Existential Psychology Weblog by Louis Hoffman

Psychotherapy Outcome Debate: Rhetoric and Marketing One’s Position

Science ought to inform one’s positions and the perspective one is advocating for, not be used as a political weapon. However, it seems today that science has too often been co-opted for self-serving purposes. This, I believe, is too often the case in the outcome therapy debates in psychotherapy.

For many years I have maintained that this debate of “who’s best” is quite adolescent and not very appropriate for professional dialog. In particular, my concern is that we have been too focused on the self-serving debate of whose approach is best and not focused enough on how to work within the various approaches to make them more effective in meeting the diverse needs of our clients. This debate is a distraction that does not serve clients and does not serve the professional community.

As I have discussed in this blog series, there is plenty sufficient evidence to, at the least, cause one to seriously question the superiority of any approach to therapy. So why does the debate continue? I believe it is more about power, control, and job security than science or protecting the profession, as is often claimed. Certainly, there are some approaches to therapy, such as rebirthing and conversion therapy, that have caused harm and warrant strong suspicion. However, one is very hard-pressed to find any evidence that the majority of psychotherapy approaches cause harm. In reality, some therapists from all the different theoretical orientations cause harm. This merely suggests that any approach to therapy can be misused and cause harm.

Obviously, a personal benefit exists in being able to say that one’s approach to therapy is superior to others. To name a few, it provides better access to managed care/insurance panels, creates job security, creates openings for academic positions, and increases access to research grant money. These are strong incentives to engage in political rhetoric about the superiority of one’s approach and to wage science in an effort to bolster this position. It provides incentive to develop research to support one’s view of the superiority of their approach. Outcome research is often done by individuals with a vested interest in a particular outcome. As an example, much of the research comparing the effectiveness of medication versus psychotherapy has been supported by pharmaceutical companies. The researcher’s paycheck is part of an investment, quite literally. In other instances, individuals that practice a particular therapy orientation often are the same individuals that compare its effectiveness to other approaches. It is not surprising that the approach they advocate for often is shown to be superior.

Any time we explore a position on outcome literature, we need to take a look at the motivations, implicit and explicit. We need to consider where the funding is coming from. We need to consider other pressures that may influence how the research study is designed and how the outcomes are interpreted. This is one of the many reasons why I have more respect for the research done by individuals such as Bruce Wampold, who did not have an invested interest in how the research came out. And his research has suggested that the various therapy modalities tend to be equally effective. In the large majority of outcome research comparing the effectiveness of different modalities, there is a very clear vested interested in finding the superiority of one approach.

Even with reviews such as this blog series, one should consider the motivations and contexts. As is evident, I am invested in demonstrating that existential psychology is a valid approach to psychotherapy that produces good outcomes. Little doubt, this impacts my motivation for writing this and how I write this blog series. But I am also invested in recognizing the value of different approaches to psychotherapy. I consider myself a scientist, a philosopher, and a critical thinker. All of these identities impact the way I view the world and professional issues. I pride myself in being passionate, yet not trying to privilege my position or values over others. It is my hope that this intent, to not privilege my views, helps me take a more balanced approach to reviewing this topic. In the end, it is necessary for these ideas, too, to be critiqued.

When you look at many of the narrowly-defined scientific paradigms, they are not open to such scrutiny. They will accept critiques coming from new science, but they discount external critiques of the basis of how they understand science. I am sure that what I write in this blog series means little to them. It is simply another unscientific threat to science. I think this is unfortunate, especially in a country that produced great scientists of the likes of William James and Albert Einstein; individuals who truly engaged in a broad based approach to scholarship and science, who try to extend the limits of science, and who recognized the limitations of their own work. 

Psychotherapy Outcome Debate: Philosophical Issues

All science is based upon a philosophy, whether it is implicit or explicit. The same is true for the science of psychology. However, through much of the 1980s and 1990s, and even into the 21^st century, there was a movement afoot that seemed to suggest psychological science had risen above philosophy to a pure science. Many seemed to believe that we no longer needed to talk about how we know what we know (i.e., epistemology and the philosophy of science). The philosophical basis of science did not go away, it was just naively ignored and pushed to the implicit levels. The devaluing of philosophy and critical thought made it easier for narrowly defined scientific approaches to begin to gain dominance, but it did so at a great cost. Increasingly, it seemed, therapists were trained to be technicians who did not need to be able to think about therapy, just apply their techniques. There were even rumors that computer programs were being written with the belief that their ‘scripts’ could provide therapy as effectively as a highly skilled therapist.

