Victor Yalom on Psychotherapy and the Pursuit of Mastery

Keeping Current

Lawrence Rubin: Dr. Yalom, you are the founder of Psychotherapy.net so by definition, an entrepreneur. But as your Editor, I also know you to be a self-taught tinkerer, craftsman, and artist, as well as a practicing psychotherapist. While I’d like to touch on each of these facets in our conversation, please tell us first what are you working on now?
Victor Yalom: Well, I am always working on many things at the same time. I don't know if that's due to an inability to focus on one thing or just that I have multiple interests and duties running this small enterprise of Psychotherapy.net. 

We're always thinking of ways to provide content in a form that is useful to therapists practicing in the field as well as adapting to current times
One of my focuses after 27 or so years of recording who I consider to be the greats in our field and making training videos, is finally stepping up to the plate and doing some recordings of my own work as a therapist. Just yesterday, I recorded a case consultation group that I led online. This should result in one or more online courses in which I will be teaching some core skills in therapy that I have learned from my mentors as well as from my clients. So, that's very exciting. 
 

In addition, we at Psychotherapy.net are always scouting out and finding experts to be featured in videos. We have a new video coming out on Emotionally Focused Therapy and another on online crisis counseling. We're always thinking of ways to provide content in a form that is useful to therapists practicing in the field as well as adapting to current times. We realize that while people have grown accustomed to receiving video content in shorter bursts, we haven't quite reduced ours to the 15-second clips of TikTok. However, we are producing, for example, a shorter series called Mastery in Minutes that are up to 30 minutes long where we're trying to present core ideas or skills to therapists.

LR: Now that you’ve made this transition from interviewing experts in the psychotherapy field to being videotaped while you personally do psychotherapy, do you see yourself at this stage in your therapeutic career as an expert?
VY:
doubt and uncertainty are inherent in our work
I do feel that after practicing for almost 40 years now, I've acquired some valuable skills that I think are important to pass on that are not commonly being taught by others. It's an evolution because I think like most therapists, even experienced ones, that there's so much ambiguity in our work that a lot of the time I feel like, gee, I'm not sure what I’m doing. Would X or Y expert think that I’ve studied enough to be doing this? What will other colleagues think? How will the establishment of experts, or those who are practicing evidence-based techniques or teaching them in universities view this?

So, those are some of my doubts. But then the other side is that doubt and uncertainty are inherent in our work. I don't think it's a realistic or even desirable idea that we should reach a state of certainty about our work, but perhaps more comfort with our doubts and our questioning, and our realization that therapy is an ambiguous and creative enterprise.  
LR: I hope that the younger therapists who read this interview will embrace this idea that certainty is elusive, and therapy works but sometimes for reasons that are simply outside of our understanding. I understand that you've also been doing work with foreign distributors so I'm wondering what that looks like and what are some of the challenges?
VY: To a great degree, we've been trying to take the valuable, rich library that we've created over the last 27 years and make it as widely available as possible. It started very slowly at first with VHS tapes and then DVDs, but once we got into streaming, it was a lot easier to get it out there widely and internationally.

a lot of businesses have pulled out from Russia, but it's not something I've struggled with too much because the therapists there want to learn
But obviously, not everyone speaks English, so we've partnered with some businesses and organizations overseas to translate our videos and make them available. We have distributors in China, Italy, Greece, Russia, and a couple other countries. Typically, they've simply translated our videos with subtitles, but the Russians have been dubbing them using voice actors as well and so it's pretty simple in that sense, but there are unique challenges.

Our Russian distributors, not surprisingly, are having incredible challenges given the war and the boycotts. We were speaking with them yesterday and they’re actually moving to Georgia, the country, not the state, and we're finding ways to advertise, get payments, have money transferred to Georgia, and then sent here. At least that's the plan.

And with that, there's the potential ethical concern. Obviously, a lot of businesses have pulled out from Russia, but it's not something I've struggled with too much because the therapists there want to learn. They’re certainly not responsible for Putin's madness and butchery. I feel pretty clear that if we can find a way to continue to offer our videos to Russian therapists, that's a good thing.  
LR: That's interesting. I was going to ask you about possible ethical concerns and conflicts, but when you couch it in the context of therapists, whether in Russia or China still want to learn, you are providing a needed service. The therapeutic skills that these therapists will learn because of our association with them will help the citizens of these countries who have access to therapy. I don't know how widely accessible therapy is, however.
VY: Right. It reminds me several years ago, we had an inquiry from some Iranian therapists who wanted to publish our videos there. Let's just be upfront, in smaller countries like that, it’s not really about making significant profit. They’re relatively small markets. But it’s more just wanting what we’ve done to be viewed and used in training therapists. It turns out they were on the list of nations that the US does not look favorably upon. We finally figured out how to apply to the US State Department to get permission to have our videos translated and sold in Iran. But, after about a year and a half, we got a one-page letter that said, “Sorry, no!”
LR: It’s interesting with regard to Russia and Ukraine and the Middle East, that some of the contributors to our websites, some of the folks who write blogs and articles are doing so from those places about some of the challenges of delivering therapeutic services to people who are directly impacted by the war and related political tensions. So, I can see the benefit of partnerships with some of these entities. I also see the ethical concerns. Are there any other challenges when translating therapy into different languages considering that much that occurs in the therapy space is non-verbal? 
VY:
in Russia, they're using voice actors to dub our videos, apparently because that's quite common there as well as in other countries
As I said, in Russia, they're using voice actors to dub our videos, apparently because that's quite common there as well as in other countries. I was concerned about that. It’s so important and that's one of the reasons I started producing videos in the first place—to capture the non-content information, like body language, facial expression, tone of voice, inflection, and all that. I was concerned that a lot might be lost or missed. However, they've assured me that their actors are capable to a remarkable degree of mirroring that of the recording. Since I don’t speak Russian, I’ve got to take their word for it that they’ve done a good job. But they typically offer both, the option to listen to the dubbed version and/or subtitles.

