by Brent Schnipke, MD, and Michael MacKay, DO
Both authors are with Wright State University Boonshoft School of Medicine in Dayton, Ohio.
Funding: No funding was provided for this study.
Disclosures: The authors have no conflicts of interest relevant to the content of this article.
Innov Clin Neurosci. 2023;20(1–3):72–75.
Department Editor
Julie P. Gentile, MD, is Professor and Chair of the Department of Psychiatry at Wright State University in Dayton, Ohio.
Editor’s Note
The patient cases presented in Psychotherapy Rounds are composite cases written to illustrate certain diagnostic characteristics and to instruct on treatment techniques. The composite cases are not real patients in treatment. Any resemblance to a real patient is purely coincidental.
Abstract
Existential issues are common in patient experiences and can present as themes in any practice setting, but particularly in psychotherapy. Existential issues are any concerns that arise from distress or questions about difficult subjects, such as death, meaning, freedom, and isolation, and can be a source of psychiatric concerns or simply a modifying factor. Because of this, clinicians should be able to recognize and understand the basic tenets of addressing existential issues in psychotherapy. This article outlines the historical context and theoretical basis of existentialism. It also discusses existential issues in relation to psychotherapy and provides practical clinical tips for addressing these issues with patients, including helpful probing questions, tips for noticing existential themes, and ideas about how to address existential issues in session.
Keywords: Anxiety, death and dying, existentialism, existential psychotherapy, psychodynamic psychotherapy
Since the advent of psychoanalysis at the end of the 19th century and the subsequent development of psychotherapy as an established discipline, therapists have been developing new iterations of therapy based on evolving therapeutic models. It is difficult to quantify exactly how many types of psychotherapy there are now; estimates of distinct types of psychotherapy are in the hundreds. Robert Coles wrote that “there are as many types of psychotherapy as there are psychotherapists,” which highlights the important idea that each individual therapist, despite specific training, background, and alliance to a certain school of thought, will develop their own style and particular emphasis.1
Even so, major academic communities typically describe a few broad approaches to psychotherapy, with various subgroups: cognitive therapies, behavioral therapies, psychodynamic therapies, humanistic therapies, and eclectic therapies (which draw from two or more of the other categories).2 In this article, we briefly discuss existential psychotherapy, which is best classified as an eclectic therapy with strong roots in both psychodynamic and humanistic therapies, but which some experts consider a subtype of humanistic therapy. More broadly, however, existential issues are prominent in many types of psychotherapy, and these issues tend to be important components of common presenting problems. This idea is reflected in more recent systems, such as the biopsychosocial model of patient care. Some people have proposed a fourth dimension, existential, be included routinely in biopsychosocial formulations.3
We propose that existential psychotherapy provides a useful model of formulation and another way of considering common patient concerns. In this way, the existential approach can be used alongside other models of formulation, rather than being considered an entirely separate mode of psychotherapy. In this article, we briefly review the history of existentialism and the development of existential psychotherapies, outline the existential themes and common issues and techniques encountered in existential psychotherapy, describe the similarities and differences with other common theories of dynamic formulation, and present fictional case vignettes that highlight practical applications of existential psychotherapy.
