Death, freedom, isolation, meaning: everyone has to face these questions. Existential therapy doesn't answer them for you; it helps you look at them squarely and live truthfully within a limited life.[1]
It's really a defence built on denial: by feeling special and refusing to accept death, we refuse death and life at the same time. And once you've refused death, death is still there, but you no longer have your life.
Have you noticed how the same thing keeps happening? You love someone, yet when it comes to marrying them, you can't bring yourself to. You try hobby after hobby without giving yourself to any one, and a job loses its appeal the moment it means "for the long term". It may not be that you love too little or take things too lightly; the reason may sit somewhere you never thought to look.
The situation at the start can be asked about in another way than through childhood and the past. Existential therapy holds that much deep distress comes not only from childhood or past trauma, but from conditions every human being has to face. The psychiatrist Irvin Yalom named four "ultimate concerns", often called the existential givens: death, freedom, isolation and meaninglessness.[1]
Each has its weight. Death: everything you have will one day be lost. Freedom: no one can decide for you how to live, so you are responsible for your choices, and not deciding is a decision too. Isolation: not a lack of friends, but the fact that however close you are to someone, no one can feel your experience exactly as you do. Meaninglessness: life comes with no answer written in advance, and meaning is something we have to find. These conditions are not illnesses in themselves; but if we keep dodging them, the way we dodge can turn into a problem. The "awareness, anxiety, defence" chain below describes how.[1]
Its roots are in existentialist philosophy: Kierkegaard, Nietzsche, Sartre and others. Sartre said that existence precedes essence: a person comes first, and only then what a person is meant to be. Sartre's own example is the paper-knife: its purpose is fixed before it is made, so its essence comes before its existence; a person arrives in the world first and only then has to decide who to become. Existentialism asks, since there is no ready-made answer, how we should live a limited life.
Now you know how it sees a person and how it works. The next questions: what is it actually like, does it work, and what is it not for?
Beyond the research, what does a course actually look like? Existential therapy is usually a weekly conversation of about an hour, often over several months, with the number of sessions set by what you need. The five steps below are not a rigid procedure; they show how the ideas above play out across sessions. Meaning-centred psychotherapy is structured and short: eight group sessions or seven individual ones, each with a theme, exercises and homework.[11,13,21]
Episodes are in Cantonese.
To read further, start with these.
Not ready to see a therapist yet? Start with these six steps at your own pace, an episode or a practice a week.
TreeholeHK's counsellors and clinical psychologists use Existential to fit what you need, alongside other approaches.
Existential therapy shares roots with several approaches, and borrows from them in turn. Start here to learn more.
You can do the exercises on your own. When you're stuck, a trained therapist can take you further.
So existential therapy is not one school but a family: Ludwig Binswanger and Medard Boss's Daseinsanalysis, the British phenomenological school, the existential-humanistic approach of Yalom and others, Viktor Frankl's logotherapy, and the structured meaning-centred psychotherapy developed later for people with cancer. What follows draws mainly on Yalom and Frankl.[9]
Follow the chain down and isolation turns out to be the most misunderstood of the four. As noted above, it is not a lack of friends, so Yalom separates three layers: the deeper you go, the more basic it is, and the less more friends can fix it.[1]
Therapy can't remove the third layer. What it aims for is the willingness, having admitted it, to still meet others for real; more on that under "The here and now" below.
Cut off from others: no one to talk to, no one to lean on. At this layer, more connection really does help.
"Six months here and still no one to have dinner with."
Cut off from part of yourself: feelings that weren't allowed growing up, until you no longer recognise them.
"I never get angry." The angry part has never had a voice.
The gap between people that can't be crossed: we each arrive, experience and leave on our own.
"Even with someone at the bedside, the last stretch is walked alone."
1The method
Yalom borrowed psychoanalysis's structure and changed only the starting point. Psychoanalysis says drive → anxiety → defence mechanism; existential therapy says what sets off the anxiety is awareness of one of the four ultimate concerns above. A defence mechanism is the mind's way of easing anxiety; it makes us feel better for now, but used too heavily it turns into problems that seem to have nothing to do with death or freedom. For example: an illness brings death to mind, an unnamed unease follows, and we fill our days with work or tell ourselves "nothing will happen to me". The situation at the start reads the same way: to commit is to choose, and to choose is to give up other possibilities, which makes us aware that we have only one life; the unease that follows is defended against by not committing and staying open. Therapy follows the problem back, layer by layer, to the condition at its root. So the existential approach does not treat anxiety or depression as illnesses to be removed; it sees them, in Kasket's words, as "understandable human responses to confrontations with givens of existence" (2017, "Nature and understanding of psychological distress").[1,2]
2The skills
Once you know what lies under the defence, what can be done? Existential therapy deliberately doesn't rest on a set of techniques; what matters more is how the therapist stays with you as you face your situation. These are common ways of working, in three directions, each answering part of the above: the first deals with awareness and defence, facing death and seeing through defences; the second with freedom and isolation; the third with meaninglessness. The logotherapy part is the most structured and the most researched.