Well, if it's a good translation, then it should work and that's not my area of expertise but just a little example. I recall looking at one of the transcripts initially done in China many years ago be one of our distributors. They were translating some discussion with my former teacher and mentor, James Bugental, who was referring to growing up in the Great Depression and the ways that impacted him in terms of his attitude towards money. It was quite a traumatic thing for that generation.

I came across the transcript, and I don't recall how I did it, because I don't speak Chinese, but somehow I became aware that they referred to the Great Depression, the historical event, as major depression, the psychiatric diagnosis. So, you have to have good translators. Language is very nuanced.

With our Chinese distributor, they're used to presenting videos in more of a weekly webinar format, so they've taken our videos and chopped them up into 30-minute segments that they offer once a week. They’ve wanted to add some live Q&A to some of our videos. For example, we have a popular course with my father, Irvin Yalom, “The Art of Psychotherapy,” and I've done some live Q&A even though I’m not him. I know the content well, so I’ve been able to answer some questions from the Chinese students that hopefully helps make it more understandable to them.  

How I Built This

LR: All meaningful ventures such as creating Psychotherapy.net have an origin story, so I think our readers would be interested to know yours.
VY:
I had the chance to study in-depth with James Bugental, who was a real master psychologist, psychotherapist, and teacher
After I completed my doctorate in psychology, I had the chance to study in-depth with James Bugental, who was a real master psychologist, psychotherapist, and teacher. I felt in many ways that my education or training as a psychotherapist really commenced with him. There was a group of us who learned from him in yearly five-day retreats, after which I formed a monthly consultation group with a smaller group. I call him a master because of his skill and dedication to the work and his thoughtfulness in teaching others.

As part of his work, he often demonstrated various aspects of psychotherapy, including doing demonstrations with us, either through role plays or with those of us who wished to be able to explore our own personal issues, particularly as they impacted our work as psychotherapists, which it always does, of course.

For several years, we kept saying “We needed to get this guy on tape” for the benefit of those around the world who haven’t had a chance to work with him personally. And at some point, I had the great realization that he wasn’t getting any younger. He was 80 years old, so a buddy and I recruited a couple of volunteer clients and secured the services of a videographer to record him doing two sessions with two clients.

Like many ventures, we didn’t really have a goal in mind at that early point
So, we created a videotape, VHS, which was an initial venture in crowdfunding. We actually snail mailed his mailing list of about 200 folks saying, “Would you be willing to purchase a copy of this videotape to help us in our production?” We raised a few thousand dollars, which got us maybe halfway there to the costs, chipped in some of our own money, and ended up producing a videotape.

Like many ventures, we didn’t really have a goal in mind at that early point. It was not my plan to start a business. I just wanted to make a tape and ended up going to the Evolution of Psychotherapy conference, getting a booth there selling some of these and some other videotapes. One thing led to another after that. But that’s the short version.  
LR: If I were to magically transport myself to that Evolution of Psychotherapy conference and interview that guy in the corner with the booth and the VHS tapes and asked him, “Have any idea where this thing’s going?” or “Do you have your next master in mind?” what would he have said?
VY: It was very exciting because Jeff Zeig, who runs those conferences, was kind enough to send out a letter to other speakers telling them that Victor Yalom, the son of Irvin Yalom, was going to be selling some tapes, and if others had some to contact me. I ended up getting a small collection of videotapes, including some group tapes of my father, and pricing them much lower than they were otherwise available, at the price of a textbook or a professional book. Not some of the very high-cost textbooks that we see today. 
  

There was tremendous demand and excitement, so I realized I was onto something. Now recall this was 1995, right at the birth of the internet, so if you were a professor or a therapist wanting to get or see therapy in action, it was very hard to do. There was no YouTube. There were no online courses. And the few videos that were out there were hard to track down. 
 

I realized I had found an untapped need
At that point, I realized I had found an untapped need. I’m not a trained businessperson, but I did learn a bit over the years, like when folks are pitching business ideas now, one of the things they think about is what problem are they solving? In looking back, I was solving a problem that I had experienced in graduate school. Up to that time, I had hardly ever seen a therapist do therapy, and I thought, “This is crazy.” So, I clearly felt there was something there. 

