Popular scholar, novelist and existentialist Irvin Yalom chimes in on the Seven Questions. To my delight, I was able to conduct this interview in person.
The Seven Questions project asks the same seven psychotherapy-related questions to influential clinicians in the field. Since November, we've heard responses from bestselling authors, historical figures and presidents of mental health associations. Dr. Yalom provides the 14th and final invited interview.
Irvin D. Yalom (MD, Boston University, 1956) is Emeritus Professor of Psychiatry at Stanford University, a prolific author and speaker on psychotherapy and existentialism. His first book The Theory and Practice of Group Psychotherapy is the definitive text on the topic, having sold hundreds of thousands of copies. He is best known for his fiction and creative nonfiction including eloquent case studies in Love's Executioner, historical fiction (and now film) in When Nietzsche Wept, and Lying on the Couch, a must-read for therapists and clients interested in how therapists think. He co-wrote the book Every Day Gets a Little Closer with a patient, a collection of their independent reflections following each session. Yalom's The Gift of Therapy, which stresses the importance of therapist authenticity and the focus on the here-and-now, was part of my inspiration to write this blog.
In the introduction I alluded to one of the biggest thrills of my professional career. This entire project has been wonderful, but the thrill refers to the hour I spent with Dr. Yalom, my unwitting literary and professional mentor. He kindly granted an interview in his Palo Alto office on a crisp winter afternoon. The majority of the interview (found here and here) covered his most recent release Staring at the Sun, but I squeezed in the Seven Questions as well. I'm very glad I did. His views on therapist self-disclosure, inducing curiosity and the future of psychotherapy (yes, I went beyond seven) are quite provocative.
My deepest gratitude to Dr. Yalom for sharing an hour with me. I hope you enjoy these responses from a major contributor to modern psychotherapy.
Several Questions for Irvin Yalom:
How would you respond to a new client who asks: "What should I talk about?"
Well, nobody really quite says that to me, but I generally start my sessions with: "tell me what ails?" But if they're very anxious and have not seen a therapist before and they need a little help I'll give them a little structure and say: "well, until you get comfortable let me get some demographic information about you" and start to ask them questions about their past and their situation in the world, who they live with. I rarely get through a first session without trying to find out what they do with their 24 hour day. "Give me a typical day." That usually gives me a good look at their interpersonal contacts and how their life is peopled and also about their sleep patterns and their dreams. So that's one device that I'll usually put into first sessions.
Sometimes I'll just wait and say: "Why don't you just say whatever comes?" People have a great deal of difficulty doing that, but I'll ask: "Let's see what comes up today." Especially patients who I've been seeing for a while and don't know what to say, I will say with a certain kind of confidence: "You know, that's terrific in a way, because sometimes meetings you haven't rehearsed or planned for are much better, so let's just take time now and see what comes." It sounds like a little bit of Freud's notion of free association, but in a much more focused way. I'll generally guide them into wherever we go with this.
What do clients find most difficult about the therapeutic process?
Letting go. Letting go of therapy, letting go of me.
You know, my answers to you about therapy are very skewed because I screen my patients. At this time of my life I'm not working with seriously disturbed people, I'm not working with people who are going to be hospitalized or have heavy mood disorders. I'm selecting people who are in some kind of an existential crisis, something going on their life, in their life stage.
They're the "worried well." I understand.
I'm working with the worried well, exactly. My comments are coming from working with these particular patients now as opposed to those from the past. And I'm also not doing any group therapy now. I haven't done that for a few years.
Ever hold groups in here?
No, never here. I had all my groups at Stanford. This room is very bad for a group. I have another office in San Francisco and I do have a student group of counselors I've been meeting with once a month for over 15 years. Nobody's changed, nobody's come in and nobody's gone out. And all of them are doing groups.
What mistakes do therapists make that hinder the therapeutic process?
You know, I think everybody I've seen has come from some other therapy, and almost invariably it's very much the same thing: the therapist is too disinterested, a little too aloof, a little too inactive. They're not really interested in the person, he doesn't relate to the person. All these things I've written so much about. That's why I've made such a practice really, over and over to hammer home the point of self-revelation and being more of yourself and showing yourself. Every book I write I want to get that in there.
You even mentioned self-disclosure in this book.
That's right, I wrote that in that last chapter. I think that's so terribly important for opening up patients. And even as I write about fictional therapy I'll put it in there. It does help a great deal. So that's what I think is one of the bigger issues. And the other thing is therapists being in therapy themselves. Therapists need to have a long experience in personal therapy to see what it's like to be on the other side of the couch and see what they find helpful or not helpful. And if possible, get into therapy at different stages of their life with different kinds of therapists just to sample a bit.
I couldn't agree more. In your opinion, what is the ultimate goal of therapy?
Hmmm. The ultimate goal of therapy...it's too hard a question. The words come to me like tranquility, like fulfillment, like realizing your potential. Things that Freud used to say; being able to work and to love, that's pretty good summary of it right there. But mainly it's this idea I tried to explain in The Gift of Therapy: you have to develop a separate new therapy for every single patient. So for some patients the goal will be this and for some the goal will be that. For one patient I have now the goal really is for him to be able to discuss some of his vulnerabilities with his wife and then have a real relationship between the two of them.
What's the toughest part of being a therapist?
Well, I think it's just holding so much pain at times. Worrying about my patients. Seeing some people that I really can't help, who in some ways are beyond help. Or seeing a sociopath knowing I can't really do anything for him or can't reach him. Or watching some people who are throwing their lives away on drugs and there's so little you can do about it. There are times in life where certain kinds of passions, for example the appetites for drugs or compulsive sexuality or many others, are simply too powerful.
Spinoza has a line where he says that "reason is no match for passion." We have to find another way. His idea is that we have to transform reason into a passion. I take that to mean we have to begin to develop a great deal of passion for logical understanding. So if only we can inculcate in the patient this passion for curiosity; to fertilize this curiosity about themselves. When people don't have any curiosity about themselves that is always a bad sign. I keep trying to figure out ways to induce curiosity, even if it's by saying to them: "how come I'm so much more curious about you than you are about yourself?"
What's the most enjoyable or rewarding part of being a therapist?
Oh, seeing people change and how their lives open up, telling me how much better they're doing with their spouse or how much better they're doing in life. Those times I find extremely rewarding.
If there was one pearl of wisdom you could give a new client coming to therapy, what would you say?
Well, you're very fortunate to be going on this trip of self-understanding. That's all that I think about. That's pretty trite, but nonetheless that's what I sense.
Is psychotherapy dying?
Oh, I think it's in definite trouble. But I think there will always be people around like you and me who really want to help. I can't imagine the desire for self-understanding is going to disappear. I have a hunch that certain trends come in various waves. Certainly CBT is so much in vogue right now.
Someone's got to do some more research, but I would really like to know: when a CBT therapist really gets distressed, who does he go see? I just have a strong sense it's not another CBT therapist. I think he wants to go out and search for somebody who's wise and can help him explore deeper levels. There's probably psychotherapy research out there that I haven't read, but it would be interesting to know that. If you come across the data let me know. I certainly see a lot of them in therapy.
People in grad school are so sorry they're not getting any exposure to dynamic therapy. It would have been such a great opportunity for clinical psychology to come to the fore here and they've gotten caught up in the marketplace in a different way but in the same way that psychiatry does now. So now you're seeing a lot of the marriage and family counselors who are taking more advantage of this. This group of students I've been working 15 years, they're all MFT's and they're such good therapists.