The undiscovered country: welcoming a new era of existentially-informed clinical psychology

Since the 19th century, the existential philosophers have written about the challenges universally inherent to being human. These problems of existence were later conceptualised in psychology as the “Big Five” existential concerns. That is, all humans must grapple with the following issues: 1) Meaning (e.g., the desire for a sense of purpose amidst a world which offers no innate meaning); 2) Isolation (e.g., the need for connection despite the “unbridgeable gap” between our own subjective experience and that of others); 3) Identity (e.g., the struggle to determine our own self-concept); 4) Freedom (e.g., the need to make decisions from the infinite number of options that life presents, and the guilt that can emerge from making unwise choices); and 5) Death anxiety (e.g., the conflict between our desire to live and our awareness of death’s inevitability).

Until recently, several of these issues had received relatively little attention in clinical psychology. Well-established theoretical frameworks for understanding these concepts have been largely neglected by our field. For example, Terror Management Theory (Greenberg et al., 1986), the leading theoretical approach to conceptualising death anxiety and its impacts on human behaviour, has remained largely confined to social psychology since its development in the 1980’s. Only recently have efforts been made to integrate its findings into the neighbouring field of clinical psychology, with results indicating that death anxiety plays an important role in numerous mental health conditions (Forrester et al., 2023; Iverach et al., 2014; Menzies & Dar-Nimrod, 2017; R. E. Menzies et al., 2019, 2021; Strachan et al., 2007). Where research has been conducted into the other four existential constructs, it has rarely done so explicitly through the lens of existential psychology (e.g., exploring loneliness in relation to psychopathology, rather than existential isolation insofar as a problem all humans grapple with).

This special issue of Clinical Psychologist is designed to publish a collection of papers exploring novel theoretical and empirical work at the intersection of existential and clinical psychology. Although a body of research now exists demonstrating the role of particular existential constructs in select domains (i.e., the role of death anxiety in anxiety-related disorders), numerous clinical problems, diagnostic categories, and treatment approaches have been explored far less through the lens of existential psychology. This issue therefore aims to move beyond more well-established areas in this field, and to highlight the vanguard of existentially-informed clinical research.

As the first paper in this special issue, Pashak et al. (2023) lay the theoretical groundwork for the papers which follow. They argue for the importance of developing existentially-informed clinical science, practice, and teaching. This paper provides an accessible overview of existential thought, while also offering practical recommendations to help researchers and clinicians integrate existential themes into their own work.

One recent phenomenon which has cast a spotlight on existential issues is the COVID-19 pandemic. The global population has been subjected to a barrage of reminders of death, including daily death tolls, face masks, and public health campaigns (Menzies & Menzies, 2020). Being restricted in one’s ability to socialise, work, and engage in hobbies and activities one is passionate about, may also have led to questioning one’s sense of meaning in life, or even one’s identity. Further, social distancing and home confinement measures would arguably exacerbate feelings of isolation.

Vail et al., (2023) collected data during the COVID-19 pandemic to explore how concerns about the pandemic and existential isolation might interact. Across two studies, they found that COVID-19 related threat and existential isolation jointly predicted higher levels of anxiety and depression, and lower levels of hope and wellbeing. Importantly, their findings also demonstrated that existential issues were key to predicting how concerns about COVID-19 impacted feelings of hope. Specifically, COVID-19 concerns were associated with reduced hope among people with high existential isolation, but increased hope among people who felt connected to others. Their findings have important implications for clinical psychologists in particular, highlighting the potential benefit of addressing existential concerns to improve psychosocial outcomes amidst current or future pandemics.

Whilst existential issues are common to all of us, they may be particularly relevant for people struggling with mental health difficulties. However, some diagnostic categories, such as psychotic disorders, have rarely been studied in the context of existential concerns. To this end, Easden et al. (2023) explore the relationship between death anxiety and schizotypy, a personality dimension associated with greater proneness to psychosis. Their findings indicate that fears of death predict positive schizotypy, particularly when combined with maladaptive coping. They highlight the need for further experimental research in this area, and the potential utility of considering existential vulnerability in the conceptualisation of psychotic disorders.

Another understudied yet vital area of research involves the link between fears of death and suicidality. Critchfield and Harvell-Bowman (2023) shed light on this relationship, providing an insightful overview on exploring suicidality through the lens of existential psychology and attachment theory. By considering perspectives from both Terror Management Theory and Interpersonal Reconstructive Therapy, they highlight the paradox between close relationships being a buffer against fears of death, and the fact that suicide may be seen as a way to bolster these same relationships among people who are suicidal. Using case examples, the authors present important treatment implications for clinicians managing chronic suicidal ideation. This paper adds important theoretical context to the handful of empirical studies which suggest small yet significant relationships between death anxiety and suicidality (for review, see Sims et al., 2023).

Another recent line of discovery concerns the potential utility of serotonergic psychedelics in ameliorating death anxiety and improving psychological wellbeing. Moreton et al. (2020) have previously proposed that these benefits may be mediated by reduced death anxiety. However, few studies had explored this possibility directly. In this issue, Moreton et al. (2023) present findings suggesting that acute effects of psychedelics predict self-reported improvements in obsessive-compulsive symptoms. Importantly, they demonstrate that reduced death anxiety does indeed appear to be a key mediator in this relationship. These findings highlight the need for further trials of psychedelic-assisted therapy in the context of psychopathology, and the need for experimental designs to confirm whether death anxiety may be a key mechanism in their efficacy.

In many ways, clinical psychology has reached a fork in the road. Transdiagnostic approaches are receiving growing attention as a potential solution to high rates of comorbidity among mental illnesses. On the other hand, some have increasingly called for the field to move away from the medical model of mental health entirely, and to abandon the assumption that distress is a sign of pathology. Existentially-informed approaches to clinical psychology may prove fruitful for both approaches. That is, an existential lens may help in identifying relevant transdiagnostic treatment targets (see further, R. G. Menzies et al., 2022), and in conceptualising distress in ways which are less reductionistic. As clinicians and researchers, we have much still to learn about the role of existential issues in mental health. I believe that the collection of papers in this special issue goes some way to illuminating new research pathways in this field. I am deeply grateful to the authors for their contributions to this important topic.

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Funding

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.