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An Open Letter to a New Generation of Therapists and Their Patients

Are you a therapist or a patient?

Then you should really read Irvin D. Yalom’s open letter to all therapists and patients out there:

The Gift of Therapy.

Who Should Read “The Gift of Therapy”? And Why?

The Gift of Therapy is primarily a book targeting therapists: especially those who already know something about Yalom and existential therapy and are familiar with the theoretical aspects of the practice.

However, the very fact that it is not systematic and structured makes it a great introductory book for patients to psychotherapy: if therapists train themselves to look through your window, here’s your chance to look through theirs.

You may see a healthier you from the other side.

About Irvin D. Yalom

Irvin D. Yalom is an American existential psychotherapist, emeritus professor of psychiatry at Stanford University, and a bestselling author of both non-fiction and fiction books.

Born to Russian parents in Washington D.C., Yalom developed a personal model of existential psychotherapy in the 1970s and his 1980 book Existential Psychotherapy is considered the classical introduction to the form.

He has written as many fiction as non-fiction books, the most famous of which, When Nietzsche Wept, was adapted into a movie in 2007.

Find out more at https://www.yalom.com/.

“The Gift of Therapy PDF Summary”

First published in 2001 – sometime around the author’s 70^th birthday – The Gift of Therapy, as stated by its blurb, is “the culmination of master psychiatrist Dr. Irvin D. Yalom’s more than forty-five years in clinical practice.”

And despite the fact that, at 87, Yalom is still alive and kicking in 2019, and, has written six more books in the meantime in addition to seeing at least two documentaries made about him, The Gift of Therapy also feels as a kind of a testament.

As poignant as essential, Yalom’s book – which has gone through several edition since its first publication – can be described as a collection of advices given by someone who has come to the end of his journey as a psychotherapist and now looks back to discover the highs and lows and so that he can pass on his knowledge to a new generation of psychotherapists.

Consequently, it’s no wonder that the book consists of 85 chapters, most of them no longer than two or three pages, and each one focusing on an important aspect of Yalom’s works and beliefs.

In the “Introduction,” Yalom provides a tentative structure of his book; naturally, we’ll try to follow it in our summary.

Introduction

Anxieties and Worries

“It is daunting to realize that I am entering a designated later era of life,” writes one of America’s leading psychotherapists, Irvin D. Yalom, at the beginning of The Gift of Therapy.

“My goals, interests, and ambitions are changing in predictable fashion,” he adds, implying that if in the past his job was to take and teach patients, now his goal is to guide and inspire a new generation of psychotherapists.

However, he says, this is exceedingly problematic today, because, in Yalom’s opinion, the field in serious crisis.

“An economically driven health-care system,” he writes, “mandates a radical modification in psychological treatment, and psychotherapy is now obliged to be streamlined – that is, above all, inexpensive and, perforce, brief, superficial, and insubstantial.”

Consequently, Yalom is worried that what he leaves behind is a world in which psychotherapy is seen as just another job from which someone is to make a profit, rather than a humane discipline whose sole objective is to help people – regardless of the cost.

He writes, movingly:

I worry where the next generation of effective psychotherapists will be trained. Not in psychiatry residency training programs. Psychiatry is on the verge of abandoning the field of psychotherapy. Young psychiatrists are forced to specialize in psychopharmacology because third-party payers now reimburse for psychotherapy only if it is delivered by low-fee (in other words, minimally trained) practitioners. It seems certain that the present generation of psychiatric clinicians, skilled in both dynamic psychotherapy and in pharmacological treatment, is an endangered species.

And yet, Yalom concludes, if not only because of this endangered species (or exactly because there are so few of them), it makes sense to write a book such as The Gift of Therapy.

Existential and Group Therapy

“Since first entering the field of psychiatry,” Yalom says, “I have had two abiding interests: group therapy and existential therapy.”

These two are parallel interests, but, nevertheless, they are also separate: as Yalom says, just as there can be no group therapy for one person, there’s also no such thing as existential group therapy.

The two things differ in their frame of reference.

In groups, Yalom’s frame of reference is interpersonal and is based on the assumption that patients “fall into despair because of their inability to develop and sustain gratifying interpersonal relationships.”

However, when Yalom deals with a single patient, he operates within an existential frame of reference, which is firmly rooted within the conviction that patients fall into despair due to a confrontation with the “harsh facts of human condition – the ‘givens’ of existence.”

If you have problems understanding what existential psychotherapy actually is, Yalom provides a neat definition: “Existential psychotherapy is a dynamic therapeutic approach that focuses on concerns rooted in existence.”

However, a definition makes no sense if you don’t understand the meaning of the words it encompasses.

So, here’s the necessary vocabulary to understand Yalom’s existential approach:

• Existentialism is a philosophical study of the human being as a thinking, acting, feeling, and living being in search of authentic existence; (to understand this even better, we warmly suggest you read our summaries of Sartre’s Being and Nothingness and Carl Rogers’ On Becoming a Person)
• Dynamic is here used in the technical sense, implying that the forces in conflict with the individual “exist at varying levels of awareness; indeed some are entirely unconscious.”
• Finally, there are four ultimate concerns, i.e., four givens of existence: death, isolation, meaning in life, and freedom.

