The Gift of Therapy

By Irvin D. Yalom, M. D.

Overview

Dr. Yalom draws on his 45 years of clinical practice and comes up with a collection of his most passionate categories of interest.  In this book he attempts to gift to the new generation of therapists his pearls of wisdom from those years by selecting 85 categories of subjects that come up in a therapy practice and elaborating on his successful interventions in these areas. 

 

Dr. Yalom has done extensive work individually and also with groups.  He works from an existential and interpersonal framework.  Existentialism with his individual clients and interpersonal in the groups.  With groups he works off the assumption that patients fall into despair because of their inability to develop and sustain gratifying interpersonal relationships.  When operating from an existential frame of reference he works from the assumption that patients fall into despair as a result of a confrontation with harsh facts of the human condition. 

 

Existential psychotherapy = A dynamic therapeutic approach that focuses on concerns rooted in existence.  Assumes that unconscious forces influence conscious functioning. 

Four ultimate concerns confronted with the givens of existence: All addressed in the chapters

1.      Death

2.      Isolation

3.      Meaning in life

4.      Freedom

 

Content and Process are the two major things to look at in terms of existential psychotherapy

Content: meaning the words spoken

Process:  meaning the interpersonal relationship between the patient and therapist

·         What do the words tell us about the nature of the relationship between the parties engaged in the interaction?

·         Therapy should be relationship driven not theory driven!

·         A heightened sensibility to existential issues deeply influences the nature of the relationship of the therapist and patient and affects every therapy session. 

 

The book addresses interventions in the following order

·         Therapist –Patient relationship

·         Process and Content

·         Everyday issues

·         Dreams

·         Hazards and Privileges of being a therapist

 

Chapter Highlights

Therapist –Patient Relationship

·         Remove obstacles

·         Avoid diagnosis except in extreme cases

·         Engage patient in the relationship by discussing feeling s about the therapeutic relationship and interactions that take place. 

·         Patients need to be fully understood, this requires unconditional positive regard and genuineness.

·         Stress that “We are in this together”.

·         Here and now

v      Capitalize on immediate events in the therapeutic hour.

v      The personal problems of the patient will manifest themselves in the here and now.

v      Groups are much more engaged in the here and now as opposed to old baggage.

v      Everything can be used in the “here and now”.

v      Let patients’ matter to you: Let them enter your mind, change you and don’t conceal this from them. 

v      Acknowledge errors; let them see your human side. 

v      Share feelings and let the other person know how you are experiencing them in the relationship. 

v      Effective therapy consist of an alternating sequence of evocation and experiencing of affect followed by analysis and integration of affect.

v      Therapist disclosure begets client disclosure.

v      Feedback:  Goal is to grow the public self (Johari’s window) and shrink the unconscious self. 

v      Be gentle; increase client receptiveness to feedback.  Feedback works best when the “iron is cold”.  I.e. patient is behaving differently.

 

Content

Death: Talk about it, patients who are facing death grow wise.

2 models of existence:

Everyday mode: Consumed and distracted with the material surroundings.

Ontologic mode: Focused on being – Filled with wonderment that things are.  Existing in ontologic mode provides a state of readiness for change. 

Life Meaning: Humans = meaning seeking creatures.  Engagement is what counts.  Our job as therapists is to remove obstacles to engagement. 

Freedom:  Freedom is psychologically complex and permeated with anxiety. 

We do not enter into a well-structured world: Instead we play the central role in constituting that world.  For therapeutic change to occur patients need to assume responsibility. 

Responsibility is the only way to freedom:

Do not reinforce Victimhood: even if 99% of the bad things that happened are someone else’s fault; focus on the 1% that belongs to the patient. 

                                   

Decision is another boundary experience (like death). Making a decision cuts us off from other possibilities.  Decision leads to finiteness and groundlessness – domains soaked with anxiety.

 

Everyday Therapy

·         Therapy works best if it approximates a continuous session.

·         Take notes.

·         Encourage weeping patients to go deeper.

·         When in a dilemma, share it with the patient.

·         Do home visits.

·         Therapists place a higher value on insight and interpretation than patients do.

·         Patients want therapists to pay attention to the minute details of their life: This gives a good jump-start on bonding.

·         Therapy is not a substitute for life – it is a means to and end and a reference point.

·         Touching is a good thing: do it properly and use if for grist in the process.

·         Life stage issues provide opening for therapy inquire.

·         Always pay attention to therapy anxiety: usually process oriented vs. content.

·         Get to know the people in your patient’s life.

·         Find out about previous therapies and do something different.

           

Dreams

·         Use dreams pragmatically – don’t try to interpret the dream fully.  Use it for the “here and now” in the dynamic of the therapeutic relationship.

 

Hazards of the Occupation

·         Be careful not to isolate: seeing patients one on one all day can be isolating.  Therapists sometimes become solitary creatures

·         Make sure you are attending to your own relationships and life, therapists too need the nourishment from friends and family.

·         Suicide and malpractice: two major stresses.

·         Patient difficulties can disrupt life: relationship strains, child rearing stresses, bereavement, marital discord, illnesses, etc.

·         Overspecialization: maintaining balance and diversity helps contribute to a sense of renewal. 

·         Attend support groups with other therapists.

 

Privilege

**We become explorers immersed in the grandest of all complex pursuits – the development and maintenance of the human mind.  For this we are very privileged.