Don't look away from death and limits, and see how you've been dodging them.
The therapist doesn't steer away from death. An illness, a bereavement, a milestone birthday: these boundary situations make the limit of life suddenly visible. Yalom calls them awakening experiences and holds that they can reorder our priorities and sharpen our sense of the present. He also describes "rippling": the influence we have on others keeps spreading after we are gone, which can make it easier to accept that we will go.[4,9]
Defences, as above, are what we use to ease anxiety. Yalom describes two basic defences against death: believing you are special and exempt from the rules, or believing someone or something will always rescue you. They are often wrapped to look unrelated to death: back to the situation at the start: a commitment is a limit, so gaining one thing means giving up others, and loving someone yet never committing can sometimes be a way of keeping hold of the sense that "my options are still endless", so that we never have to admit we are like everyone else, with one life only. The therapist helps you unwrap them slowly to see what lies underneath.[1]
Own your choices, and practise meeting someone for real in the therapy relationship.
The other side of freedom is responsibility. The therapist notices how you place responsibility elsewhere ("it's their fault", "I had no choice") and helps you see yourself as one of the authors of your situation. Choosing one path gives up the others, which is why deciding feels heavy; but not deciding is also a decision, with consequences. In the situation at the start, not committing is a choice too: the choice to leave every possibility where it is.[1]
Yalom gives weight to what happens in the room right now: how you draw close to or avoid the therapist often mirrors your relationships outside; if you tend to pull back at the moment you get closest to commitment, that pattern can show up in the therapy room too. The therapist shares their own reactions with care, so the relationship itself becomes material. This bears on isolation: existential isolation can't be removed, but it can be shared in a genuine meeting. The philosopher Martin Buber called this purpose-free kind of meeting "I–Thou", as against "I–It", where the other is a means to an end.[1,3,6]
Frankl's line: meaning isn't handed to us; it is found in the situation we're in.
The earlier directions face the givens; logotherapy answers the last question: if life comes with no ready-made meaning, where does meaning come from? Frankl held that it can be found in three ways: by creating something or doing a deed; by experiencing something or encountering someone; and by the attitude we take towards suffering we can't avoid. Logotherapy uses Socratic dialogue: questions rather than answers, so that you see the meaning in your own situation. The aim is not to make the pain go away but to give it somewhere to go.[7,8]
Last time you said that in the ten months since your wife died, the first thing you notice every morning is how quiet the flat is. Where would you like to start today?
As if no one sees how heavy this is.
The dialogues are illustrative composites, not real clients; skills that stir strong emotion or touch on trauma should be done with a trained therapist.
The research support above comes mainly from people facing serious illness such as cancer; in practice it is also widely used for difficulties tied to life's circumstances.[9,21]
Apart from serious illness, most of this rests on clinical experience rather than research. If you are thinking of hurting yourself or ending your life right now, please don't face it alone: call The Samaritans' 24-hour line on 2896 0000, or 999 in an emergency. For severe depression or anxiety, talk with a therapist about the better-researched treatments first.
How much evidence backs these ways of working? To be frank, there is little research on existential therapy, and most of it is with people who are seriously ill. What exists is mainly on the structured meaning therapies described above; the open-ended, Yalom-style work has even less. Studies usually split people at random into two groups, one given the therapy and the other put on a waiting list or given usual care (the control group), then compare results: a randomised controlled trial. Here is how firm the evidence is, one question at a time.
A 2015 meta-analysis (which pools many studies) found that structured therapy that talks about meaning in life directly seems to help people who are physically ill feel their lives have more meaning, and in the better-run studies it also eased low mood, hopelessness and quality of life in people with advanced cancer. But there are not many studies, most compared against waiting lists or usual care, and many people did not finish the assessments, so the results need careful reading.[9,12]
One-to-one meaning-centred therapy did better than enhanced usual care, with small to moderate effects; against ordinary supportive therapy it was only slightly ahead on quality of life and sense of meaning. In other words, there is not yet enough evidence that it beats other approaches.[13]
The more open-ended kinds showed only small effects on symptoms in the same review, and some showed none that could be told apart from chance. That is not the same as no benefit, but the research so far has not shown that it helps.[9]
Most trials involved people with serious illnesses such as cancer, and there are almost no direct trials for everyday depression and anxiety. A later review reported larger effects, but only about four in ten of its studies were randomised trials, so those numbers deserve caution.[9,10]
Dignity therapy is a brief therapy for people near the end of life: they talk through what mattered most, and it is edited into a document for their family. In a trial of 441 people near the end of life, it did not lower distress more than other care did, though participants started with little distress. Patients were more likely to say it helped and that it changed how their family saw them; whether it eases distress is still unproven.[16]
Yalom's framework assumes that a pushed-down fear of death turns into other difficulties. Studies find that people who fear death more tend to have more mental health difficulties, but that is a link, not proof of cause. A classic finding (called mortality salience) that reminding people of death makes them more defensive could not be reproduced in a large 2022 replication. For now this part rests mainly on theory, and the evidence is weak.[17,18,19,20]
Overall, the evidence is thin and uneven. The authors of the main review themselves call the studies few and low in quality; most control groups were waiting lists or usual care, and most participants were physically ill, mainly with cancer, so there are almost no direct trials for everyday depression and anxiety. A later review of meaning-centred therapies reported larger effects, but only 26 of its 60 studies were randomised trials, and its looser criteria mean those numbers deserve caution. Little evidence isn't the same as no effect; it means the approach hasn't been studied well yet.[9,10]
Knowing what it can do means knowing what it can't. Existential therapy takes on life's heaviest questions. That is its depth, and also where it falls short:[9,10,21]
There are still few randomised trials (15 in the 2015 meta-analysis, 26 in a 2018 one on meaning-centred therapies), mostly with people who are physically ill. Whether it will help you is hard to predict from the research so far.
