This article presents a discussion with an anonymous psychiatrist, Dr. E., of the importance of philosophy for the psychotherapist. The focus of the interview is on the question of the nature of the ultimately real, the concern of metaphysics. This question is approached in an interchange about three psychiatric patients whose worlds departed dramatically from all that is conventionally held to be real and true. Dr. E. argues that applying an understanding of the phenomenology of annihilation states allows such discrepant realities to be interpreted in terms of the subjective truths they contain.