Although it has been a while since I’ve heard rumors of the therapy computer programs, many therapists still aspire to be more like computers than genuine, healing human beings. I have many concerns about this, but will limit this post to a few. The first philosophical blunder is the belief that all means lead to the same end, so the shortest means is best. Stated differently, if all therapies tend to be equally effective in treating symptoms and diagnoses, then shouldn’t we focus on the quickest route? My answer is a resounding “No!”

The most evident example is the therapy versus medication debate. It is evident that there are differences between relying upon a psychoactive chemical to produce a mood change as compared to using an interpersonal relationship. These medications produce side effects that often are undesired. And, quite frankly, these medications have not been around long enough for us to have any conclusive evidence about their long term impact. When we apply this to psychotherapy, we can see that the various therapy approaches also have different “side effects,” or what David Elkins (personal communication) liked to refer to as “extra-therapeutic benefits.” These “side effects” or “benefits” of therapy are often positive, as compared to the negative effects of medication. As an example, cognitive-behavior and rational-emotive therapies are likely to have the extra-therapeutic benefit of promoting a rational thought process. Psychodynamic therapy is likely to have the extra-therapeutic benefit of increased insight into one’s history and relationship patterns. Existential and humanistic therapies will provide the extra-therapeutic benefit of increased insight into intrapersonal and interpersonal issues, as well as the various existential givens. I would maintain that existential and humanistic therapies would also promote deeper, healthier relationships, recognition of one’s life meaning, and an improved ability to constructively utilize a wide range of one’s emotions in personal growth. So, yes, most therapies may help alleviate symptoms equally effectively, but therapies are not all the same. We need to help clients consider what extra-therapeutic benefits they are seeking when considering the fit to a particular approach to therapy.

Let me briefly discuss one more philosophical issue: The belief that outcomes measures measure what they purport to measure. I discussed this some from a research perspective in the previous blog, but allow me to look further into the demand characteristics this time. Demand characteristics refer the idea that clients often will consciously or unconsciously attempt to understand what the researcher is looking for and then modify their behavior to conform to this. In psychotherapy research, it is pretty evident what is being investigated, but when there is a high level of congruence between the therapy measure and the approach to therapy, there is an increased susceptibility to demand characteristic. For example, when the Beck Depression Inventory (BDI) is used to measure therapy outcomes, it is pretty evident that this measure is focusing on the cognitive appraisals similar to what is being discussed in CBT. Other approaches, which may focus on encouraging a client to experience and then work though feelings, may encourage a different type of response (i.e., demand characteristic) on the BDI. Therefore, the measure is inherently biased toward CBT in this example.

Similarly, it could be argued that in CBT you are ‘teaching to the test.’ The primary focus in CBT is encouraging clients to change their thoughts with the belief this will change their emotions. If, then, the client is given a test on how well they are doing on these lessons, they may feel pressure from the therapist and internally to answer the questions in a way suggesting that they are learning what they are supposed to learn. In other words, they want to pass the test. This leads to the inherent possibility that clients will feel pressured toward self-deception instead of healing. I don’t mean these criticisms to invalidate CBT. I truly believe CBT is a valid, effective approach and believe this approach to therapy is the best fit for many clients based upon what they want from therapy. However, there are serious limitations to the outcome research often interpreted to suggest this approach is superior to other approaches to therapy.

In this blog, I only covered a few of the many serious limitations to a narrowly defined scientific approach to outcome research. Many more exist, but that would be the subject of a journal article or book, not a blog. Science without philosophy and critical thought is nothing more than rhetoric. We must understand the context of science, critically think about its findings, and understand the implicit biases in the approach to science if it is going to have any validity at all. Promoting blind science is no better than promoting blind faith; both are dangerous. 

Psychotherapy Research

Research on psychotherapy has taken many different directions over time, as discussed in my previous blog. Although a bit of an oversimplification, most outcome research tends to fall into one of two camps: 1) Empirically Supported Treatments and 2) Common or Contextual Factors Research. I will discuss each approach briefly analyzing the strengths and weaknesses of each. 