Brief History of Existentialism
The ideas that have come to be defined as existential have arguably existed since the earliest human experiences. In the history of Western philosophy, the seeds of existential thought could be glimpsed as early as the Roman stoics. Between 100 and 200AD, three separate individuals, Seneca, Epictetus, and Marcus Aurelius, from disparate social positions, were unified in their writings on promoting personal choice and responsibility and addressing death. The Latin phrase memento mori (remember that you must die) has been associated with stoics, such as Aurelius, as they did not wish to avoid the topic of death; rather, they aimed to acknowledge the importance of one’s future and uncertain death as a way to remain focused on the present experience.4
In 19th century Europe, there was a trend in philosophy that was more focused on the individual’s relationship with the world. Two particular writers, Soren Kierkegaard and Friedrich Nietzsche, informally known as the grandfathers of existentialism, were at the forefront of this movement. While Kierkegaard opined that an individual could have unique and personalized relationships with God, Nietzsche famously put forth the thesis that “God is dead.”2,5 Nietzsche followed this by proposing an alternative worldview in which individuals are tasked with establishing their own values, beliefs, and codes of conduct. As a result, the individual was responsible for finding purpose in existence in an otherwise indifferent world.2
In the last 100 years, particularly during the turmoil and humanitarian crises of World War II, the first branded existential philosophers came to notoriety—Jean-Paul Sartre, Simone de Beauvoir, Albert Camus, and Martin Heidegger. Though each of them largely rejected the title of existentialist, they addressed the common themes of finding meaning in a meaningless world, understanding the nature of being and experience, and personal isolation and separation from others. It was during World War II that psychiatrist Viktor Frankl’s experience interned in a concentration camp allowed him to integrate some of these existential themes into a way to approach psychotherapy, which he called logotherapy.6 Meanwhile, in the United States (US), the psychologist Rollo May was writing on topics such as meaning and anxiety, relying on both psychological theories and philosophy.7 Each of these writers helped lay the groundwork for existential therapy as a distinct discipline.
Today, no history of existentialism and its relationship to modern psychotherapy could be complete without extensive reference to Irvin Yalom. Yalom is a US-trained psychiatrist who has written prolifically on psychotherapy. Yalom’s comprehensive work, Existential Psychotherapy, introduces readers to core existential themes, case examples, and a psychodynamic understanding that allows existential therapy to be incorporated into broad therapeutic practice.8 The themes that follow are heavily based on the framework that Yalom presents, and except where noted, are referenced from his 1980 textbook Existential Psychotherapy.
The Four Core Existential Themes in Therapy
Existential themes are broad and, as such, are often difficult to describe. Defined as themes or issues that are central to human existence or the human experience, nearly any issue could be thought of as existential. Yalom divides the common existential issues into four core themes, which are now widely accepted by many therapists and experts in the field. The four themes—death, freedom, isolation, and meaning—are categories that help reframe common problems individuals encounter as givens of human existence. Furthermore, they provide a framework for formulation by clarifying the nature of a patient concern or issue.
Death. While death is easy to define (i.e., the end of life via the ceasing of biological processes), it is elusive to discuss. Yalom and other existential psychotherapists go so far as to propose that death anxiety is the primary neurosis that underlies all others. May describes this anxiety as “what we feel when our existence as selves is threatened.”7,9 An individual’s awareness of their own inevitable death and the significant unknowns that accompany this (when, how, and what happens after?) have the potential to create considerable distress. Avoidance of this distressing fact is common, and the existential perspective suggests that it can be one cause of psychopathology. Conversely, morbid ideation or other types of preoccupation with death may also be presenting problems, and the existential perspective offers a way to name and address these issues.
Freedom and responsibility. Another core existential theme is freedom. Yalom notes this framework is somewhat at odds with other analytic theories, such as psychic determinism, as humans are treated as beings with free will and the capacity to make choices. Despite this, the two theories can coexist; it is possible to recognize that individuals think, feel, and act the way they do for specific reasons and still hold that they can ultimately choose to act otherwise. Indeed, the goal of a psychoanalytic approach to such a problem would be to help “free” a stuck person from more unconscious patterns. With this wider view of human agency and freedom, individuals may become overwhelmed with their own capacity for choice; helping a person come to terms with this freedom and make meaningful choices anyway is one objective of existential therapy.
Isolation. As Yalom defines it, “Existential isolation refers to an unbridgeable gulf between oneself and any other being. It refers, too, to an isolation even more fundamental—a separation between the individual and the world.”4 This hearkens back to the bleak notion that an individual is born alone and must ultimately die alone. Yalom additionally describes two other forms of isolation, interpersonal and intrapersonal isolation. Interpersonal isolation may be readily identified by the therapist, as this refers to feelings of isolation from others, manifesting in a sense of loneliness. Intrapersonal isolation refers to ways that an individual can isolate from oneself, potentially through the form of defense mechanisms, dependence on others, or a separation from one’s own autonomy. Therapists may attempt to discover ways that the individual attempts to overcome a personal sense of isolation. This can present in problematic relationships and intrapersonal psychopathology.
