by a unified understanding of all dimensions of a human being: physical, psychological, and existential. For Frankl, the existential self is the core of the human being, the essence of our humanity. This existential self carries in itself the drive of its expression and recognizes the occasions that allow this expression. It contains resources that the individual can mobilize, allowing him to face disturbing and traumatizing situations.

Frankl had three more deep convictions about human being: (1) *The liberty of choice*, which supports that human beings carry the liberty and capacity of finding a meaning as long as they are conscious. Liberty of choice does not deny biological, psychological, or psychosocial determiners, but rather refers to the human capacity of consciously choosing an attitude when facing conditions of life. Frankl also believed in (2) *the choice of meaning*, which maintains that human beings possess an intrinsic will of finding meaning in life. Last, Frankl put forward the third concept (3) *meaning of life* which states that human beings know deep down inside that life has a meaning. The principle of the choice of meaning reminds us that human beings are motivated to find a meaning to their lives, that they are attracted by this search for meaning, rather than being pushed to act by some force or drive. Finally, the meaning of life refers to the meaning that each person gives to particular moments of his life, and not to a universal ultimate meaning that could be revealed at the end of life.

#### **3.5. Man's search for meaning**

trauma survivors, Kampman et al. [24] tried to capture the meaning of such an experience. The analysis highlights essential themes to describe the significance posttraumatic growth may

First, the analysis suggests that the trauma experience forced individuals to question the very basis of their existence. It deeply moved them from their essential core. The findings of Kampman et al. highlight how traumatic injury may trigger existential awareness and force individuals to deeply reflect on the meaning and purpose of their lives. Posttraumatic growth also involves the contemplation and acknowledgment of the unchanged aspects of life, as well as the recognition of the changed aspects of life that are positive. Such an increase in existential awareness may lead to greater sense of meaning and purpose in life. Kampman et al. also noted in individuals a new awareness for physiological and psychological potential despite limitations, and gratitude for the fulfilling meaningful aspects of life that remain unchanged and that can still be part of life (e.g., physical activity, arts, travel). In other terms, it allowed people

Finally, Kampman et al. insist on the deep personal qualities that can be developed from the experience of suffering. In fact, this is reflected in the statement of a participant in Salick and Auerbach (2006) study [cited by 24, p. 289]: "*I guess suffering makes you feel more human. You relate to other people*." Kampman et al.'s essential theme "*humanity*" tries to capture the increased sense of humanity developed among trauma participants. The authors define this new sense

of humanity by altruism, kindness, and act of love toward fellow human beings.

**3.4. Posttraumatic growth and existential awareness: making the invisible more visible**

Posttraumatic growth can be comprehended as the increased existential awareness that is triggered by the traumatic event. Of course, the experience of trauma is not sufficient in itself to facilitate existential growth [20]. However, one of the recurrent themes in understanding the meaning of posttraumatic growth is the enlargement of existential awareness. Such awareness accounts for fuller appreciation of life and gratitude for the different sources of meaning in life remaining unchanged. Existential awareness may trigger an existential

Existential meaning in life was notably introduced in clinical psychology by Viktor E. Frankl (1905–1997). One cannot fully appreciate Frankl's work without considering his exceptional life's story. Austrian and born in Vienna from a Jewish family, psychiatrist and neurologist, Frankl lived for 3 years in different concentration camps during World War II. This period of

Alongside with the premises of humanistic-existential psychology, the psychotherapeutic approach of Victor E. Frankl is based on meaning and responsibility. It is also based on the premise that human beings need to find a meaning to their life. Like the humanistic-existential movement, Frankl's approach is characterized by a unified understanding of all dimensions of a human being: physical, psychological, and existential. For Frankl, the existential self is the core of the human being, the essence of our humanity. This existential self carries in itself the drive of its expression and recognizes the occasions that allow this expression. It contains

suffering helped him to pursue the development of the existential approach.

take for physically impaired individuals following trauma.

186 A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice

to experiment their world more fully and more consciously.

wound, but also reveal existential meaning.

For Frankl, three avenues contribute to give meaning to life: (1) *creative*, (2) *attitudinal*, and (3) *experiential values*. All these represent reasons why life has meaning. Deep recognition, concrete embodiment, and full awareness of these values allow human beings to face suffering and absurdity of the modern world.

*Creative values* represent what we bring to the world and those around us, anything we contribute to and create. Those values include, among other things, the meal that we prepare or the comfort we bring to a patient. What makes those simple actions significant is the level of consciousness in which they are set in. No matter how those actions can seem common, recognizing our contribution to a situation or to someone else's life adds to the meaning of our own life and brings satisfaction.

*Experiential values* signify that meaning can emerge from experiences as simple as appreciating beauty, whether it is artistic, natural, or in the experience of love; in fact, everything that is given to us, that we did not need to work for. The natural beauty of mountains, masterpieces of artists, as well as encouraging and loving relationships are given gratuitously and help us find a meaning and reasons to live. To Frankl, the salvation of man resides in his capacity to love (and to appreciate). Even if life can be generous and has the possibility to add meaning to our existence, a lack of consciousness and sensibility can keep us from seeing and enjoying it. Therefore, increasing our presence and consciousness is necessary to benefit from experiential values.

For Frankl, the third source of meaning resides in *attitudinal values*. He explains that meaning can come from the acceptance of situations that we cannot change and through a change of attitude toward inalterable situations. For example, death situations that involve physical, mental, and emotional suffering have the potential to bring meaning to the life of an individual and his family. Frankl suggests that human beings develop a greater spiritual and existential maturity and grow out of suffering, which can be enriching and strengthening. As such, Frankl deeply believed that the suffering experienced from trauma may be transformed in an opportunity for growth. When the physical self, or even the psychological self, are threatened by trauma, the individual faces new forms of suffering. To be tolerated, this suffering has to be transformed in opportunities to find meaning. The possibility to give a meaning diminishes psychological suffering. Inevitable suffering can offer the opportunity to discover a meaning. Conscience is the tool that enables the identification or discovery of meaning. For Frankl, despite life experiences, human beings always have an opportunity to discover a meaning through creative, experiential, and attitudinal values.

For Frankl, if living necessarily involves suffering, surviving means giving meaning to suffering. As such, surviving from trauma would mean giving meaning to suffering and searching for new life meanings. Frankl's approach, alongside with humanistic-existential basic premises on human being, healing and growing offers support to explore, identify, and transform the experience of suffering from trauma. In the following section, we will explore how the humanist-existential approach, inspired by Frankl's theory among others, can concretely inspire psychotherapy with PTSD patients.