Logotherapy needs imagination, and enough ego strength (staying steady under strong feeling) to hold an inner world and reality at once without losing touch with reality. If someone's own sense of love, life and death is still unclear, forcing their pain to connect with a meaning can leave things more tangled.
Some people find the ideas abstract, and talking about death and meaning can overlap or clash with the answers of a person's faith, so the therapist needs to respect your worldview.
If you are in a suicidal crisis or severely depressed, the first step is safety and stability. Pressing on life's meaning before that can deepen despair.
These limits don't make the big questions go away: the situation at the start, loving yet unable to commit, still arrives at the moment of choosing, whichever approach you use. That's why many therapists bring the existential lens into other approaches: once the symptoms are dealt with, life's big questions are still there, and it helps you face them.
Seasonal food tastes good partly because the season ends. A life that happens only once is the same: to commit is to let other possibilities go, which is a cost and also where this one life actually begins; the fear may not vanish, but you can carry it with you as you choose.
I'm not going to tell you to go for walks. I'd like to ask you something a bit hard to think about together; if it's too much, we stop. Is that OK?
Suppose that ten months ago it had been you who died, and she was the one left. How would she be now?
So this pain of facing the empty flat every day…
You said "carrying it for her". When you look at it that way, what's different inside?
The pain is no smaller, but it has somewhere to go.
If she could see these ten months, how would she want you to live?
"Living properly": what's the smallest piece of that, for you? You don't have to decide today.
Notice: This exchange shows the third route: finding a stance towards suffering that can't be changed. The therapist hears the grief out first, doesn't prescribe walks in the park, and asks permission before posing a hard question. The role-reversal question comes from a case Frankl describes, but the client names the meaning himself; the therapist only reflects it and never says "so you should feel better". The pain is no smaller, just "not wasted"; the small step at the end grows out of that meaning, and the client chooses it. A question like this belongs after the grief has been properly heard, never as a way to hurry someone on.
Meaning-centred psychotherapy turns Frankl's ideas into a structured course: his three routes become four sources of meaning, with "historical" added. The middle sessions each take one source: historical (where you come from, what you received, what you want to leave), creative (work, contribution, responsibility), experiential (love, beauty, connection with others) and attitudinal (the stance you take towards limits and suffering). Each session has a short teaching part, a reflective exercise and homework, and in the group version members share a legacy project in the final session.[11,12,14]
Today's source of meaning is the historical one: where you come from, what you've received, what you want to leave. Last week's homework was to think about something you received from your family. Did anything come to mind?
What did she leave you?
That tradition lives in you now. Since you became ill, how do you see it?
The illness has taken a lot, and you don't want it to take this as well.
We don't have to pretend it hasn't taken things. Can I also ask: in this tradition, is what matters most that you make them yourself, or something else?
If you were to hand it on, who would you hand it to?
Is there a small way she could take it on?
That sounds like something to leave her. Would you like to make writing it down your project for the next few weeks? However much you manage is fine.
Notice: This exchange shows the "historical" session, which starts from last week's homework. The therapist acknowledges that the illness really has taken things away and doesn't tell the client to look on the bright side; instead they ask what matters most in the tradition, so the client separates the meaning from doing it with her own hands. The legacy project is small and concrete and comes from the client; the sadness is still there.
Logotherapy also has two techniques aimed at symptoms. Dereflection: when watching yourself closely makes a problem worse (the more you check whether you're asleep, the less you sleep), turn your attention outward, to something worth engaging with. Paradoxical intention: with self-distance and humorous exaggeration, deliberately "wish" for the feared thing to happen, breaking the loop in which a symptom and the fear of it push each other up. Frankl describes a patient who feared sweating in public: the more anxious he got, the more he sweated. When he began telling himself he would show people just how much he could sweat, the sweating stopped.[7,8]
Mental Health
Psychology
Psychology
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