LR: So, an unintended pioneer in a market that didn’t yet exist. A venturer without capital. Aside from the technological savvy that you had to acquire along the way, were there any major obstacles in accessing the masters or getting people to sign on to this “little engine that could?”
VY:
What was more surprising was that clients were and still are willing to be on camera and reveal personal things about themselves
I think I’ve been pretty fortunate. Perhaps my enthusiasm has carried me quite a long way, and honestly, sharing the last name of my father certainly opened some doors for me. I can’t say that was a great benefit in what I was doing at the time, which was doing private practice. Certainly, name recognition is nice—and has some downsides as well—but nobody refers patients to you just because you have a famous last name. But in terms of getting legendary clinicians to return a phone call or be willing to trust themselves with me to make a recording of them, I’m sure that helped.

What was more surprising was that clients were and still are willing to be on camera and reveal personal things about themselves for the benefit of having the opportunity to get some free treatment by famous therapists, as well as contribute to the training of our field. Of course, not all clients are willing to do so, but every time we’ve wanted to produce a video, we’ve been able to find clients who are willing to bare their souls to a wider audience. I’m always grateful for that, and also feel protective of them in terms of wanting to carefully screen them to make sure that they are comfortable with the types of things that might come up and be willing to edit out material that just felt too sensitive, even if they were willing to share.  
LR: That’s an interesting perspective because in Narrative Therapy, one of the goals is to help the client assert expertise over their own life, and one aspect of that expertise is giving clients the opportunity to teach other clients through written narratives or through videotaping. 

I hadn’t thought until you just mentioned it how much value, over and above whatever benefits accrue to the audience of these videos, the clients might reap in being with a master, and how putting themselves out there might give them an opportunity to share in some way beyond the isolated room of therapy, and even truly benefit others who might be reluctant. 

VY: I feel, although I don’t know this for a fact, that some of the clients with whom we’ve worked obtain a sense of advocacy from their participation, particularly when they are part of an underrepresented population, for example, a military veteran or an African American client. We recently published a video series on counseling African American men. You know because you were a part of that. 

I strongly suspect that part of the clients’ motivation in that series was, “I can help normalize this therapy process for African American men who have certain struggles often related to racism, and I want to encourage others who may have similar struggles as me to get therapy and to train therapists in how to better work with this population.” So, I suspect there’s some sense of advocacy and caring that therapists get the best training possible to treat folks that are similar to them in whatever characteristics. 

LR: Having well over 300 video titles, how has Psychotherapy.net kept pace with the expanding demographics that psychotherapists serve?
VY: Just to be clear, yes, we do have over 350 titles now, but we have not produced all of those ourselves—maybe a third of those. The rest we’ve found by going far and wide looking for videos that were out there but, in many cases, not widely available. 

I made a conscious effort starting several years ago to produce videos with both therapists and clients of more diversity
One case always stands to mind. I made a video with Natalie Rogers, art therapist and daughter of Carl Rogers. At the end of the production, we were filming in her house, and she brought out a shoebox full of old VHS tapes and DVDs for me to look through. She entrusted me to take them home, and I reviewed them. Some were home recordings with poor video or audio quality. But I came across one excellent interview of him, professional quality, and finally tracked down that this was produced in Ireland by RTE, I believe it stands for Radio Television of Ireland. Lo and behold, they had the original master in the vault and managed to work out a deal so we could distribute it, so I recorded a new introduction with Natalie. That’s a little aside just to state that we haven’t produced all the videos we offer. 
 

But we have a legacy of titles. And I realized some time ago that we were, not surprisingly, overrepresented with master therapists. Let’s take out the term master therapists, but with White male therapists and Caucasian clients. So I made a conscious effort starting several years ago to produce videos with both therapists and clients of more diversity. So, we’ve been doing that, but I have a lot of catch-up to do. 

LR: In this era of YouTube and TikTok, the consuming public seems to crave products that pack their punch in shorter bursts. Do you see that as an obstacle to your goal at Psychotherapy.net of portraying therapists doing the real and often laborious work of therapy?
VY: It’s a balancing act, indeed. Several years ago, we did a focus group with some of our customers to try to better understand their needs, and that was certainly one of them. Therapists told us they may have a 30-minute gap in their schedule, or they may have a cancellation, and your typical videos of one or two hours in length, often showing full sessions of therapy, didn’t fit that particular need. So, we launched a collection of videos called “Mastery in Minutes” that are 30 minutes or less. They are at times new productions, at other times excerpts of our longer videos with some additional introduction or discussion. 

So, we try to meet both needs. We do try to offer shorter videos, and our longer videos are broken up into chapters. We have some very long courses that might be 6 to 10 hours, but they’re broken up into shorter chapters. 
 

One of our productions I'm most proud of, Emotionally Focused Therapy Step by Step, is the most ambitious project we’ve ever done
One of our productions I'm most proud of, Emotionally Focused Therapy Step by Step, is the most ambitious project we’ve ever done and frankly, I think that anyone has done. We filmed over 100 hours of EFT sessions with six couples and four different therapists over a year and a half, edited that down to about eight hours of sessions and a few hours of discussion and commentary. I have to give my wife, Marie-Hélène Yalom, our Senior Director of Strategy and Product Development, a lot of credit. While she’s not a therapist, she’s learned a lot about EFT and painstakingly edited this down with Rebecca Jorgensen, the main therapist featured in this project. 
 

