It can arrive like a collision, or it can arrive in the silence of 3am—the moment when the usual answers to your life simply stop working. You showed up and did all the achieving, and yet something remains, restless and unanswered: What does this life even mean? Who am I? What even matters to me?
Existential psychotherapy and analysis was built for this terrain. It is also the subject of a growing body of rigorous clinical research because, for decades, critics and insurance companies have demanded an answer to the same question: Does this actually work?
A 2023 research review by psychological researcher Dr. Joel Vos, published in Pratiques Psychologiques, synthesizes the empirical literature and arrives at a clear answer: yes, with effect sizes comparable to those of other psychotherapeutic modalities.
For those of us who work in this tradition, or who have been transformed by it as clients, this is not surprising. However, the research matters enormously in a data-obsessed world and confirms what many philosophers have recognized for centuries.
The Core Idea: We Suffer by Narrowing
At the heart of existential therapy lies a deceptively simple and profound insight. Human suffering often arises not from a chemical imbalance or a distorted cognition but from a psychological narrowing, a habitual refusal to face the full, paradoxical, often uncomfortable totality of our human experience.
We may suppress death anxiety by staying perpetually busy, or silence the question of meaning by chasing the next goal; other times, we may avoid freedom by telling ourselves we had no choice.
Drawing on philosophy, Vos articulates such behavior as the difference between our primary flow of experiencing—the raw, alive, unmediated contact with the world—and the secondary layer of interpretations and advanced defences we drape over it. Neuropsychological research corroborates this: Consciousness begins as felt experience before it becomes thought. So, existential therapy invites clients back to our original felt-sense experience of the world.
Vos’s landmark review organizes the process through appraisal levels that describe how we make meaning of our experience.
Primary Appraisal: How we initially experience a situation, such as: Is this threatening or manageable? Existential anxiety (about death, vulnerability, isolation) often distorts this first layer of perception before we are even aware of it.
Secondary Appraisal: Our sense of inner resources. Self-efficacy and existential flexibility shape how we respond. Viktor Frankl’s insight that we can always choose our inner attitude, even when in a concentration camp, lives here.
Tertiary Appraisal: The meaning we make of our situation. This is where existential therapy does its most distinctive work, as it helps clients negotiate the meaning of a specific crisis against their broader sense of what makes life worth living.
Dual Awareness: The capacity to hold paradox and to find personal meaning while accepting that there is no absolute cosmic answer. Research links this capacity for tragic optimism to better psychological health outcomes.
The Existential Moods Beneath the Symptom
One of the most practically important contributions of this literature is the concept of existential moods. These are not emotions about a specific thing, like a fear of spiders. Instead, they are diffuse, pervasive, and embodied orientations toward existence itself: death anxiety, meaninglessness, shame, or dread. They frequently underlie the presenting depression, anxiety, or relational difficulties that bring someone to a therapist’s office.
There are direct clinical implications. A client presenting with persistent low-grade depression after achieving a long-sought goal may not need behavioral activation; they may need a space to sit with the messy existential question the achievement has uncovered.
The symptom is not the destination within depth work; it is an arrow pointing toward something deeper. For practitioners, developing the sensitivity to detect the underlying themes and skillfully work with them is essential.
“Hundreds of studies indicate that a large majority of the general population actively searches for meaning and that the presence of meaning and meaning-oriented coping-styles is moderate to strongly correlated with a higher quality-of-life, lower levels of psychological-stress such as depression and anxiety, and better physical well-being” – J. Vos, 2023.
The Research Evidence
Vos’s meta-analysis draws on decades of randomized controlled trials. For a modality often dismissed as “unscientific”, the numbers are striking. A multilingual review of 60 clinical trials on meaning-centered therapies (combined n = 3,713) found large effect sizes on quality of life (Hedges’ g = 1.13) and psychological stress (g = 1.21) from pretreatment to post-treatment, and effects that held at follow-up. When compared against only control groups, meaning therapies still showed large effects on both quality of life (g = 1.02) and psychological stress (g = 0.94). Critically, meta-regression confirmed that increases in meaning in life directly predicted decreases in psychological distress.
In other words,the data confirms that existential-therapeutic mechanisms create positive and long-lasting psychological change in clients. The numbers place existential therapy on equal empirical footing with most bona fide therapies.
Existential Therapy Matters
We are living through a period of conspicuous existential distress. Post-pandemic disorientation, collapsing meaning-structures in the broader culture, and the ongoing hollowness that follows external achievement in Western societies are not simply symptoms to be managed. They are existential invitations, however uncomfortable. Vos notes that COVID-19 brought latent existential questions to the surface worldwide, as people began re-examining their priorities from a wider perspective.
Existential therapy does not promise to dissolve the big questions. Rather, it offers something more sophisticated and valuable: the companionship and skill to descend into them honestly and to discover that a life engaged with its own depths and paradoxes can be more livable than one might expect.
The serpentine path of life rarely runs straight, but, thankfully, it does run somewhere real.