The focus of the Empirically Supported Treatment, at its heart, is to evaluate the effectives of a narrowly defined treatment approach. This is a noble effort. First, it provides information that gives the appearance of being rather clear and straightforward. Oftentimes, it facilitates the development and improvement of very structured therapy approaches that are fairly easy to follow. These approaches often are very appealing to insurance companies and managed care, allowing psychotherapy to have an inroad in to reimbursement options. 

However, this approach has too often attempted to become something more than it is, leading to several major problems. First, this approach has often gone down the path of comparing psychotherapies trying to 'prove' which approach is best. I have concerns about the motivations, utility, and philosophy of science of such attempts. Researchers often are rooted in one of the therapy approaches reflecting a particular philosophical system and design or utilize measures that are best suited for the particular approach to therapy. Stated more clearly, different outcome measures are better suited to measure different types of therapy. 

Let me provide a brief example. The Beck Anxiety Inventory (BAI) and the State-Trait Anxiety Inventory (STAI) are two common measures of anxiety, both reflecting different theories. The BAI focuses mostly on one's perceptions of anxiety (i.e., cognitions) and little on visceral symptoms (i.e., bodily symptoms). The STAI, conversely, focuses more on visceral or bodily symptoms. The BAI is typically used in evaluating the effectiveness of cognitive behavioral therapy (CBT), which makes logical sense in that in focusing on defining anxiety primarily by cognitions and perceptions. In CBT therapy, the therapist is working on helping the individual change cognitions and the BAI evaluates this. However, it assumes that cognitions and experience will be equivalent. This creates a few problems, such as demand characteristics, in which clients are encouraged to change their cognitions in a direction with the assumption that the accompanying emotion will follow. This is not always the case. Sometimes cognitions change, the BAI results change, and the experience does not. Other forms of therapy focus on targeting the visceral symptoms more directly, without being as concerned about the cognitions. This therapy could potentially be effective by the STAI and not the BAI. In other words, as soon as an outcome measure is introduced, so is a bias. 

Studies rooted in the Empirically Supported Therapies tradition tend to emphasize a fairly controlled research setting, which also introduces limitations. This approach is biased to more structured, solution-focused therapies and against the more fluid, relational depth psychotherapy approaches. However, even many solution-focused practitioners point out that the therapy conducted in these research studies often do not reflect therapy in the real world. It takes the relationship out of even the solution focused approaches. In particular, therapists often follow structured guidelines on how to intervene at a particular point in treatment and are discouraged from following clinical judgment and experience about when adaptations are necessary. 

The controlled aspect introduces another serious limitation. First, careful screening is conducted to assure the client meets the right criteria, which often means not including individuals with complex issues or dual diagnoses. This is a large portion of the population entering therapy! Studies also have to carefully consider which factors to include and control for as potential confounding variables, but cannot include too many factors as if enough factors are controlled for, the natural co-variance across influences would reduce any unique variance to non-significant levels. Variables such as the therapeutic alliance and client motivation, which meta-analytic studies suggest are very important, are generally not included. Thus, it is very difficult to say that it is the techniques, or what is intended to be measured, that is actually being measured. These serious limitations do not suggest we should throw away this type of outcome research, but rather we need to acknowledge there are many very significant limitations. We are only getting a small bit of truth at most in these studies. 

Common Factors Research emerged from broad, critical reviews of the research, meta-analyses of previous research, and new research across therapy approaches into other factors not accounted for in the empirically supported treatment paradigm, such as empathy and therapist factors. This includes many very rigorous research approaches that are better able to take into consideration factors, such as the therapy relationship, that the empirically supported treatment paradigm frequently ignores.

The results are consistent: The two most important factors predicting therapy success are 1) client factors and 2) the therapy relationship. Both of these factors are generally not given much consideration in the empirically supported treatment paradigm! These two factors alone account for most of the therapeutic change (see Humanistic Psychology: A Clinical Manifesto, 2009, by David N. Elkins, for an in depth review of this research). 

One of the most fascinating aspects of this research is regarding technique. In the various meta-analytic studies, the role of technique generally accounts for somewhere between 1.5% to 7% of the variance in therapy outcome. However, even with this, it is not a particular technique that accounts for the variance, but that techniques are used. This means that the efficacy of any particular technique would be much less than the 1.5 to 7%! What accounts for a greater portion of the therapy effectives could be labeled as the therapist and client belief in the therapy modality used. In other words, the therapist believing in what they are doing and being able to inspire hope in their clients is more important than the type of therapy the therapist employs! The moral of this story is to make sure you believe in what you are doing and choose a therapy orientation that fits. From this perspective, we should be less interested in coercing young therapists into a particular orientation, but more interested in helping them find the orientation that is the best fit for them. 