Process and Content

Now that you have understood the theoretical definition of existential therapy, it’s time that you understand a bit better how it works in practice.

And to do this, first you must make a distinction between two major aspects of therapy discourse: content and process:

• Content is just what the word says it is: “the precise words spoken, the substantive issues addressed.”
• Process, on the other hand, refers to the “interpersonal relationship between the patient and the therapist.”

In other and plainer words: it is one thing to explicitly start a discussion about death, isolation, meaning and freedom (content), and a completely another thing to implicitly derive conclusions from stories which seemingly bear no relation to these existential topics.

“Therapy should not be theory-driven,” writes Yalom, reminding us of Carl Rogers’ beliefs, “but relationship-driven.”

In fact, that’s exactly how this book was born!

Because, in theory, you can say that existential psychotherapy is all about the givens of existence, but in practice, it would be both contra-productive and fruitless to force upon a patient a discussion which includes any of them explicitly.

“A heightened sensibility to existential issues” and awareness of the process of interpersonal communication is what helps a psychotherapist really understand what do the actual content of the words of the patients says about them, their health, and their objectives.

The Structure of the Book

Described by Yalom as both “a sequence of tips for therapists,” and “a nuts-and-bolts collection of favorite interventions or statements,” The Gift of Therapy is “long on technique and short on theory.”

Consequently, the book should not be understood and/or used as a “systematic manual,” but as “a supplement to a comprehensive training program.”

Originally, it began as a list of more than two hundred pieces of advice only to be pruned away by Yalom to the most essential eighty-five.

These are chosen, by Yalom’s own admission, quite haphazardly, but are grouped, as an afterthought, in five tentative sections:

• Process (therapist-patient relationship): first 40 chapters;
• Content: chapters 41 to 51;
• Everyday issues: chapters 52 to 76;
• Dreams: chapters 77 to 83; and
• Hazards and privileges: the last two chapters.

Process (1 – 40)

Here are the highlights from the first section:

#1. Remove obstacles to growth;
#2. Except in extreme cases – and for insurance companies – avoid diagnosis: you are talking with a unique human being, not with a general concept;
#3. Think of your patient as a fellow traveler, not as your follower;
#4. Engage your patient in a deeply personal relationship through discussion;
#5. Be supportive;
#6. Be sympathetic: look out the patient’s window;
#7. Do not only practice but also teach empathy;
#8. Let the patient matter to you;
#9. Acknowledge your errors: mistakes bring people closer;
#10. Treat all of your patients as individuals: create a new therapy for each of them;
#11. Talk the talk, but also walk the walk;
#12. Engage in personal therapy;
#13. Never forget that while the therapist has many patients, the patient has only one therapist;
#14 – #24. Use the Here-and-Now method: your patients are not only their past experience but also what’s happening during the therapy sessions; develop here-and-now rabbit ears by keeping in mind a simple principle (particularly evident in group therapy: one stimulus, many reactions;
#25. Forget the blank screen: instead of being a robot, be your very self to your patient;
#26 – #32. There are three realms of self-disclosure: a) the mechanism of therapy: be transparent; b) revealing here-and-now-feelings: use discretion; and c) revealing the therapist’s own personal life: use caution;
#33. Avoid the crooked cure;
#34. If you can – and it is possible – take your patients further than you have gone;
#35. Sometimes allow your patient to help you;
#36. Encourage patient self-disclosure;
#37. Use the Johari window for feedback;
#38. Provide feedback effectively and gently;
#39. Increase receptiveness to feedback by using “parts;”
#40. As far as feedback is concerned – strike when the iron is cold.

Content (41 – 51)

The second part comprises eleven pieces of advice.

The first three (#41 – #43) concern the first given of existence: death.

“Though the physicality of death destroys us,” writes Yalom, “the idea of death may save us.”

That’s why it is important to talk about it.

It is discussions about death which help us move from our everyday mode of existence (full of distractions with our material surroundings) to an ontologic mode of being (filled with wonderment and readiness for change).

Yalom’s advice #44 concerns two givens of existence: life meaning and isolation.

Unlike other beings, humans are unique in the fact that they are meaning-seeking creatures. However, as Joseph Campbell often reminds us, the goal of the journey is the journey itself.

It doesn’t matter if one finds meaning; what matters is the engagement in the pursuit; and therapists need to remove all isolation-creating obstacles to this engagement.

After this, the book includes several chapters (#45 – #51) dealing with the last of the givens of existence – freedom – and its corollaries: responsibility and decision-making.

Yalom understands freedom in the way most existential philosophers understand it: as a way of assuming responsibility for your life in a chaotic, unstructured world.

