Existential Therapy: How It Works, Cost, & What to Expect

What Is Existential Therapy?

Existential therapy starts with the premise that the therapist-patient relationship is what heals, and it is the therapist’s role to help their patient get to the point where they are able to make their own choices. The desire to engage in life is in us all, so the work is to remove whatever obstacles are in the way.¹ Ultimately, existential therapy is about forming a relationship that allows you to courageously explore yourself, choose meaning and end goals, and develop the ability to use your will to make them happen.

An existential therapist will want to look at how you present and deal with anxiety, specifically death anxiety. While they will definitely work to help you ease your immediate mental health concerns, the treatment involves learning to accept and use some level of the existential dread and pain you’re experiencing to guide you through deeper work.

In order to help you make choices, engage in life, and learn to use your anxiety to establish a worthwhile goal, existential therapy tries to free and apply your willpower to achieve that goal; it works to remove the obstacles that you internalized in your development. Doing so will help you grow naturally healthier.

Development of Existential Therapy

The history of existential therapy begins with the philosophers Kierkegaard and Nietzsche at the end of the 19th Century grappling with angst and loss of meaning, and began to pick up steam in the aftermath of WW2, with near-simultaneous development of existential themes by the physician Viktor Frankl and the philosopher Jean-Paul Sartre. Frankl created his own form of existential therapy which he called Logotherapy, while Sartre’s ideas took hold in the psychology community of the UK in the 1960s.³

What Can Existential Therapy Help With?

Existential therapy can help people with a range of mental health issues, especially those linked to existential topics:

• People facing serious issues such as major health problems, end of life, and other life-altering situations (e.g. marriage, divorce, having kids, career change) can benefit from this style of therapy.
• Existential therapy is an excellent choice for all manner of anxiety disorders, including social anxiety disorder, agoraphobia, and generalized anxiety disorder.
• It also works well for trauma-related issues such as post-traumatic stress disorder (PTSD), acute stress disorder, adjustment disorder, as well as hypochondriasis and substance abuse disorders. After all, trauma and concerns about our physical health are clearly boundary issues.
• Depression can also be treated with existential therapy, as it so often has at its core questions about meaninglessness, and extreme feelings of guilt.

Who May Want a Different Approach?

Existential therapy may not be the best fit for everyone. This approach is based in philosophy, and many concepts are complex and may be difficult to understand. For those with strong religious beliefs, principles of existential therapy may conflict with those beliefs. Existential therapy focuses on a person’s overall views on life, so clients who are interested in exploring traumatic past experiences may benefit from a more psychoanalytic approach.

Clients who are in crisis, or who have a severe, persistent mental health disorder, should not begin with existential therapy. Finally, those seeking to enact change in their life quickly should seek a more solution-focused intervention.

Key Concepts of Existential Therapy

Perhaps the key concept of existential therapy is the influence of death in the creation of our personalities and defenses. Existential therapy assumes that all mental health issues are ultimately unsuccessful attempts to cope with death anxiety. The combination of your anxieties and how you deal with them results in you being in therapy.

Death Anxiety

The intrinsic, fundamental death anxiety moves to more tangible, less scary problems as part of your defense against it. Another way to think of it is that we first get anxious when we first realize we’re helpless to solve some problem (like death), and that it gets activated when we face similar situations. Death doesn’t have to be a major theme of your discussions because your existential therapy therapist will use it as core to the explanatory system they use to help your exploration.

Freedom & Responsibility

While we tend to think freedom is great, in truth most of us are paralyzed by it; realizing that we actually create the world, make up rules, that it’s not organized out there for us to find, leads us to the mortifying reality that there is no structure unless we make it up, we are radically free. Closely related to this is the awareness that things can’t have any inherent meaning; there is no reason to live or to do anything, unless we construct it.

We turn to burying or transforming our anxiety, focusing especially on decisions that we can’t change. We come to face that we do all sorts of things, make up all manner of restrictions, to refuse our freedom. But these rules ultimately create the failure to live our lives, creating more guilt and anxiety. The remedy lies in believing in yourself, in giving yourself permission to grow your skills, and through this process, to create meaning.