In conclusion, outcome research is complex. Anytime you heard that it is clear and simple, be suspicious. I believe that the most rigorous and complex research on therapy outcome strongly suggests that what we should be most concerned about is 1) client factors, 2) the therapy relationship, and 3) helping therapists find a therapy modality that they believe in. This last factor, although not in the two factors identified by meta-analyses as most predictive of successful therapy outcomes, I think is related. When therapists are doing something they believe in and are passionate about, and are concerned with helping clients find the best fit (as opposed to trying to convince every client they are the best therapy for them), they will build better therapy relationships with their clients. 

Understanding the Fort Hood Shootings: An Existential Psychology Approach

The United States has suffered another great loss with two of our citizens opening fire on fellow citizens. In the aftermath, we see the beauty of concern and compassion for those who are suffering. We also see the media frenzy trying to understand what happened and why. Striving to make meaning from tragedy is a basic existential concern; however, we also need to take a close look at the process of how we make meaning, which is the concern of this blog post. 

Withing hours, we heard psychological diagnoses being made, sometimes with appropriate caution, sometimes recklessly by mental health professionals happy to be in the national spotlight. I am glad that the media seeks to interview mental health professionals and there is nothing wrong with responding to this request. However, it bothers me when these professionals sensationalize their responses in exchange for 10 seconds of fame. It is unethical to diagnose these individuals without having known them, having access to the records, and being able to see the behavior in context. When Hasan is given the label PTSD, all of a sudden the many wounded warriors who suffer from PTSD become a threat instead of something deserving compassion. Compassion is replaced with fear for too many. I plan to write more on PTSD tomorrow in honor of veterans day. For now, I just want to highlight how this diagnosis can be used inappropriately. 

We also heard of people focusing on the shooter's last name, Hasan, and speculation that this could be because of his last name. In both the Florida and Fort Hood shootings, much was made of their ethnicity. Lost in much if this discussion is the basic reality that no cultural group in history has engaged in more mass shootings of this type than the White male. Few talk much of the role of ethnicity when the White male kills, but much seems to be made when a White person is victim. The dominant culture seems to feel safer by distancing the perpetrator from their personal identities. 

We also can use a psychological understanding of the impact of trauma and other factors to analyze what may have occurred. In doing this, the responsible mental health professional should always emphasize that this is speculation that may have nothing to do with the actual cases. Personally, I think diagnosing does not help this process most of the time, but using psychological ideas that carry less discriminatory power can be helpful. 

Most of the attempts to understand events such as the Ft. Hood shooting focus on wanting to distance ourselves from the killer. We attempt to categorize, label, and discount the individual instead of understanding him or her (almost always him in this type of event). Instead, if we truly want to understand what has occurred, we must be able to take a more sympathetic view of the individual. I understand this is not an easy idea to consider. Shouldn’t we focus our compassionate energies on the victims and their families? Yes, absolutely. However, if we want to prevent such tragedies in the future, we must take the risk of empathetically trying to understand the shooter. This does not excuse the behavior. I must stress this: empathetic understanding does not excuse the treacherous acts committed by the individual, it simply brings understanding. As James F. T. Bugental once said, he was convinced that if he had the opportunity to work with Hitler in therapy, he was confident that underneath all the anger he would find a hurt, suffering individual. This does not excuse Hitler or the holocaust; it helps understand it.

I imagine things were not easy for Hasan. To be of Middle Eastern ethnicity in the military must be difficult. I have heard many soldiers express concern about their immediate negative reactions to anyone who Middle Eastern, despite not wanting this to be the case. This is learned behavior. When deployed in Iraq or Afghanistan, they had many bad experiences with people of Middle Eastern origin shooting at them, trying to kill them, or otherwise intending harm toward them. It is basic behaviorism – learned responses. There has been some reports that Hasan did experience some blatant racism and mistreatment because of his race.