Obviously, we don’t expect someone to sit down and watch that all at once. So it’s broken down as the title implies, step by step, into many small skill sets, and EFT, for people who know, is broken down into steps and stages. So, you can watch our longer videos in shorter chunks and skip from chapter to chapter. 

LR: It sounds like a real challenge to balance the demand to satisfy the customer but remain faithful to the practice of psychotherapy. From an insider’s perspective, I think you’ve done a nice job of that balance, but I’m a bit biased. 
VY: Yeah, it’s a tension that exists in our field and in many aspects of society, people want short-term fixes, quick fixes. People want short-term therapy. Some therapists promise that. Some approaches promise that, but whether they’re able to fulfill that promise? That’s debatable. I think at times you can convey some powerful ideas in a short amount of time. But to master them, like anything, takes—
LR: Hours….
VY: Dedication. Practice. Maybe some luck, or the right circumstances with the right clients who are ready to make some changes. Other times it’s painstaking, and you may work with a client for years and not see a lot of changes but nonetheless, they may benefit greatly from having support.
LR: How have you evolved in your approach to interviewing the masters over the last several decades?
VY:
I’m able to be myself more and reveal more of myself in all aspects of my life. I believe that shows up in doing interviews
I think it parallels my development as a human being, which is not an unusual progression in that I feel more comfortable in my skin, have more confidence that I have something to offer, and have come to accept parts of myself that I felt uncomfortable with or ashamed of not as only part of who I am, but that I like and feel proud of. So, I’m able to be myself more and reveal more of myself in all aspects of my life. I believe that shows up in doing interviews. That hopefully shows up in how I do therapy, how I relate to my friends and loved ones.

Specifically, in interviews, I feel more confidence that I know a lot about therapy. I have to be a jack of all trades to know a little bit about different techniques and approaches as I’m producing videos of various types. I don’t have the academic background like you do, and don’t keep up as much with the research, but I feel I know enough to ask questions and engage in dialogues that I hope are informative to our viewers and entertaining to watch in the sense of seeing the discussions and the therapy sessions, which are typically featured in our videos as being alive and representing the best of humanity.  
LR: One of the qualities of your interviewing style, which I assume filters into your therapeutic style as well, and perhaps into your personal style, is that you don’t seem afraid to ask hard questions. You’re clearly willing to put someone on the spot in search of the most real they will allow you to have access to.

And that, to me, suggests a certain degree of confidence, and also an unwillingness to accept what’s offered as expertise without proof of that expertise. So, that’s just sort of a side comment for those of who will venture into this interview, which will probably take more than five minutes to read. I think it’s as important to watch your style of interviewing these masters, and the way you hold them accountable for their presumed expertise, rather than just fawning over these masters.  

The Art and Artistry of Psychotherapy

LR: Most of your audience “knows” you through the interviews you’ve done with master therapists and through the cartoons you create for the site, but they likely don’t know that you also work in paint, metal, and wood. I’m wondering how this continual drive to express your creativity has manifested in your own identity and practice as a therapist?
VY: Interestingly enough, I didn’t grow up doing things I considered artistic, certainly not in the visual arts. This all started at a workshop with my mentor, James Bugental. I have a hard time sitting still and listening, so I would draw. I was drawing little stick figure cartoons, one of which eventually evolved into a cartoon. It was a stick figure of a cactus laying on a sofa saying, “Well, I didn’t come from what you would call a touchy-feely family.” 

My drawings were literally stick figures. And when I created the website, I had an idea to put a few cartoons up there, so I hired some people who knew how to draw and took these ideas and made cartoons out of them. And then at some point, an ex-girlfriend of mine said, “Well, you have a very primitive drawing style, you should draw them yourself.” So, I started drawing my own cartoons, and that led me to taking a painting class, and as you mentioned, I now do metal sculptures. But this all started maybe 20 years ago when I was about 40. So, I credit Psychotherapy.net with helping me to discover some activities that bring me a great deal of pleasure. 
 

increasingly view therapy as a creative enterprise
In terms of your question about how that may impact my therapy or show up in my therapy, I increasingly view therapy as a creative enterprise. I grew up in an academic family. My parents are writers. I’m taking another little aside here, but I always had an interest in or fascination with the business world but was very much an outsider, and back then, you know, when I graduated from college, you couldn’t start a business as you can today. If you wanted to work in the business world, you worked in a Fortune 500 company. I tried and I was fired. I failed miserably. 
 

And in the process of creating Psychotherapy.net, which was just a side hobby for many years while I was in full-time practice, I came to realize that building and growing a business is the ultimate creative enterprise. I had an idea to make a videotape, I took that idea and created something from it, and then that evolved to something else, which evolved into something else. 
 

And now here, you and I are having this interview on a technology that didn’t exist when I started this, so getting finally to your question about psychotherapy; it’s an extremely creative enterprise, just like this conversation. A client comes in and says something and you react, you have internal reactions, and then somehow words come out of your mouth and you say something, and it goes from there. 
 

