Irvin Yalom on Existential Psychotherapy and Death Anxiety

Irvin Yalom on Existential Psychotherapy and Death Anxiety

by Ruthellen Josselson
Irvin Yalom reflects on instrumental moments in his career as a psychotherapist and writer. This excerpt from his biography, Psychotherapy and the Human Condition, begins with him recalling his first case presentation in medical school.


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From Chapter One: Origins

Ruthellen Josselson: This was your first case presentation.
Irvin Yalom: Right. I was pretty anxious about it. I remember my patient very clearly—a red-headed, freckled woman, a few years older than I. I was to meet with her for eight weekly sessions (the length of the clerkship.) In the first session she told me she was a lesbian.

That was not a good start because I didn't know what a lesbian was. I had never heard the term before. I made an instant decision that the only way I could really relate to her was to be honest and to tell her I didn't know what a lesbian was. So I asked her to enlighten me and over the eight weeks we developed a close relationship. She was the patient I presented to the faculty.

Now I had been to several of these conferences with other students and they were gut- wrenching. Each of these analysts would try to outdo the other with pompous complex formulations. They showed little empathy for the student who was often crushed by the merciless criticism.

I simply got up and talked about my patient and told it as a story. I don't think I even used any notes. I said here's how we met. Here's what she looked like. Here's what I felt. Here's what evolved. I told her of my ignorance. She educated me. I was profoundly interested in what she told me. She grew to trust me. I tried to help as best I could though I had few arrows of comfort in my quiver.

At the end of my talk there was a loud long total silence. I was puzzled. I had done something that was extremely easy and natural for me. And, one by one, the analysts—those guys who couldn't stop one-upping each other—said things to the effect of, "Well, this presentation speaks for itself. There's nothing we can say. It's a remarkable case. A startling and tender relationship." And all I had done was simply tell a story, which felt so natural and effortless for me. That was definitely an eye-opening experience: Then and there I knew I had found my place in the world.

This memory is perhaps a life-defining moment for Yalom. As he remembers and talks about it, he is deeply moved. In some ways, his work ever since has been about telling stories, stories about his encounters with people as a therapist, stories that instruct us about how to connect meaningfully with others. He has retained his essential humility—he still allows others to teach him about their reality as he tries to encounter them in their deepest being and offer them a relationship in which they can heal. This moment also marked for Yalom a route out of the anonymity he had experienced throughout his education. Despite his academic successes, no one had recognized that he had any particular talent and he had only the vaguest sense that he had some special ability. For the first time, he was recognized—and for doing something that his teachers had never seen done before.

RJ: Where did you get the courage to do that?
IY: It didn't feel like anything courageous, as I recall—but this is over fifty years ago—I didn't have other options. It was my turn to present a case, this was my way to present a case. Whenever afterward I presented a case, whenever I presented at grand rounds or a lecture, I had the audience's full attention. I always had that ability.
RJ: So this moment when you told the case to the analysts and they were silent, they were unable to respond in their usual ways and start to compete with each other with formulations, you felt that they saw in you and that you had done something worth noticing, something important?
IY: Oh, yeah, for sure. If I try to understand it now across all those decades, I think it was because I was talking about a psychiatric case, but speaking in a whole different realm, a literary, story-telling realm. And their formulations had no sway. The jargon, the interpretations, all that had nothing to do with the story I told them. Of course that's my view: I'd love to go back in time and learn what they were really thinking.
RJ: There are so many different ways to tell a story, including the usual case presentation which is also a way to tell a story. But this was a different way to tell a story.
IY: I didn't know anything about telling a story or what telling a story meant in any kind of technical way, but I somehow knew how to put things together to create a drama.
RJ: With yourself in it.
IY: Oh, with myself in it. How I met her, how I didn't know anything about her being a lesbian, how baffled I was, how I guessed she must feel to work with a therapist who's admitted that he's totally ignorant of her lifestyle, how she must have worried about my accepting her, how I must have given to her some representative of the whole world who knew nothing about her and who possibly might ostracize her in some way.
RJ: You didn't judge her, or pathologize her, or do something like that. You were able, in fact, to engage with her in a very human way.
IY: Yes. I think that's true. I did not ostracize her—just the opposite, my confessing my ignorance drew us closer together—a relationship forged in honesty.
RJ: As opposed to the psychiatric way or psychoanalytic way that would look at her as a carrier of symptoms and pathology.
IY: That's right, case formulations which focus narrowly on pathology were very distasteful to me.
RJ: It was distasteful even in medical school.
IY: Even in medical school—I didn't like the distant disinterested stance of many psychiatrists I encountered.
RJ: But you were still clear you wanted to go into psychiatry even though what they were doing was not something that you felt was at all appealing.
IY: That's right. Once or twice I wavered because there were so many things I liked about medicine. I liked taking care of people, liked passing on to them what Dr. Manchester had passed on to me. But I never seriously entertained doing anything else in medicine. So I was committed. At this point, I was already starting to read a lot about psychiatry.