Additionally, I am sure he experienced many microaggressions. Microaggressions are unintentional, often well-intended forms of racism. A common example is when an individual of a particular skin tone or cultural group is asked to speak for everyone who shares that identification, or when an individual from a minority group is told they are articulate when a person of majority speaking the same way would be perceived as speaking quite normally. For Hasan, I’m sure he heard many stories like I have heard, of soldiers who have returned and struggled with their reactions against individuals from the Middle East. Most of the time, these soldiers cognitively realize that there is no just reason for their negative view of individuals of Middle Eastern origins. They speak of this because they do not like that they have this reaction, not because they embrace it. However, it still can be hard to hear these comments and others feel their reactions are justified.

We also need to consider the concept of vicarious trauma. Surely, in Hasan’s role, he heard many horrific stories, as do all of us mental health workers who work with soldiers and veterans. These are hard to hear; they are painful. When I hear soldiers talk of accidently killing a civilian and their guilt associated with this, or stories of being haunted by watching a friend get violently killed right next to them, it hurts. It traumatizes me.  I am sure that Hasan, as a psychiatrist, heard these stories, too. It is not as traumatic as being there, experiencing the violence and death, but it is still traumatic.

Last, I think it is important to realize that mental health professionals are people, just like everyone. There are checks to try to make sure that people entering the field meet certain standards of mental health. Yet, some individuals make it into the field that should not. Others are psychologically healthy when entering the field, but because of life experiences become unhealthy over time. However, ALL mental health professionals have their own struggles and issues. This is part of the human condition. Furthermore, some of the individuals most recognized in the history of the field as exemplar therapists were individuals who struggled deeply with their own psychological problems. Carl Jung, Harry Stack Sullivan, and R. D. Langs are just a few examples. If our expectation for mental health professionals is to have no psychological problems, then we might as well close down the professional.

In conclusion, I do not know why Hasan committed the terrible acts he did and I believe he should be held fully accountable for them. Nothing excuses his behavior. However, I do want to know why he did these things beyond discounting him as evil or acts of mental illness. He was a person who did a horrible thing. Discounting him will not help me be a better person or psychologist, but understanding him, finding ways to be compassionate toward him while holding him accountable, may just help me become a better person and professional.

Existential Psychology and Religion: A Response

As an existential psychologist interested in religious and spiritual issues, I have heard many interesting comments from people who have been taught inaccuracies about existentialism. Often, these individuals have been taught to be fearful of it. For example, I had one student who, while on break, mentioned to their minister that they took a class on existential psychology with me and really enjoyed it. Her minister quickly informed her that existentialism is atheism and that I was probably secretly trying to persuade her away from her faith. She was warned to be weary of me (that pastor had never met me and knew nothing about me except I taught a class on existential psychology). The student obeyed for a while before sharing with me what her minister said. Gradually, she began to trust, at least to a degree, that I was "safe" and that I respected her beliefs, but she always seemed leery. 

Recently, there was an article published in a peer-reviewed professional psychology journal on integrating a religious perspective into existential psychology. At first, I was excited to read this article; however, I quickly became disappointed. The article, to be blunt, was poor scholarship that does not meet proper academic standards in addition to misrepresenting existential psychology. The only references to existential psychology within the last 30-years were to Yalom. There were also two references to Frankl within the last 30-years, but one was inaccurately cited (it was published much earlier) and the other was a publication after Frankl's death comprised of revised articles he had written and published much earlier. There was not a single reference anywhere in the article about the numerous contemporary perspectives on religious/spiritual issues in existential thought. The journal should have been responsible enough to find an existential scholar to review the article and any contemporary existential scholar easily would have pointed out the many problems in this article. 

Both humanistic and existential psychology have had similar problems. Seligman, in the article that is considered the birthing of positive psychology, drastically misrepresented and discounted humanistic psychology. Both humanistic and existential psychology are frequently misrepresented in undergraduate and even graduate psychology courses. . 

So why are these perspectives so misrepresented? Well, there are many reasons. The primary reason is that they have not had much of a popular voice in the past 20-years. This is beginning to change and the last several years has evidenced a resurgence of existential and humanistic psychology. Most of the critiques I have run into are not even familiar with the majority of major contributors to these fields, yet feel confident in their critique. There is also the problem of history. Many will cling to one or two historical representatives of existential psychology, or maybe even mix in 1 or 2 contemporary figures, and then use this as their view of existentialism. Existentialism is a broad, complex collection of perspectives that share some common values and beliefs; however, there is not full agreement on any one issue. 