You don’t know what’s going to happen with what you do with them and what’s going to happen with their life. You try to adapt what you do and what you say in a way that’s going to be helpful. Certainly, there are certain approaches that give you more structure or guidance, and those can be critiqued as overly manualized or cookie-cutter, but ultimately, in my opinion, if you’re going to do work that’s at all meaningful and helpful, you need to find a way to enter their world and to do so in a creative and imaginative way. 

LR: And that goes back to what you were saying before in terms of your own personal evolution, becoming more comfortable with who you are in your own skin, warts and all. I think therapists are most effective when they are most genuine and when they’re most vulnerable, and they invite themselves into a co-creative experience with their client. That’s evident in watching you work, at least in the interviews.

You have taken what I consider a heroic step, as you recently transitioned from the man behind the camera to the man in front of it. You did part one of an experiential teletherapeutic interview with an Italian woman. I wonder what it took for you to put the director’s hat down and step in front of the camera and, in a sense, expose yourself to your audience in a new way?  
VY: I feel very fortunate that I had a chance to study with quite talented therapists like James Bugental and, of course, learn a tremendous amount from my father, and then in the process of creating other videos work with and get to know Sue Johnson and Peter Levine and Otto Kernberg and Reid Wilson, and many others. Some I had more contact with and thus learned more from, and others less. 

I feel reasonably confident that I have some things to offer myself and some important things I’ve learned that I don’t think are widely taught
And over the years, like I think any maturing therapist, I have been able to integrate and internalize that into my own style of working to the point where I feel reasonably confident that I have some things to offer myself and some important things I’ve learned that I don’t think are widely taught. 

LR: Such as?
VY: Two things come to mind. From Bugental, some specific techniques to help clients more vibrantly explore their internal world, their subjective experience in an alive and present way versus just talking about themselves. In particular, he taught some specific techniques as well as an underlying philosophy, and numerous ways to deepen that exploration. He suggested that therapists often encounter what he referred to as resistance, which can be a confusing term. Another way of thinking of it is that we get stuck in our ways, whether you call them defense mechanisms or just modes of coping or ways of being.

As we know as therapists, it’s hard for clients to really change the way they adapt to situations even when they aren’t helpful. So, we can help clients explore themselves, but often they reach a wall or there are restrictions in their ability to explore freely, and those could be that they intellectualize, that they shut down, that they focus excessively on pleasing you and the people around them and have a hard time accessing their own experiences and needs. So, in the process of getting them to do this internal searching, as he called it, you hit these roadblocks. He taught ways to help identify and loosen up those roadblocks; that might be a way of putting it. So those are some things that he taught me that feel very vital and powerful, and I don’t think are widely known.

with the advent of online therapy, it's been much easier to make recordings of not just one session, but longer-term therapy
And my father writes a lot about working interpersonally in the here and now between client and therapist in a way that I haven’t seen discussed much in other forms of therapy. How do you use the here and now of the therapeutic relationship? How do you work with that in a way that’s beneficial to the client?

So those are a few ideas that I feel are important and I don’t see discussed or represented in most of the types of therapies that are generally taught. Now, there are exceptions to that, but I feel compelled to teach them. And I’ve been mulling over this for several years now. And finally, with the advent of online therapy, it's been much easier to make recordings of not just one session, but longer-term therapy. I’ve just completed the course of seeing a client for 18 sessions, which we recorded, and I’m at the beginning stages of producing a course that will include excerpts of these sessions, and hopefully of some other colleagues as well, to teach some of these ideas.   
LR: You’ve mentioned James Bugental numerous times as being historically and personally influential in your own life’s work. So, I want to ask you, Victor Yalom—perhaps you haven’t thought in these terms before, but do you see yourself as an influencer?
VY:
I’m proud of what we’ve created with Psychotherapy.net, and I think we’ve done something useful and I’m certainly part of that
IOver the years running Psychotherapy.net, we’d get phone calls and emails, and sometimes when I’d answer the phone, I would get comments like, “Oh, I can’t believe I’m talking to Dr. Yalom,” and I always assumed they were confusing me with my father.
LR:  would never do that. [Note: LR actually did this when first applying for the Editorship]. 
VY: And many times they were. But since you asked, I can’t resist responding from time to time to customer emails. I find it helpful to keep my finger on the pulse of what’s happening there. And occasionally I do get people who know me from the videos I’ve made. Our videos are widely used in universities in the US and around the world, so it’s fair to say that I’m proud of what we’ve created with Psychotherapy.net, and I think we’ve done something useful and I’m certainly part of that.

The Long View

LR: As someone who has had a front seat to the evolution of the field of psychotherapy over three decades, how do you think the field has changed on your watch? Or more specifically, what tensions in the field have you noticed?
VY: It’s really hard to say. I remember when I just started grad school, Nick Cummings, who started the California School of Professional Psychology, and hence the whole professional psychology school movement (we have an interview of him on our site), gave us a rousing lecture about how private practice is dead. This was in the late 80s, and that hasn’t come to pass. 

In terms of approaches, CBT and other so-called evidence-based approaches are being taught much more widely. I have concerns about that. I think that yes, we want to do therapy that’s effective, and yet we seem to have traded on the idea that evidence-based treatment somehow defies this entire other line of valid research showing that the most important elements of change are the therapeutic relationship and client factors. 
 

