Existential Crisis & Loss
Tomoko, 52, architect
Fictional teaching case
Compare the formulations ↓Presentation
Six months after her mother's death, Tomoko walked into her firm one morning, looked at the models and renderings covering the conference room walls, and felt nothing. The career she had spent thirty years building (the firm with her name on it, the awards, the buildings standing in three cities) suddenly felt like something that had happened to someone else. Insomnia since. Food tastes like cardboard. She still functions (meets clients, reviews plans) but describes it as 'performing a role in a play I no longer believe in.' Doesn't meet full criteria for MDD. Says: 'I built everything I was supposed to build. None of it matters. I keep thinking... what was it all for?'
Read the full case history and clinical context
Japanese-American, second-generation. Father died of a heart attack when she was 15. She responded by doubling down on achievement: valedictorian, architecture degree at Berkeley, licensed at 26, her own firm by 35. Never married. A few significant relationships, all ended by her: she says she 'couldn't make room.' Few close friendships outside work. Her mother was her primary attachment figure, the one person she called every Sunday. Her mother's death from pancreatic cancer was swift: six weeks from diagnosis to funeral. Tomoko managed the logistics. She has not cried.
Compare how approaches understand this case
Two approaches to begin with; change them below. These are starting examples, not a clinical ranking.
Choose up to three approaches:
Showing 2 of 10 formulations.
CBT
Negative cognitive triad activated by grief: negative view of self (purposeless), world (meaningless), and future (hopeless). She has not withdrawn from activity, but the activity has stopped paying anything back, and that loss of response-contingent reinforcement maintains the flatness. Graded activity scheduling restores contact with reinforcement while the triad itself is tested against evidence.
Behavioral activation, cognitive restructuring of nihilistic thoughts, activity scheduling, identifying values beyond achievement, grief processing.
"The thought 'none of it matters.' Let's examine that. Is that a fact or a conclusion your grief is drawing? What evidence would you need to test it?"
Buddhist Psychology / Contemplative Psychotherapy
The mother's death has dissolved the constructed self that achievement maintained. Rather than pathology, this is an opportunity to see clearly: the impermanence that was always true is now undeniable. The suffering is in the resistance.
Mindful investigation of grief and meaninglessness without trying to fix them. Exploring impermanence directly. Maitri, unconditional friendliness toward all experience, including the hollowness itself and the part of her that wants it gone.
"What if you could just sit with this meaninglessness without trying to fix it? Not forever. Just right now. What happens when you stop fighting it?"
Morita Therapy
Fixation on the feeling of meaninglessness (toraware) is maintaining the suffering. The feelings are natural: grief and existential questioning after a parent's death are healthy. The problem is the attempt to resolve them through thinking.
Accept the feelings as they are (arugamama). Redirect attention from internal fixation to purposeful external action, staged the way the original protocol stages it: a period of rest with nothing to do, then light work, then full occupational activity. Morita would also read the complaint itself as sei no yokubo, the desire for life. Only someone who wanted the years to count would be this disturbed by the thought that they might not have.
"You don't need to figure out meaning before you can act. The meaning may come through the acting. What needs to be done today?"
Existential Psychotherapy
The mother's death has cracked open an existential confrontation that achievement had been papering over: death, isolation, meaninglessness, freedom. This is not pathology but an encounter with the givens of existence.
Sitting with the questions rather than solving them. Exploring death anxiety, isolation, the meaning vacuum. Not rushing to fill it but letting the confrontation do its work.
"You say none of it matters. I want to take that seriously, not reassure you out of it. What would matter?"
Logotherapy
Existential vacuum: the will to meaning has been frustrated. Achievement was a surrogate for meaning, and the mother's death exposed the emptiness underneath. The task is not symptom removal but meaning-discovery.
Socratic dialogue about values and purpose. Dereflection from the meaninglessness. Exploring creative, experiential, and attitudinal values. Finding meaning in the suffering itself.
"You keep asking what it was all for. I want to turn the question around. Your mother is gone and thirty years of work is standing in three cities. What is being asked of you now, by that, and by the people who are still here?"
IFS
The Manager that carried Tomoko through thirty years of achievement has collapsed. Its job was to keep her building so she would never have to feel the fifteen-year-old whose father died, and it did that job under her mother's gaze. With her mother gone it has lost both its audience and its reason, and the Exile it was holding down is close to the surface: the girl who never mourned. 'None of it matters' is most likely a Firefighter numbing what the collapse exposed, and Tomoko is blended with it, which is why it arrives sounding like a verdict rather than like a part.
Get to know the achiever part: what was it trying to do, what was it protecting, what does it fear will happen if it stops. Ask its permission before going anywhere near the Exile, because in IFS you do not get past a protector, you get invited past it. Then Self witnesses the girl who lost her father and never grieved, and the burden she has carried since can be unburdened. The meaning vacuum may close on its own once the grief has somewhere to go.