From Chapter Six: Yalom's Reflections on His Work

RJ: I am impressed by how much philosophy you have read and integrated in your work as a therapist and a writer.
IY: I spent 10 years reading philosophical works and writing Existential Psychotherapy. It was a good friend, Alex Comfort (a man known for The Joy of Sex but who wrote over fifty scholarly books) who advised me it was time to stop reading and start writing. But I've continued to read philosophy ever since. Existential Psychotherapy was a sourcebook for all that I've written since then. All the books of stories and the novels were ways of expanding one or the other aspects of Existential Psychotherapy.
RJ: But you don't think about Existential Psychotherapy as being a school of psychotherapy?
IY: No. I never have. You cannot simply be trained as an existential psychotherapist. One has to be a well-trained therapist and then set about developing a sensitivity to existential issues. I've always resisted the idea of starting an institute or a training program. I have such a strong pull towards writing. I really love to write.
RJ: With the widespread success of your case story books and then your first novel, did you then start writing more to the general public?
IY: No, I always thought my audience was the young therapist, young residents in psychiatry and student psychologists and counselors.
RJ: So you never thought about writing to the general public? They would be eavesdropping as you spoke to therapists.
IY: Yes, they would be eavesdropping because they had been in therapy or were interested in the topic of therapy. I think the Love's Executioner book description proclaimed that this book was for people on both sides of the couch. And I also thought people in philosophy would be interested, especially in the Nietzsche book and the Schopenhauer. That psychobiography of Schopenhauer was original—there's no other work like that.
RJ: How come you chose Schopenhauer? With Nietzsche it's clearer to me, because you are so close to his philosophy.
IY: Schopenhauer was always in the background. You have to remember that he was Nietzsche's teacher. (I mean intellectually—they never met.) But Nietzsche turned against him eventually and that break fascinated me for a long time. It was of great interest to me that they started from the same point, the same observations about the human condition, but one became life-celebrating and one life-negating. So what was that all about? I suspected it was driven by character, or personality, issues.

And also Freud was interested in Schopenhauer. He was the major German philosopher when Freud was educated. A great many of Freud's major ideas are sketched out in Schopenhauer's work. His work was very rich. He wrote voluminously about so many other topics such as politics, musicology, and esthetics but I concentrated solely on his writings about life and existence.

You have to recognize the human condition before you can figure out how to deal with it. Schopenhauer can inform us about the futility of desire and the inevitably of oblivion, but eventually it's the Nietzschean idea of embracing life that is the viable answer to this dilemma.
RJ: In so many of your stories as well as the novels, there is a recurrence of the themes of sex obsession and love obsession. Can you tell me about how come this captured your interest?
IY: I've always been struck with the idea of romantic love and losing oneself in the other in that way, which I've often characterized as "the lonely I dissolving into the we." And therefore you lose the sense of personal separateness and find comfort in the lack of loneliness. That's why I've always been intrigued with Otto Rank's formulation of going back and forth between the poles of life anxiety and death anxiety. And also Ernest Becker, who is very Rankian, and developed Rank's ideas in his wonderful book, The Denial of Death.