The research consistently shows that one approach is not better than another approach
The research consistently shows that one approach is not better than another approach. And that may be just a research limitation—there are so many complexities and variables involved. But it’s clearly easier to research treatment methods than relationship variables, and there’s more funding available to research certain types, so there may be more data showing that those approaches are effective, but that does not mean that other approaches are less effective. 
 

So I don’t know what the answer is. I’m not involved in policy making or in formal training programs. But I am concerned about the narrowness or limitations that seem to be taught in many of the clinical graduate programs that students are being trained in. 
 

There are obvious other big changes in the field, the most striking of which is the move to online therapy that accelerated with the onset of COVID. And that’s never going to go back to fully in-person, though it’ll be a hybrid model. I think in many ways, it’s a good thing. It’s going to increase accessibility. It’s going to increase availability. 
 

I continue to do a group that moved online. While I was reluctant to do so initially, it allowed people who have moved or are on vacation or in another town to continue to be in the group. So, it’s better in that way, but you do lose the vitality of the in-person group experience. 
 

We all know of these other changes, app-based therapy, chat therapy, different pricing models, etc. There are problems with many of them, the reimbursement rates for therapists are quite low. Does chat have a useful place in therapy? The good thing, I think, is that it’s loosened up this historic and restrictive idea that therapy should be once a week in the office for 50 minutes, which came out of the idea that people have to get in their cars every day and drive to the office. Well, you know, I was guilty of that as well, in having our staff work primarily in the office. Suddenly we realized, as with all our assumptions, that doesn’t need to be the case. 
 

Therapy, like most every other business, has moved online and is doing just fine. So, in terms of therapy, what’s the best way to do it? Can it be fully online? Can you, when possible, combine online with in-person sessions? Should it be every week for 50 minutes? Should it be some more fluid model? I mean, for clients in crisis, why not meet for 90 minutes or two hours, and why not be able to have email or text during the week? Then you have to come up with different pricing models for reimbursement. But surely, we’re not going to go back to once a week in the office for 50 minutes, and I think that’s a good thing. 

LR: Traditional models have to be challenged and evaluated on a regular basis, or else they just become vestigial.

As we near the end of our time together and this journey you’ve taken us on, I can’t help but to reflect on the passage of time since I was in graduate school and what I have witnessed. And maybe it’s just a function of my getting older, but are therapists getting younger? It seems that therapists are getting younger and younger each day.  
VY: It’s incredible.
LR: They’re getting master’s degrees at 22 years old and within a year, and at the cost of sounding jaded and cynical, they have business cards advertising that they specialize in working with children, adults, and the elderly.
VY: I don’t know if people even have business cards anymore.
LR: Right. We have websites. It just seems that the entire field, both therapists and clients, if not society, is so much more restless, so much more impatient, and as you said before, hungry for quick change. Everybody’s an expert. There are a thousand books out there, 18 ways to this and 17 ways to that. How will Psychotherapy.net survive that seemingly insatiable hunger for more, faster, shorter, and sexier? What will be the secret to your survival? 
VY:
as many of the masters die off or have died already, we try to find clinicians who are doing good work and try to capture that work on camera
I’m not worried about that. I think we just have to keep producing relevant, good content, and
as many of the masters die off or have died already, we try to find clinicians who are doing good work and try to capture that work on camera. That’s what differentiates us from most of the competition out there. 

Most of the online training seems to be done primarily by talking heads, lectures, webinars, and it just seems crazy to me that this is the way training has traditionally been done in our field, reading books, talking about therapy. In every other field, and I’ve said this over and over and over again, whether you’re a plumber, a dancer, a lawyer, or an architect, you learn by watching others do their work. I mean, you have to study and know the basics, but you learn by watching other masters doing their work, your bosses. 
 

You’re in court. You’re in second seat in a trial, and then your bosses are watching you do the work and giving you feedback, giving you coaching. Hopefully, constructive feedback. So, that’s kind of the essence of what we do, which is to show excerpts of therapy in action and explain why we’re doing it. Now, certainly, we’ll adapt. We’d like to do some live events, live webinars, and do these interviews. I don’t know what we’ll be doing, exactly. People talk about gamification and interactive video. I haven’t seen much of that yet, at least in our field, that’s useful. So, I’m not worried about that. 
 

I think the great thing about our field is that life experience helps
In terms of your thing about therapists getting younger, well, obviously, there’s partly a tongue-in-cheek thing going on there, because we’re getting older. I still have this little thing going back to Transactional Analysis, kind of a one-down stance where I still feel like I’m the kid in the room. I’m often surprised, I may be emailing people, I get on a Zoom call, and “Hey! You look so young.” I’m still kind of assuming that I’m going to be the youngest. 
 

But I think the great thing about our field is that life experience helps. Yes, you’re more in touch with young students, or have been as a professor for many years, but it’s a great profession for people to go into as a second career. If you start doing this when you’re 30 or 40 or 50, what a gift that you know something about life, having worked in other fields, having children, having a family, having suffered losses that invariably occur. So, you do what you can with the resources you have, and hopefully those grow over time. 