"The part of you that built everything (the career, the reputation), it worked so hard for so long. Can you ask it what it was afraid would happen if you stopped building?"
Gestalt Therapy
Tomoko is at the fertile void: the ground has fallen away and no new ground has formed. The hollowness is unfinished business, two deaths' worth, pressing for completion. The interruption to contact has a name here. She deflects, turning away from feeling into doing, and she retroflects the grief, holding back the crying by managing the funeral instead. The paradoxical theory of change applies exactly: she will not move by finding new ground but by fully being where she already is.
Stay with the void rather than filling it. Explore the body's experience of emptiness. Empty chair with mother, with father. Complete the interrupted grief. What emerges from the void when she doesn't flee into doing?
"You say none of it matters. Right now, sitting here: what do you actually feel? Not what you think about it. What's happening in your body, right now, in this moment?"
Prolonged Grief Disorder Treatment (PGDT/CGT)
Too early to diagnose prolonged grief disorder, which DSM-5-TR sets at twelve months, but this is the trajectory the protocol exists to interrupt. She has not been able to let the loss become real: she managed the logistics, she has not cried, and she went straight back to the firm. In dual process terms she is locked in restoration-orientation and cannot enter loss-orientation at all. It is the absence of oscillation, not an excess of grieving, that predicts a stalled course.
Alternating loss-focused sessions (imaginal revisiting of the death, situational revisiting of avoided reminders) and restoration-focused sessions (rebuilding goals, re-engaging with life).
"I'd like you to tell me the story of the day your mother died. Start from the morning. We'll take it slowly."
Narrative Therapy
'None of it matters' has become a totalizing story that erases Tomoko's complexity. Achievement was one story; the mother's death has destabilized it. Alternative stories exist but are subjugated.
Externalize the 'meaninglessness' story. Map its influence. Search for unique outcomes: moments of meaning, connection, or purpose that the dominant story obscures. Then re-membering conversations, which run in the opposite direction from letting go. What did her mother know about Tomoko that nobody else knew, and what membership does her mother still hold in her life?
"This story that nothing matters: when did it first arrive? Has there been any moment in these six months when it loosened its grip, even briefly?"
Psychoanalysis
Mother's death reactivates the original loss of father at 15. Achievement was a manic defense against grief and dependency. The career was built on a foundation of unprocessed mourning. Now both losses demand attention.
Long-term exploration of both losses and their interrelation. The dependency she has organized her life against will show up in the transference before it shows up in her account of anything: in how she handles the frame, the breaks, the end of each hour. That is where it becomes interpretable rather than merely discussed. Gradually mourning what was lost and what was never had.
"You lost your father at fifteen and became someone who builds things. Now your mother is gone and the building feels empty. What connects these two losses?"
Where Approaches Genuinely Disagree
Nihilistic thinking is a cognitive distortion that maintains depression. Challenge it.
The meaninglessness may be accurate. The task is to confront it and create meaning from within it.
Philosophical Lenses
These are not treatment plans. They are ways of seeing — philosophical perspectives that illuminate aspects of this case that clinical modalities may not address directly.
Tomoko's mother's death has shattered the they-self: the anonymous, socially constructed identity in which she took shelter. The career, the buildings, the status: these were what Heidegger calls 'fallenness,' absorption in the world of the 'they.' Now, being-toward-death has disclosed itself: not as an abstract concept but as lived reality. The hollowness she feels is not depression. It is the clearing (Lichtung) in which her own finitude becomes visible. Authentic existence does not mean returning to the old meanings. It means taking hold of her own possibilities in the light of her mortality: what Heidegger calls 'resoluteness.'
Tomoko is confronting all four ultimate concerns simultaneously: death (her mother's, and through it, her own), freedom (the terrifying fact that she chose everything she now questions), isolation (the fundamental aloneness that her mother's presence had masked), and meaninglessness (the collapse of the life narrative that organized her existence). Yalom would not pathologize this. He would say the crisis is the therapy: that Tomoko is doing the work that most people spend their lives avoiding. The therapeutic task is to be a companion in this confrontation, not to resolve it.
Tomoko is experiencing what Ricoeur calls a crisis of narrative identity. The story she told about herself, 'I am the person who builds things,' has lost its capacity to integrate past, present, and future into a coherent self. Her mother's death ruptured the plot. But Ricoeur would insist that identity is always narrative, always in process. The therapeutic work is not to recover the old story or to find a 'true self' beneath it, but to engage in re-emplotment: the creative act of re-narrating one's life so that even rupture and loss can be woven into a story one can inhabit.
Sources & Method
This is a composite fictional case — no real client is depicted. Formulations represent how each modality would typically conceptualize and approach a case with this presentation, based on published clinical literature and training materials. Each formulation draws on the modality's own theoretical framework, key texts, and clinical principles as documented on its modality page. Full source citations for every modality are available on the Sources page.