So as to help your patients achieve this, never reinforce victimhood – even if nine-tenths of the bad things that happened to them are someone else’s fault, focus on the one-tenth in which their actions mattered.

The psychology of decision making is also glanced upon since it is another boundary experience, located somewhere between freedom and death.

You’re free to make a decision, but that usually means not making some other decision which means that you’re willingly cutting yourself off from other possibilities.

That’s where anxiety stems from – and therapists need to deal with this appropriately.

Everyday Therapy (52 – 76)

The third section (#52 – #76) is, not even arguably, the most random one.

Here, interspersed with examples from his own clinical practice, you’ll find many useful pieces of advice regarding numerous different aspects of psychotherapy.

Here they are:

#52. Conduct therapy as a continuous session;
#53. Take notes of each session;
#54. Encourage self-monitoring: may your patients take notes as well;
#55. When your patient weeps, encourage him to go even deeper;
#56. Give yourself some time for repose between patients;
#57. Express your dilemmas openly with the patient;
#58. When you can, do home visits;
#59. Don’t take explanations too seriously;
#60. Use therapy-accelerating devices such as the “Who am I” question;
#61. Consider therapy a dress rehearsal for life;
#62. Use complaints as leverages;
#63. Don’t be afraid of touching your patient;
#64. However, unlike Jung, never be sexual with patients;
#65. Look for anniversary and life-stage issues;
#66. Never ignore ‘therapy anxiety;’
#67. Ask your patient what you should say to make him feel better;
#68. Love and therapy are incompatible: “the good therapist fights darkness and seeks illumination, while romantic love is sustained by mystery and crumbles upon inspection;”
#69 – #73. When in need, systematically collect the history of your patient, including interviewing his/her significant other and exploring previous therapy;
#74. Share the shade of your shadow with your patient;
#75. Freud was wrong about many things – but he was not always wrong;
#76. Don’t be afraid of the EVT (empirically validated therapy) bogeyman.

Dreams (77 – 83)

Next on Yalom’s agenda: the interpretation of dreams.

Of course, he advises therapists to use dreams in their sessions; however, he’s not that keen on a deep, full interpretation such as the one of Irma’s dream in Freud’s seminal book on the subject.

Use dreams pragmatically: first master some dream navigational skills, then pay attention to the narrative and then pillage and loot through them!

Hazards and Privileges (84 – 85)

In the last two chapters, Yalom unearths the occupational hazards and privileges of being a therapist.

As far as the former ones are concerned, you need to be careful of a few dangers:

• First of all, you need to try hard not to isolate yourself from others: therapists are sometimes just too solitary creatures;
• Secondly, find nourishment in your friends and family; otherwise, you’ll too become anxious and confront problems;
• Nevertheless, be aware that some patient difficulties can – and sometimes will – disrupt your life and may cause relationship strains and even thoughts of suicide;
• If so, attend support groups for therapists: apparently, this exists as well.

Why bother being a therapist if this is the cost?

Well, Yalom has an answer for that in the final chapter:

Life as a therapist is a life of service in which we daily transcend our personal wishes and turn our gaze toward the needs and growth of the other. We take pleasure not only in the growth of our patient but also in the ripple effect – the salutary influence our patients have upon those whom they touch in life/

Key Lessons from “The Gift of Therapy”

1.      Existential and Group Therapy
2.      The Four Givens of Existence
3.      Therapists Are Descendants of Jesus and Buddha

Existential and Group Therapy

Irvin Yalom practices two types of therapy: existential and group therapy.

The former is reserved for individuals and is “a dynamic therapeutic approach that focuses on concerns rooted in existence;” it is based on the assumption that despair is the result of a personal confrontation with the givens of existence.

Group therapy is interpersonal and operates within the idea that patients “fall into despair because of their inability to develop and sustain gratifying interpersonal relationships.”

The Four Givens of Existence

According to existential psychotherapy, there are four givens of existence: death, isolation, meaning in life, and freedom.

These are the things everyone is explicitly or implicitly interested in; it is through an analysis of a subject’s relation to them that we can learn most about him or her.

Therapists Are Descendants of Jesus and Buddha

According to Irvin Yalom, therapists are privileged with hearing out the deepest and most intimate secrets of their subject; and they should act accordingly.

He writes:

We therapists are part of a tradition reaching back not only to our immediate psychotherapy ancestors, beginning with Freud and Jung and all their ancestors – Nietzsche, Schopenhauer, Kierkegaard – but also to Jesus, the Buddha, Plato, Socrates, Galen, Hippocrates, and all the other great religious leaders, philosophers, and physicians who have, since the beginning of time, ministered to human despair.

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“The Gift of Therapy Quotes”

Our Critical Review

The Gift of Therapy is not Irvin Yalom’s best book – if you want to read that one, look for Existential Psychotherapy – but it may be the one which will endure the longest.

Absorbing and wise, this one is also self-help styled, so it’s more accessible than other books by Yalom.Yalom is right: The Gift of Therapy is perfect as a supplement to a comprehensive psychotherapy training program.