Meaning and meaninglessness. At the core of human experience, there lies the question of meaning and purpose, one of the major foci of philosophy. Many philosophical and spiritual systems provide a prescriptive view of how to find meaning in the world. Existential philosophy instead argues that there is limited or no fundamental meaning in the world; others suggest that the individual is responsible for discovering one’s own unique meaning in life.6–8 This concept can place a heavy burden on an individual, as they are now the author of their own purpose. As this may be an overwhelming task, the individual seeking meaning might look outward to others to find the way forward. Meaninglessness and a lack of purpose are commonly unearthed in the therapeutic encounter, across a wide range of problems, giving the therapist a unique opportunity to explore the nature of meaning in the encounter.
Techniques and Components
Techniques of existential psychotherapy can comprise an entire psychotherapeutic approach or work to supplement another primary therapeutic modality. Identifying and naming existential concerns can begin as soon as the intake process. The therapist can listen for clues about how people experience death and its associated anxiety. One way to facilitate this could be to incorporate a death history, in which the therapist screens for an individual’s first encounters with death, learns how it was perceived and processed, and provides an opportunity to explore beliefs about what happens after death. Some of this information can be gathered in the traditional spiritual history. Extra attention to the patient’s close relationships and how the patient sees their self in relation to others is helpful, since this can provide insight into how one experiences isolation and attempts to compensate through distinct relationship styles. Dissatisfaction with work and relationships and strong affect with respect to the future may be signs of an individual’s struggle to find meaning. During the assessment, therapists can direct questions about how an individual finds meaning, not only in the good moments of life, but also through moments of pain and suffering; additionally, they can ask what gives an individual purpose and keeps them going, despite adversity. Early identification of how existential themes exist and interact in the individual’s life will facilitate the therapist’s ability to normalize these fundamental experiences and make meaningful interpretations as therapy progresses.
As we have said, existential issues co-occur with other types of issues and provide an alternative, but not necessarily conflicting, lens through which to formulate patients. As in other types of therapy, existential therapists emphasize common elements (e.g., positive regard, empathy, acceptance, alliance), boundaries and frames (although typically allowing for more self-disclosure than classic analysis), and an insight-oriented approach (i.e., the encouragement of a patient’s understanding of their self).
Not unlike more mainstream psychotherapies, including psychodynamic, cognitive-behavioral, or humanistic approaches, the existential therapist will continue to provide an empathic, nonjudgmental space to explore transference-countertransference dynamics, navigate disruptive thought patterns and challenge core beliefs, or be present to provide unconditional positive regard. For those that choose to incorporate existential themes and techniques into their work, this can provide an opportunity to enrich the therapeutic alliance by participating as a partner in the core human experience. The existential therapist will not be disheartened or discouraged to tackle what can be viewed as taboo themes; rather, they will be actively exploring the existential themes as ways to empower individuals to live their most authentic and meaningful lives. The existential therapist will also bear witness to the suffering of individuals, providing an opportunity to bridge the perceived, isolating gap between the individual and others, affording a corrective emotional experience.
Fictional Case Vignette 1
A 75-year-old female patient with a history of depression and anxiety presented to the clinic for follow-up. She had been stable on antidepressants for many years, but reported that over the last few months she had less interest in completing tasks or going out. She reported feeling physically strong enough to take care of her household, but admitted that it had become messier. She lost her husband of 50 years to illness nearly one year ago. Her husband had provided financial support and stability and had planned most daily activities.
On intake, she stated, “I’m not sure who I am anymore. I don’t know what I want out of life.” Due to her multiple medical comorbidities, she admitted to asking herself more often, “How much time do I have left?”