So I've always been interested in this idea of romantic love and also in religious submission, which is similar—both relate to the ultimate concern of isolation. And this issue of obsession was a predominant theme in Nietzsche.

I had a patient recently who was obsessed about a woman who had broken off with him but he couldn't get her out of his mind and he went and read the Nietzsche book and came back and said it did him more good than the two years of therapy we had done.
RJ: So we strive to be autonomous but have difficulty dealing with our separateness?
IY: Yes, and also underneath much compulsive activity is a lot of death anxiety. Often the death anxiety is overlooked because of other issues such as rage.
RJ: So in the pain of existential isolation, the lonely I is connected to rage which is connected to death anxiety. And the fear and the rage is about both aloneness and death. We are thrown into this finite existence alone. In your Nietzsche novel and in some of the stories, the aim is to help people give up the obsession.
IY: Helping them find some more authentic way of relating to others.
RJ: Do you see love obsession and sex obsession as the same thing?
IY: I see them as first cousins. In The Schopenhauer Cure, Phillip's anxiety was assuaged by the sexual coupling, but the relief was evanescent. In romantic love, life can't be lived without this person and if you lose her, you're in continual grief—that's been the problem for many of my patients.
RJ: How do you distinguish between authentic meaningful connection and love obsession?
IY: The basic distinction lies in rationality, not thinking in irrational terms. A love obsession is highly irrational. It's ascribing things to the other that aren't there, not seeing the other as the other is, not being able to see the other person as a finite, separate person who doesn't have magical powers. A love obsession comes from the same stuff as religion, ascribing powers to the other.
RJ: Don't you think that when people love one another, they do some of that's a certain amount of idealizing, making the other person very special?
IY: I think that a true love relationship is caring for the being and becoming of the other person and having accurate empathy for the other person where you are trying to care for the other person in every way you can. But that may not be the focus of a love obsession. Like the first story in Love's Executioner—where one of the dyad did not even know the other was having a psychotic experience. People will fall in love with someone they hardly know. In true love, you see the other person accurately as a human being like yourself. You fall in love with someone by seeing who they are and what they are so they aren't forced to be someone they're not. For me, the kind of love relationship I want to espouse is one where one's eyes are wide open.
RJ: So that would be a measure of the rationality of the relationship.
IY: Yes.
RJ: In your most recent book, Staring at the Sun, you return to the theme of death. I wonder why now?
IY: I'm dealing more with this because of my age. I'm 76 now, an age when people die and I see my friends aging and dying. I see myself on borrowed time. I spoke about much of this in Staring at the Sun.
RJ: What has it meant to write this book at this age?
IY: I've been so inured, so plunged into the topic. Originally I was going to write a series of connected fictional stories about dealing with death anxiety. I had been reading a lot of Plato and Epicurus and I thought I would write a series of stories with some connection. I was inspired by a Murukami book called After the Quake in which all the stories were connected by one thing: the Kobe earthquake. I had six stories in mind and my plan was to start each story with the identical nightmare about death. In each story the dreamer wakes up in a panic about dying, leaves the house and searches for someone who can help him with his death anxiety. The first story was set in 348 BC and the dreamer goes out in search of Epicurus. A second story would involve a minor Pope of the middle ages, then in Freud's time, then more contemporary stories. But I spent so much time researching the first story on Epicurus, reading about what the ancient Greeks had for breakfast—what's a Greek café like, what clothing was worn, then I started reading novels about ancient Greece, a novel about Archimedes, and about the priestesses at Delphi—until six months had elapsed and I realized that the background research would take years and I reluctantly gave up the idea, which I thought was a splendid concept. Perhaps one of the readers of this interview will write it some day.

