The paper describes a conceptual model that illuminates why existential issues are an essential element of history taking and need to be addressed in clinical practice. There are four layers in the encounter with the patient: (1) the analysis of the clinical syndrome; (2) the investigation of the way the patient relates to her condition; (3) analysis of the way the psychiatric condition affects this latter relation (example: demoralization as depressive symptom affects the way the patient relates to her depression); and (4) investigation of the way the personality of the patient affects her relation to the clinical condition. Existential factors play a role in layer (4) and maybe crucial not only for understanding the patient but also for compliance and effectiveness of interventions. The paper will relate to other attempts to an integral view on patient care and will describe efforts to implement this view in clinical practice and residency training.