Meaninglessness

The truth is that life is inherently meaningless, which sounds awful. But the idea that thus it is not worth living is not a fact. It is an assumption based on refusal of responsibility, on fear of freedom and choice. Accepting that you are responsible for your life, for the meaning of it, gives you the power to change, and thus to alleviate your mental pain.

You will alleviate your unhelpful anxiety and other mental health issues by creating meaning. As Frankl said, mental health isn’t a “tensionless state but rather the striving and struggling for a worthwhile goal, a freely chosen task.”

Isolation

There are three types of isolation discussed in existential therapy.

• Interpersonal isolation: While this kind of isolation is most easily understood as being alone, away from other people, it can also refer to feeling isolated within relationships that do not meet a person’s relational needs. Research suggests that lonely people do not necessarily spend less time in relationships with others. Rather, they spend the same amount of time with strangers and larger groups as those who are less lonely, who instead spend their time within a few meaningful relationships.⁴
• Intrapersonal isolation: A person’s way of splitting off from themselves and others, preventing them from being present in relationships. This supports the theory of loneliness resulting from a way of being in relationships, as opposed to a lack of relationships.
• Existential isolation: Describes the fact that, as humans, we are never able to fully overcome isolation. The more people fight this truth, the unhealthier their relational patterns. When we can embrace this limitation, it actually frees us to enjoy deeper, more meaningful connections with others.⁵

Answering the Question, “Why Am I Here?”

Existential therapy employs questions that explore the meaning of life and the human experience. “Why am I here?” is a foundational existential question discussed in therapy. Other questions might examine the meaning of suffering, what it means to be alive, how we ought to act in relation to others, what happens after death and what makes life worthwhile.⁶

What’s the Goal of Existential Therapy & Who Determines That Goal?

Existential therapy will work with your presenting problems, but improving your anxiety requires awareness of and working through ultimate concerns. Existential therapy will help you confront your existential concerns. To do so is to help you to own your responsibility, make choices, and create meaning for yourself.

You wind up in therapy because your defenses against your fundamental and existential therapies haven’t worked and now you’re left feeling painful mental health issues. Or your defenses have saved you from surface anxiety, but at the cost of a stultifying life. In either case, you’re left anxious, depressed, or otherwise in anguish.

When you find and embrace your actual limits, talents, and interests you will find that you have total freedom to do, and not do, as you wish within them. Existential therapy will try to help you see how the myriad small choices you make every day determine who you are and where you’re going, and that different choices will lead to healthier outcomes.

For you to be responsible, embrace your freedom, own your choices, ultimately requires you to have meaning in your life, so the final goal is helping you create your meaning, to help you realize what you want, what you could do, who you could be. Your therapy should help increase your sense of your ability to create and order your life in a meaningful way, it should help you define your “because.”

Existential Therapy Techniques

Here are some techniques often used during existential therapy sessions:

• Open, nonjudgmental dialogue: Existential therapy rests on the assumption that life has no inherent meaning, and that it is up to each person to design meaning for their life. Open, nonjudgmental dialogue is important in providing a space where the client can talk freely and work toward discovering what life means to them, personally.
• Mindfulness: Mindfulness involves a nonjudgmental openness to one’s own subjective experience in the present moment, and is often employed in existential therapy.
• Asking the client questions about their experiences: In this approach, the therapist will ask the client to consider what brings meaning to their life, and what changes they can make to bring more meaning into their life.
• Treating all experiences as equally important in their potential for meaning: In existential therapy, all experiences are considered to be helpful in the client’s search for meaning.
• Exploring negative feelings and conflict: In this approach, negative feelings and conflict are not to be avoided or “cured” but instead explored to learn what meaning a person can glean from them.
• Encouraging exploring new ideas and experiences: Clients are encouraged to open their minds to new ideas and experiences that support the meaningful life they are creating.
• Discussing the client’s place in the larger world: Finding the client’s place in the world around them, in their community and society as a whole, is one goal of existential therapy.⁷

Existential Therapy Examples

Existential therapy is often a longer-term therapy and does not lend itself to short examples.