So I went to the other project I had in mind, a revision of Existential Psychotherapy. I reread it carefully and underlined things I wanted to change and organized a course of students who would read it with me and help me to select the dated material, but, in the end, I was overwhelmed by the task, especially the scope of the library research looking up the empirical research on the ultimate concerns that has been accumulating in the twenty-five years since I first published this book. So I gave that up and wrote a book on what I had learned about an existential approach in the years that have passed since I wrote the textbook. Next my agent, noting that seventy-five per cent of the book addressed death anxiety, suggested that I might write a tighter book if I concentrated only on death anxiety. Finally the book underwent one more metamorphosis when my publisher suggested I direct it more to the general public. I agreed to do so but insisted upon a final chapter directed at therapists. I believe the strongest chapter is a personal chapter dealing with the development of my own awareness of death.
RJ: Would you say that doing this book makes you even less fearful about death than when you started it?
IY: I think so. But writing about death anxiety wasn't an effort to heal myself about it. I've never been that consumed with death anxiety. It was more of an issue a long time ago when I started working with cancer patients. I don't think I've been unusual in my degree of death anxiety. Now I feel like I've become effective in dealing with patients with death anxiety and am confident that I can offer help.

Irv shared with me a number of email letters he gets daily from people all over the world. These are heartfelt (often heart-rending) letters from people expressing their appreciation of the ways in which his writings have changed their lives.

"It is not enough to say that your words moved me or affected me. When at the end [of The Schopenhauer Cure] Pam placed her hands on Phillip and told him what he needed to hear—the words on the page began to blur, all I could do was lean my head back, swipe at the onslaught of tears and wait for my faculties to return. It was the catharsis I needed." Or from another: "I know I am alone and finite, but I feel connected to the rest of humanity in reading your books because everyone else, I realize, is in the same boat—and thanks for that insight/comfort." And from a professor in Turkey: "I'm writing to you in appreciation of keeping me excellent company through the rough hours of the day: when you are alone, or even worse (better?) when you think you are alone . . . I usually start my lessons with a saying or a thought of yours in order to boost my class—and me—to open a new window and see things a little bit different."

Other letters are from people longing to find some salve for their emotional pain, some of what he has provided his own patients. He answers each of these letters personally, acknowledging their meaning for him or, when he can, offering counsel.

RJ: What have these letters meant to you?
IY: I feel I have another, a second therapy practice. I know I mean a lot to some of my readers. I'm aware that they imbue me with a lot more wisdom than I have and they long to connect with me. I try to answer every letter, even if it's just to say thank you for your note. This correspondence makes me unusually aware of my readership. I took an early retirement from the Department of Psychiatry ten years ago. One of my main reasons was that psychiatry had become so re-medicalized that my students had little interest in psychotherapy and instead were far more interested in biochemistry and pharmacological research and practice. I didn't really have students who were interested in what I had to teach. So I now feel that my teaching is done through my writing. I don't miss classroom teaching because I feel that I now have this whole other way of teaching. I consider my writing teaching and getting this correspondence keeps me aware of that all the time.
RJ: What message do you try to convey in response?
IY: As I said, some simply express appreciation for the writing or tell me it was meaningful to them and I simply state that I feel good that my writing had a positive impact. Sometimes I say that writers send their books out like ships at sea and that I'm delighted that a book arrived at the right port.