When it comes to religion, there a many different perspectives. Still, when existentialism is talked about from religious leaders and scholars they draw almost exclusively on Nietzsche and Sartre, occasionally recognizing Kierkegaard as an existential thinker. Using Nietzsche and Sartre, and maybe Yalom as the recent journal article did, as representatives of existential thought, they will often present a case against existential thought that condemns it as anti-religion, excessively individualistic, and morally dangerous, possibly even the same as relativism. 

Religion, in my experience, has been the biggest culprit misrepresenting existential thought. This often is a fear-based response. An example can be drawn from the popular bumper sticker, "Nietzsche: 'God is dead.' God: 'Nietzsche is dead.'" I find this quite humorous as it really demonstrates a drastic misunderstanding of Nietzsche's point. Never did Nietzsche intend this to be a metaphysical statement about the reality of God. Indeed, this would make no sense as Nietzsche did not believe in God (Nietzsche was more of a non-believing agnostic than a true atheist). Instead, Nietzsche was really arguing that faith, or belief in God, was no longer impacting how Christians lived their lives. This critique is not far off from what often is said in the pulpits on Sunday morning. To put it in theological terms, Nietzsche was really saying that Christian faith was no longer producing works or that Christians were not living in accordance with their beliefs. Most voicing an objection to this statement of Nietzsche have never read more than "God is dead" from "Thus Spoke Zarathustra" and, if they have, they often read it too defensively to ever understand Nietzsche's point! 

I would like to address one last issue related to ethics, relativism, and guilt. In the journal article referenced, it was essentially claimed that existentialists have had nothing to say about guilt and no moral ground for ethics. There are many problems and inaccuracies in this statement, which deserve a blog on their own, but I will briefly clarify. First, it is quite audacious to claim that existentialists have nothing to say about guilt. In fact, I doubt that any psychological orientation has spent more time talking about guilt than existential psychology! There basis for this, however, is different than many traditional religious views. 

From an existential perspective, guilt and ethics do not have to do with some external set of rules. Instead, morality is rooted in our existence, in being human (in theological terms, this would be a form of natural theology). To appeal to a set of external, concrete rules can only limit ethics. Instead, existential thought appeals to a set of abstract principles that can only be applied in context. In other words, ethics is always an applied ethics from an existential perspective. We can talk about ethics and morality, but detached from a context, it is meaningless and primarily just an intellectual exercise. 

Let's take an example of the most frequently cited objection to this: 'Thou shall not kill.' Some will respond saying that existential thought is unable to make a moral statement about murder. This is not true. First, drawing on a natural ethics, or natural theology, there is a basic principle of respecting life and human dignity that is part of an existential morality. How, then, does this fit in a view that murder is wrong if there is a claim that ethics are always applied and contextually understood? As an example, most ethics systems allow for different interpretations of what murder is. We differentiate between 'involuntary manslaughter' and 'murder' in the United States. Also, we do not consider capital punishment murder, even though it is taking someone's life. In other countries, our stance on allowing capital punishment is a form of state sanctioned murder and morally wrong.

Let me now return to the problem of guilt. What is guilt from an existential perspective? Existentialists distinguish existential guilt from normal guilt and neurotic guilt. However, in essence, most or all forms of guilt are rooted in an existential guilt. Camus is the true genius when discussing guilt, although he addresses it more implicitly than explicitly. For Camus, guilt is part of the human condition: to be human is to be guilty. This, although rooted in a natural theology as opposed to many Christian perspectives, has many parallels to the idea of original sin. But Camus, in contrast to Sartre, did not have just a pessimistic view of human nature. In fact, it was this issue that caused his separation from Sartre and his resistance to being called an existentialist. Camus, as many existentialists do, believed that human limitation should be balanced with human potential. The theological parallel could be cited as Luther's idea of the sinner-saint (Indeed, it is quite evident to see the influences of Lutheranism throughout much of existential thought, particularly through the influences on Kierkegaard and Tillich, who had Lutheran ties). 

To conclude, existentialism in it many variations -- philosophy, psychology, theology, and the many variations within each of these -- has always had a complex relationship with religion. Increasingly today, existentialists seem to be very interested in religion/spirituality through addressing religious and spiritual issues; however, there also remain some existentialists who take a very negative view on religion. Yalom is maybe the best known representative of this view. To pit existentialism against religion, or to discount the significant work existentialism has done with religion and spirituality, is really misinformed and based upon a limited view of the existential literature. Instead, there is a exciting realm of scholarship addressing spiritual and religious issues in existential thought with a long history that continues through today.