Here’s what it might look like to take on depression, generalized anxiety, or end-of-life therapy through existential therapy:

Existential Therapy for Depression

Darryl, 35, comes to therapy due to concerns that he has stagnated in his career, has not had a meaningful relationship, and has lost enjoyment of life. He’s tired of it all and doesn’t see any way out. The therapist will work to establish a real connection and build a sense of trust, a sense that she really does care what Darryl is going through and wants to help. As the bond grows, she will pay special attention to whether there is anything happening in the here-and-now of sessions that might point to any maladaptive tendencies. She will also listen for signs of wrestling with themes such as death anxiety, existential depression, denial of responsibility, rejection of choices, lack of meaning in life, isolation, and overall stuntedness.

As therapy progresses and these sorts of concerns pop out, the therapist will work to connect developmental influences on the world view Darryl has created. She will relate them to the here-and-now concerns that brought him to therapy such as his cold boss and difficulty dating. It is likely that Darryl just fell into a job because he never saw any obvious vocation for himself the way some of his friends did. Similarly, it is likely that Darryl feels he’s been unlucky to never have found a woman “special” enough to commit to. All of which has left him in a place where there’s little motive to get out of bed on weekdays or go out on weekends.

Darryl’s therapist will challenge him to consider that it wasn’t simply circumstance and accidents that left him in a dead-end job with no one to connect with. He has chosen this life for himself, most likely by refusing to make conscious choices, or perhaps by doing what his upbringing told him was “sensible.” He might come to find that his dreams were to be an educator or a coach, but he determined that it wouldn’t pay enough.

Darryl may come to accept that his fear of being “trapped,” has led him to never give enough time and attention to a woman to develop a loving bond, and thus feels deeply disappointed in himself. But also he will begin to feel empowered. If he’s chosen to live this way, he can choose to do it a different way. Darryl can find ways to volunteer to coach, he can consider going back to school, he can slowly build the social skills and self-regard he needs to be more secure in engaging with women.

Working together with his trusted therapist, Darryl can choose his because and act on it. He will know that his anxieties are pointing him to where his meaning lies, and his progress will lead his malaise to dissipate.

Existential Therapy for Generalized Anxiety

Rhoda, a 26-year-old transwoman, has made amazing steps in her journey toward realizing her true self. Yet in therapy she finds herself in therapy again, unable to shake the restless sense that the world is an inhospitable place; dangers lurk, and not just from the bigotry and ignorance of others. Rhoda just can’t shake the feeling that they will never quite get therapy ahead.

As she bonds with her therapist, she explains how growing up she was teased for being short, for having bad breath, how she was punished for not getting good grades, for not finishing dinner on time. Working with her therapist, Rhoda comes to see that she was handed a world full of rules that she seemed to not be able to live up to, but took to be true.

Rhoda will come to see that ultimately, it is her choice whether to continue to accept these rules and to try to live up to them. Rhoda will realize that it was her fear that she wasn’t special enough to “get away with” disregarding all expectations, not just those around her gender identity. Rhoda slowly practices owning her feelings and listening to her guilt that she’d accepted all these strictures even after being such a vocal proponent of LGBTQ+ rights. Though upset with herself, her self concept will improve enough that she comes to truly embrace that she is in charge of her whole life, and that the threats she sees are merely reflections of the threat of dying without having lived.

Existential Therapy for End of Life Concerns

Amira, 67, comes to therapy after her oncologist explains to her that it was likely she would be dead within a year. Having raised a family of three and cared for her husband of 45 years, she wonders if she’s had a full life. Being somewhat religious, she felt she had mostly been a pious person. But she lamented that never got much of an education or had much of a life outside her family. Still she was surprised that she had a deep terror about the idea that it would be over so soon.

Amira’s therapist asked her to consider who she was, what qualities made her who she was. Amira was stumped: wife, mother, sure. But what else? After a few sessions she was able to write out a list of ten qualities she identified with, and a whole slew of others that were more peripheral. Working with her therapist, she slowly considered each, and talked through her thoughts and feelings as she “discarded” each.