LR: Kicking and screaming in some cases. I think that’s it for me for now, Victor. Do you have any last thoughts or questions you want to ask me or reflections on how our time together went for you?
VY: It’s been a pleasure working with you over the last several years, Larry. In terms of this conversation, what I’ve tried to do is to respond in the moment to thoughts or feelings that come up as we’ve been talking.

I’ve done a number of these interviews, we’ve been on podcasts, and I just realized it’s easy to start telling the same stories over and over again. It’s an interesting phenomenon. And if you think about therapy, it’s easy for clients to do that. They tell a story about the losses they’ve had or the disappointments they’ve had, and it’s important for them to convey that to you. But as Frieda Reichmann has allegedly said, “Patients need an experience, not an explanation.”

It’s strange and honorable, and at times a captivating and rewarding profession to be able to sit with clients and enter their world
I don’t know if I’ve said anything new. Hopefully, I’ve conveyed some ideas that someone will find interesting. As I reflect on our conversation, the one thing that stands out is when you asked me about my own evolution and I talked about becoming more comfortable with myself and things that I was uncomfortable with, and I used the words “ashamed of.” That felt like one moment where I said something I don’t think I’ve said before.

I’m sure it’s true for all of us. We have things about ourselves that we don’t feel good about or feel ashamed of or feel vulnerable around. And it’s also true that those, in general, for me, are much more contained and more in the past, and I’m grateful for that.

As I say that, it makes me think about the work of a therapist and the work we do with clients to really cherish and embrace the idea that everyone has this unique world inside of them, and sometimes that world is extremely painful and chaotic. Sometimes that world is just chugging along and doing okay, and sometimes that world is expansive and exciting. It’s strange and honorable, and at times a captivating and rewarding profession to be able to sit with clients and enter their world and see what help we can be to them in navigating their life’s journey.  
LR: From my perspective, and as I prepared for this interview, I was acutely aware that our relationships these past five years have evolved. And as I became more comfortable in my space in our relationship, I’ve come to feel more confident, not just in my role as Psychotherapy.net’s Editor, but also in my own skin. I think every good relationship, whether it’s therapeutic or not, is a growth opportunity, whether it’s inside of a therapy room or not.

And I wasn’t looking for this interview to be a growth opportunity per se. I wanted to offer you something interesting; how do I ask interesting questions when you’ve been asked so many similar questions before? There was a part of me that wanted to ask interesting enough questions to interest you, to please you. I wanted, and perhaps still do want, to be interesting, relevant. Perhaps even more so after having retired from the university. I wanted to honor what you’ve done, and I wanted to also provoke you when I could without unnecessarily doing so. I wanted to create, I guess, as in therapy, a safe space where sharing could happen.

This was different from some of the other interviews that I’ve seen conducted with you. I sensed an even greater level of vulnerability, especially in that comment you made about shame, and I was very impressed with your willingness to share that. So, before we sign up as the first two members of the mutual admiration society, I’ll say goodbye and thank you again for welcoming us into your space.  
VY: Well, thank you very much, Larry. It’s been a wonderful and enriching conversation. 

A Matter of Death and Life

Excerpted from A Matter of Death and Life by Irvin D. Yalom and Marilyn Yalom, published by Stanford University Press, ©2021 by Irvin D. Yalom and Marilyn Yalom. All Rights Reserved.

Numbness, 50 Days After

Numbness persists. My children visit. We take walks in the neighborhood, cook together, play chess, and watch movies on TV. Yet I remain numb. I feel uninvolved in the chess games with my sons. Winning or losing has lost significance.

Yesterday evening there was a neighborhood poker game, and my son Reid and I both played. It was the first time I’ve ever played together with one of my sons in a game of adults. I’ve always loved poker but at this game, at this time, I could not shuck the numbness. Sounds like depression, I know, but still I took pleasure in seeing Reid’s happiness about winning thirty dollars. As I walked back to my home, I imagined how good it would have felt to arrive home, be greeted by Marilyn, and tell her about our son’s winning night at poker.

The following night I try an experiment and place the portrait of Marilyn in plain view in the room while my son, his wife, and I watch a movie on TV. But, after a few minutes, I feel so much tightness in my chest that I again put Marilyn’s portrait out of sight. The numbness persists as the film proceeds. After about a half hour, I realize that Marilyn and I had seen this movie several months before. I lose interest in seeing it again but remembering that Marilyn had enjoyed it a great deal, I honor the bizarre notion that I owe it to her to watch the entire film.

“I notice that the numbness recedes the first few hours of the day when I am immersed in writing this book and also when I work as a therapist”. Today, a woman in her late twenties enters my office for a consultation. She presents her dilemma. “I’m in love with two men, my husband and another man I’ve been involved with for the last year. I don’t know which is the real love. When I’m with one of them, I feel that he’s my real love. And then the next day or so I feel the same way about the other man. It’s as though I want someone to tell me which one is the real love.”

She discusses her dilemma at length. Midway through the session, she notes the time and mentions that she had seen my wife’s obituary. She thanks me for being willing to see her at this difficult time. “I worry” she says, “about burdening you with my issues when you’re suffering such a huge loss.”

