Existential Therapies
Much of what presents as psychopathology is the cost of evading the given conditions of existence — death, freedom, isolation and meaninglessness — and therapy consists in helping a person face those conditions squarely enough to live deliberately rather than by default.
Anxiety is not always a symptom. Sometimes it is an accurate response to being alive.
Who built it
Ludwig Binswanger
1881–1966Swiss psychiatrist
Daseinsanalysis: applied Heidegger’s phenomenology to psychiatry, insisting that a patient’s world be understood from inside rather than explained from outside.
DaseinsanalysisViktor Frankl
1905–1997Viennese neurologist and psychiatrist; Auschwitz survivor
Logotherapy: the will to meaning as the primary human motivation, and the claim — grounded in the camps — that meaning can be found even in unavoidable suffering, through what one makes of what happens.
LogotherapyRollo May
1909–1994American psychologist
Brought existential thought into American psychology. Distinguished normal from neurotic anxiety, and made the daimonic — the natural human capacity that becomes destructive when disowned — central to psychotherapy.
American existential psychologyIrvin D. Yalom
1931–Stanford psychiatrist
The four ultimate concerns — death, freedom, isolation, meaninglessness — and the most usable clinical statement the tradition has produced. Also the leading theorist of group psychotherapy.
Existential-integrativeEmmy van Deurzen
British existential psychotherapist
Systematised existential practice for training, mapping the four dimensions of existence — physical, social, personal and spiritual — and building the British existential school.
British existential analysis
Theory of personality
Existential therapy begins from a refusal. It refuses to treat the person as a mechanism whose outputs are explained by prior causes — drives, contingencies, schemas — and insists instead that human beings are self-interpreting: what a person makes of their situation is itself constitutive of the situation. This is not a preference for warmth over rigour. It is a claim about what kind of thing a person is.
The givens
Yalom’s four ultimate concerns are the tradition’s most teachable form. They are not problems to be solved; they are conditions of being alive, and the way a person handles them shapes their character and their symptoms.
| Given | The confrontation | Common evasions | Clinical presentation |
|---|---|---|---|
| Death | I will end, and so will everyone I love | Specialness; belief in an ultimate rescuer; frantic activity | Health anxiety, midlife crisis, panic, workaholism |
| Freedom | There is no ground; I am responsible for what I make | Compulsion, indecision, blaming, "I had no choice" | Chronic indecision, victim stance, procrastination |
| Isolation | No one can enter my experience; I am finally alone | Fusion; compulsive sexuality; needing to be needed | Dependency, serial intensity, terror of solitude |
| Meaninglessness | The universe supplies no purpose; I must make one | Nihilism, frantic consumption, crusading | Emptiness, "successful" depression, anhedonia |
The four dimensions of existence
Van Deurzen’s scheme is the most practical assessment map the tradition offers, because it locates where a person’s difficulty actually lives.
- Umwelt — physical
- The body, the natural world, mortality, illness, sexuality, material conditions.
- Mitwelt — social
- Other people, culture, belonging, status, love and its absence.
- Eigenwelt — personal
- Identity, self-experience, one’s own character and history.
- Überwelt — spiritual
- Values, beliefs, meaning, the ideal, whatever a person holds sacred.
Authenticity
Heidegger’s distinction between authentic and inauthentic existence underlies the whole tradition. Most of the time we live in "the they" — doing what one does, wanting what one is supposed to want, with our choices made for us by convention. Authenticity is not self-expression or being nice to oneself; it is the acknowledgement of one’s own finitude and freedom, and the willingness to choose in their light.
Theory of psychopathology
The tradition makes a distinctive and clinically consequential claim: some anxiety is correct. May’s distinction between normal and neurotic anxiety is the hinge. Normal anxiety is proportionate to a real threat and does not require repression; neurotic anxiety is disproportionate, is out of awareness, and is maintained by the very defenses that reduce it.
The person becomes neurotic not because they are anxious, but because of what they do to avoid being anxious.
Symptoms as evasions
On this account, a symptom is frequently a solution to an existential problem — a way of not having to face something. That does not make symptoms unreal or the suffering deserved. It changes what treatment is aimed at.
- Compulsive busyness as a defense against the awareness of finitude
- Chronic indecision as a way of never having to be responsible for a choice
- Fusion in relationships as an escape from the fact of separateness
- Achievement without satisfaction as a substitute for a purpose one has not chosen
- Guilt not about what one has done, but about the life one has not lived — existential guilt
Where it is genuinely the right formulation
- Life-threatening or terminal illness, and the anxiety that accompanies it
- Bereavement, especially where the loss has made mortality real
- The "successful depression" — everything achieved, nothing meaning anything
- Life transitions in which an old structure has collapsed: retirement, divorce, migration, career loss
- Moral injury, and the distress of having acted against one’s own values
- Distress that is proportionate to circumstances and does not warrant a diagnosis
Theory of change
Change comes from confrontation, not from insight into origins. The therapist does not explain the patient to themselves; they refuse, gently and persistently, to collude with the evasion — and they stay present while the patient encounters what they have been avoiding.
- 1Awareness of the given — the patient stops looking away from the death, the freedom, the aloneness or the emptiness.
- 2Anxiety rises, and is framed as appropriate rather than pathological.
- 3The therapist stays. Encounter — genuine presence with another person who does not flinch — is the mechanism, and it is why this tradition treats the relationship as the treatment rather than as its precondition.
- 4Responsibility is assumed: from "this is happening to me" to "this is what I am doing".
- 5A choice is made, and acted on. Existential therapy is not complete until something in the person’s actual life changes.
Key concepts
The vocabulary you need to read the literature and to be understood in supervision.
Where it sits in the transtheoretical grid
Which change processes the system leans on, and at what level of content it aims.
- Consciousness raising
Increasing information about oneself and the problem - feedback, interpretation, education, observation.
- Self-reevaluation
Appraising how one thinks and feels about oneself with respect to the problem; values clarification.
- Self-liberation (choosing)
Choosing and committing to act, plus the belief that one can change - the deliberate exercise of agency.
- Helping relationship
Being open and trusting about problems with someone who cares; the relationship as vehicle, and as medicine in its own right.
- Catharsis / dramatic relief
Experiencing and expressing affect about the problem, whether by corrective emotional experience or by evoking what has been avoided.
- Intrapersonal conflicts
- Current interpersonal conflicts