This individual was grieving the loss of her husband, but perhaps was also grieving the loss of her purpose in life. The following dialogue illustrates this individual’s major concerns, as well as ways to respond to them.
Dialogue 1
Patient: I’m embarrassed to say this, but I don’t know what I’m doing anymore. I’m forgetting things, my home is a mess, and I don’t want to see my friends. They don’t understand how much I miss my husband. I always knew what to do, when to do it, and how to feel when he was around. What do you think I should do?
Therapist: The loss of your husband has been very hard on you. It sounds like he brought purpose and direction to your life.
Patient: I don’t know who I am without him, or what the point is. What should I be interested in? I don’t even know how much longer I have.
Therapist: For so many years, you found meaning in your husband’s goals and values. It must feel overwhelming now to think about what you want for yourself.
Patient: I’m not sure if I’ve ever stopped to think about what I want or what I believe. I’m scared to think about it now.
Practice Point
Clinically, it may be noted that this individual has dependent personality traits. Through an existential lens, we may see an individual who had merged with her husband in an attempt to avoid an overwhelming sense of isolation. She internalized the values and purpose of her husband, thus finding her meaning in life as a faithful spouse. With his passing, she was confronted by the heavy feeling of isolation from others, but also, more importantly, from herself. She struggled to identify herself as an individual with her own values and beliefs. Perhaps she was experiencing the unbearable weight of freedom and responsibility to understand her life and choices in her own individual terms. Furthermore, the loss of her husband removed her personal rescuer, the idea of whom had successfully allowed her to avoid death anxiety associated with her advancing age and numerous medical problems. The therapist may approach this situation by normalizing her fears of death and working together to explore where she can continue to derive meaning in her life, despite suffering loss and medical maladies. Another avenue would be to explore the fears around making choices, providing a space where she can safely begin to think about her own values and needs. The therapist might anticipate significant resistance while exploring how she can begin to make meaningful choices for herself without the compulsion to escape her freedom by relinquishing choices to those around her.
Fictional Case Vignette 2
A 64-year-old male patient with a past psychiatric history of moderate depression and cocaine use disorder in full remission sought psychotherapy over concern that he was “depressed” and “unsure what to do” in the context of several recent life changes, primarily the death of a close friend and a bout of severe illness in himself, from which he was now recovered. During intake, the patient reported dissatisfaction with his job at a small marketing firm and several health issues, including Type 2 diabetes and high blood pressure. He stated he was having difficulty managing his blood sugar and was not able to diet and exercise as he wanted. He reported strong relationships with his wife and one sister, but had an overall lack of close friends. He reported a complicated relationship with his parents, who were now both deceased. He stated his goal for psychotherapy was “to unravel whatever it is that’s causing all this mess.”
In this initial description, the therapist may be aware of several potential existential themes. The patient’s phase-of-life problem (i.e., issues related to aging) points to several potential areas of existential concern, including death (death of a friend and recent illness both pointing to his own death anxiety), isolation (lack of close friends), and meaning (work dissatisfaction and general sense of stagnation). Keeping these themes in mind can help guide interpretations and fruitful directions in therapy. What follows is a dialogue that highlights the therapist’s attempt to name these issues for the patient.
Dialogue 2
Patient: I just feel so fed up with work. I took three days off last week, and I felt guilty. I just sat at home, worried the whole time they were going to call me to help them fix something anyway. I’ve been at this company for 40 years, and it’s been mostly fine… but I don’t really know why I’ve stayed. I guess it’s because of my father; I can’t shake the work ethic thing. I just can’t see the point of going in anymore.
Therapist: It sounds like you are having a difficult time finding meaning at work.
Patient: Exactly. And I’m getting exhausted looking for it.
Therapist: I wonder if there are other areas of your life in which you do find meaning?