She had been athletic once, but was far from that now. Her lustrous hair used to be the envy of her friends, now it was coarser and grey. These losses naturally gave pangs of sadness, but ultimately she will let therapy go of them. Working further, Amira will come to realize that while she’d never articulated it, she was always deeply proud and satisfied to live a life of loving service to others.

As she considers all the lives she’d touched, all the joy that had filled her heart, she will be able to conclude that her life had been well spent. She will further start to understand that she’d still spent too much time on trivial matters, and it was time to really focus on what else she cared about. While her anger at the likely sudden end she is facing made some sense, ultimately her anger is best used as an accelerant not a block, and she can choose to spend the rest of her days totally, consciously, on her own terms.

How to Find an Existential Therapist

It may be harder to locate a therapist that uses existential techniques than a therapist who uses modalities such as CBT and Person Centered Therapy. It is not commonly taught in training programs, and while there are a number of institutes dedicated to existential therapy, there is no “official” training program.

There are also people with advanced degrees in philosophy who may be able to provide you with existential thought on life’s problems. But these well-meaning people are not required to be licensed therapists, which means it is likely they have no formal training in psychology, and their treatments won’t be covered by any insurance.

But existential therapy is a growing modality. All you need to do is use an online directory to find a therapist practicing this kind of therapy. It would be good to find out if they have read quite a bit by existential therapists such as Irvin Yalom, Rollo May, and Viktor Frankl, and even better if they’ve also studied existential philosophers such as Kierkegaard, Nietzsche, and Sartre.

Is Existential Therapy Covered by Insurance?

If you work with a licensed therapist, your therapy should be covered by insurance. Whether your insurance plan covers your therapy will depend on whether your therapist is in-network or you have out-of-network coverage.

What to Expect at Your First Appointment

Your first therapy session will not be fundamentally different from how it might go with another therapist; intakes function to gather background info, hear of your presenting problems, and to share other nuts-and-bolts type info. However, you can expect a much more conversational approach as opposed to silence or box-checking, and perhaps more psychoeducation on the therapist’s process (e.g. using here-and-now, looking at deeper issues) than with other modalities.

Ideally you will come away from it feeling like your therapist is trustworthy, knowledgeable, eager to learn more about you, and has a plan for helping you get to know yourself.

Effectiveness & Criticism of Existential Therapy

Existential therapy is a highly effective form of treatment.^8,9 But compared to other modalities, there are fewer empirical studies about it.^10,11 It is also fair to point out that existential therapy has been criticized for “over-intellectualizing” therapy, and lacking a consistent, defined method.¹²

The simplest reasons for the comparative lack of scientific evidence for existential therapy are that its practice does not easily fit into the parameters of a strictly controlled study, and that the issues it tends to address are not amenable to short term treatment.^10,13,14

While therapies such as person-centered therapy advocate for patients having and expressing their emotions and having the therapist reflect these back to the patient, there is some evidence that patients benefit more from intellectually wrestling with their emotions rather than simply letting them out intensely.¹⁵ Furthermore, it is unclear if the charge is even fair; as I explained above, existential therapy likes to stay in the “here-and-now” and depends on creating a real relationship between therapist and patient, both of which engender emotional resonance.¹⁶

While it is true that there is not an official existential therapy of practices that constitute existential therapy, as there are various schools), it is unclear why this should be a criticism of the modality as opposed to a frustration with how to test it. (DBT and REBT are often similarly eclectic.) In fact, Existential Therapists see it as a benefit that existential therapy can use methods from various therapies.^1,13

How Is Existential Therapy Different Than Other Therapies?

Existential therapists believe that they, like all therapists, do well to encourage patients to choose and to act. Consider Viktor Frankl’s claim that “any therapy tries to make the patient aware of what he actually longs for in the depth of his being.” And since at its core, existential therapy is an integrative approach, there will be overlap with other therapy experiences.¹⁷

But existential therapy aims to help people focus on their deepest concerns, issues that stem from just being a person.¹ These deep concerns dovetail with traditional therapeutic concerns such as repression and denial, but are quite different; unlike more explicitly dynamic or cognitive-behavioral therapies, existential therapy starts from the idea that the patient is confronting inescapable facts about human existence, issues that often get (seemingly) blissfully ignored much of the time.