There are other readers who ask for help for some personal issue and, if appropriate, I urge them to seek therapy. Some write a second time thanking me for being instrumental in their obtaining help. Some readers comment that their current therapy isn't helping and ask for email therapy. I don't do therapy by email and urge them to be direct with their therapist and to express these sentiments openly. I even suggest that concealing these feelings may be instrumental in their therapy not being useful. Their job in therapy is to share all their feelings and wishes with their therapists. Able therapists will welcome this forthrightness. My main message though is to let them know that I've read their letter.
RJ: It makes me so sad to hear that you had students who didn't want to learn what you had to teach. What does this say about the future of psychotherapy?
IY: I do feel there is a pendulum swinging, even in psychiatry. I do hear about more programs starting to introduce therapy again. Many contemporary therapists are trained in manualized mechanical modes—all of which eschew the authentic encounter. After some years of practice, however, a great many of these therapists come to appreciate the superficiality of their approach and yearn for something deeper, something more far-reaching and lasting. At this time therapists enter postgraduate therapy training programs or supervision. Or they learn by entering their own therapy. And I can assure you they never never seek a therapist who practices mechanical, behavioral or manualized therapy. They go in search of a genuine encounter that will recognize the challenge inherent in facing the human condition.
RJ: From Afterword
IY: In 2005, Irv and I went to visit Jerome Frank, Irv's mentor and friend, who lived in a nursing home nearby my own home in Baltimore. We had been visiting him, separately and together, over many years, as he steadily declined with age. Even as his physical and mental impairments progressed, Jerry was always professorially dressed in suit and tie. "Tell me what you're working on," Jerry would usually ask Irv when we arrived, and they would embark on lively conversation about Irv's work and whatever Jerry was reading at the time. (My role was usually to sit and smile and enjoy the warmth of their connection. I knew Jerry far less well and for less long, of course.) On this particular occasion, Jerry was not wearing his suit and, after a few moments, it became clear that his mental decline was far worse. In fact, we soon realized that he didn't know who we were. I was very embarrassed and unsure what to do, and I left the conversational challenge to Irv. He tried a few topics to engage Jerry and found that Jerry could still remember some people from the distant past and they talked some about them. But then, Irv's genius asserted itself in the flow of this difficult interaction and he asked, kindly and compassionately, "What is like for you, Jerry, to be sitting here talking to people when you aren't sure who we are?" Always the here and now! And Jerry understood and responded to the care in the question. "I'm glad of the company," he said, "and you know, it's not so bad. Each day I wake up and see outside my window the trees and the flowers and I'm happy to see them. It's not so bad." Once again, Irv had penetrated to the existential core of Jerry's experience, and he did so by daring to speak the simple reality of our being together. Perhaps the message of his whole corpus of work is just this. It's all we have.

Copyright © 2008 Ruthellen Josselson, PhD. Reprinted with permission from the publisher, Jorge Pinto Books, Inc. Published May 2009.
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Irvin Yalom Psychiatrist and author Irvin Yalom, MD has been a major figure in the field of psychotherapy since he first wrote The Theory and Practice of Group Psychotherapy in 1970 (now in it's 5th edition). Other significant contributions have included Existential Psychotherapy, and NY Times Bestseller Loves Executioner and Other Tales of Psychotherapy. He has written four novels on psychotherapy: When Nietzsche Wept, Lying on the Couch, The Schopenhauer Cure, and The Spinoza Problem.  His works, translated into over 20 languages, have been widely read by therapists and non-therapists alike. Visit Dr. Yalom's website.

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Ruthellen Josselson Ruthellen Josselson is a Professor of Psychology at The Fielding Graduate University and was formerly a Professor at The Hebrew University of Jerusalem and Harvard University. She is the author of Playing Pygmalion: How People Create One Another, Revising Herself: The Story of Women's Identity from College to Midlife, and The Space Between Us: Exploring the Dimensions of Human Relationships. She has been for many years the co-editor of the annual The Narrative Study of Lives. Recipient of the Henry A. Murray Award from the American Psychological Association and a Fulbright Fellowship, she is also a practicing psychotherapist and holds a diploma in Group Psychotherapy.

CE credits: 1

Learning Objectives:

  • Discuss the roots of Yalom's approach to psychotherapy in his early experiences
  • Describe the role of storytelling in Yalom's career
  • List the key themes that show up in Yalom's work, including death anxiety

Articles are not approved by Association of Social Work Boards (ASWB) for CE. See complete list of CE approvals here