Practice Point
One possible direction in interpreting a patient’s reported search for meaning or sense of meaninglessness is to understand what areas do provide meaning. Existential therapists sometimes describe a conflict between meaning-seeking and meaning-creating in humans. For this patient, it may be helpful to discuss both, reframing the search for meaning as potentially located in areas outside of work, while also exploring the possibility of creating meaning at work despite feeling stuck, as an increased sense of meaning at work would likely improve satisfaction and therefore overall mood and outlook.
Fictional Case Vignette 3
A 59-year-old patient was admitted to the medical floor of a large academic hospital due to fevers and acute respiratory failure. The patient was found to have sepsis and previously unidentified cirrhotic liver, contributing to both the infection and the respiratory failure. The patient disclosed a significant drug and alcohol use history that was never before reported or treated. An urgent liver transplant was recommended. Before transplantation could be pursued, however, the patient became ill with pneumonia and abdominal fluid overload. He was interviewed by the psychiatric consult team about his history and goals of treatment.
Dialogue 3
Patient: I want to get better. I want the transplant…I think. I am just sick of feeling so awful.
Psychiatrist: It sounds like you are weighing the decision to pursue treatment and make this work. What do you imagine your life would be like after all this?
Patient: I want to stop using, but I don’t know… I never really have before, and I don’t know what it’d be like. I also just feel so bad that I think maybe I’m headed toward the end.
Psychiatrist: Are you having thoughts about wanting to give up or end your own life?
Patient: No, not ending my own life. But giving up… I guess I can see the writing on the wall… that my life is just going to be really hard, and I might struggle with these illnesses forever. If I even pull through this.
Practice Point
This case illustrates that existential issues can present in any practice setting and are not limited to the therapist’s office. General hospital settings might be one of the most common places for existential issues to arise, as patients are often faced with severe illness, new and major diagnoses, and overwhelming new environments. Furthermore, psychotherapeutic skills remain helpful and relevant in these settings, allowing the clinician to understand the underlying issues affecting medical care. Despite this interaction not being formal existential psychotherapy, the techniques are largely the same. For many patients, understanding the existential issues named—in this case, concerns about the purpose of life, especially in the face of severe illness, and thoughts about death—is essential for treatment. In this case, the clinician may be able to normalize some aspects of these concerns, gather more information, and determine the risk of suicide, which might be low, despite the frank discussion about death and dying.
Conclusion
There might be as many psychotherapies as there are psychotherapists, but it is without doubt there are as many unique experiences as there are individuals. Existential psychotherapy taps into a rich school of philosophy to find ways to connect to the core human experiences and struggles through an individual-focused therapeutic framework. In uncertain modern times, with shifting social dynamics and threats of illness and death, existential themes remain at the core of our collective experiences. These themes include death, freedom and responsibility, isolation, and meaning and meaninglessness, which can be explored and addressed in therapeutic encounters. Though this has served as a brief introduction to existentialism and its application to psychotherapy, the interested psychotherapist can use these concepts and techniques to start incorporating these themes into clinical practice.
References
- Coles R. The Call of Stories: Teaching and the Moral Imagination. Houghton Mifflin; 1989.
- Nietzsche FW. The Gay Science: With a Prelude in Rhymes and an Appendix of Songs, 1st ed. Kaufmann W, trans. Vintage Books; 1974.
- Grassi L, Mezzich J, Nanni M, et al. A person-centered approach in medicine to reduce the psychosocial and existential burden of chronic and life-threatening medical illness. Int Rev Psychiatry. 2017;29(5):377–388.
- Aurelius M. The Meditations. Random House; 2002.
- Kierkegaard S. The Essential Kierkegaard. Hong HV, Hong EH, eds. Princeton University Press; 2000.
- Frankl VE. Man’s Search for Meaning. Beacon Press; 2006.
- May R. The Meaning of Anxiety, Rev. ed. W.W. Norton & Co.; 1977.
- Yalom ID. Existential Psychotherapy. Basic Books; 1980.
- May R. Man’s Search for Himself. W.W. Norton & Co.; 1953.