“Thank you for those words,” I reply, “but some time has gone by, and I find that it helps me if I’m engaged in helping others. And also, there are times when issues arising from my grief enable me to help others.”

“How does that work?” she asks. “Are you thinking of something that may be helpful to me?”

“I’m not clear about that. Let me just ramble for a minute. Let’s see . . . I know that getting involved in your life in this session temporarily diverts me from my own. I’m thinking, too, of your comment that you don’t know your real self and that you cannot know which of these two men the real you really wants. I keep thinking about your use of real. I feel this may be tangential, but I’ll just trust my instincts and tell you what our discussion stirs up in me.

“For a very long time I’ve felt that an event often felt ‘real’ only after I shared it with my wife. But now, weeks after my wife’s death, I have this very strange experience of something happening and my feeling I must tell my wife about this. It’s as though things don’t become ‘real’ until my wife knows about them. And, of course, that is entirely irrational because my wife no longer exists. I don’t know how to put this in a way that will be helpful but here it is: I, and only I, have to take full responsibility for determining reality. Tell me, does this have any meaning for you?”

She seems deep in thought and then looks up and says, “That does speak to me. You’re right if you’re implying that I cannot trust my sense of reality and that I want others—perhaps one of my two men, perhaps you—to identify reality. My husband is weak and always defers to my observations, to my sense of reality. And the other man is stronger, very successful in business, very sure of himself, and I feel safer and more protected and trust his sense of reality. Yet I also know that he’s a long-term addict who is now in AA and has now been sober for only a few weeks. I think the truth is that I mustn’t trust either of them to define reality for me. Your words make me realize that it’s my job to define reality—my job and my responsibility.”

Toward the end of our hour together, I suggest that she is not ready to make a decision and should tackle this in depth in continued therapy. I give her the names of two excellent therapists and ask that she email me a few weeks from now to let me know how she is doing. She is deeply touched by my sharing so much with her and says that this hour has been so meaningful that she didn’t want to leave.

Holding Two Worlds Together—Apart: On the Duality of Being a Therapist

Consigned to Separate Lives

Am I the only therapist who sometimes feels that she lives two separate lives? One with my friends, family, and loved ones; and another entangled in the stories of my client’s lives, dramas, and company. What other professions dictate that the personal life can’t intersect with the professional? CIA agent, detective, spy? The duality of being a therapist often feels to me like I am holding onto two different worlds at the same time. Yet, as mysterious as what goes on between me and client often is, the paradox is that it is also meant to be an open and safe space where they can truly allow themselves to be authentic.

Therapists, social workers, psychologists, counselors, healers, and superheroes live double lives. We go to work every day and immerse ourselves in the stories of our clients. We fight for them, cry with them, laugh, get angry, and know things about them that most people don’t. We form relationships and bonds. We see them at their lowest, and watch them transform, fall again, move through relationships, pain, loss, birth, and death. We come to care about them deeply. We learn to love them. Yet we go home each and every day, and the people in our intimate lives know nothing about these stories. Sure, our significant other may know that we had a rough day or that we had to send our chronically suicidal patient to the hospital yet again, but they don’t know and will never know the complex, rich lives that we learn to treasure. The stories we hold dear and how brightly our clients’ souls shine even during agonizing darkness are ours alone, not to share outside of the therapeutic space.

Who’s Internalizing Whom?

I went back to school in my mid thirties to get my MSW and felt like I didn’t have much time to spare to really do what I wanted to do. I wanted to know people. To really know them. It was naïve of me to think that getting to truly see my people while having them tucked away from my real world would be easy. Just part of the job. However, it remains something that I often think about, struggle with, and theorize over as my career progresses. Part of the old school education I received when entering this field centered around a stoicism towards our people that I can’t quite understand. I was trained to travel the profession with an ingrained fear that it’s weird, and even wrong, to think about my clients when I am not with them. They are the ones who are supposed to internalize me in order to “feel better”—the process is not supposed to work the other way around!

To internalize is to incorporate within oneself guiding principles learned in the course of socialization. One of the biggest wins my clients experience is when they begin to internalize me outside of the room. When my re-parenting, nurturing, and insight become guiding lights in their every day, and when they don’t feel alone and know that the faithful kindness I provide them within our relationship is present even outside of our being near one other. Much is written about this phenomenon and the changes that clients start to make when they take us in. But what about the other way around? What about when we internalize our clients? I have thought about this often.

In his brilliant book The Gift of Therapy, Irvin Yalom urges us to allow our clients to matter to us, to allow them entry into our minds and to influence us. He also asks us to share this with them. When I read those words, layers of shame and frustration within myself seemed to melt away. For so long I felt guilty that I thought about my clients and their worlds long after our weekly meetings ended. How liberating it was to allow them to be with me, change me, to think of them, and allow their stories to move parts of me as well. One day, I was having a particularly hard week personally. I was letting old feelings of “not good enough” seep into my story. Not a good enough parent, wife, daughter, friend—you get the drill. I was sitting in session with a client, and she looked over to me and told me she wanted to send me an article she found online that “made me think of you because it talks about unconditional love.”

We finished our session, and I forgot about the article she had sent me. Only later in the evening when I was winding down for the day did I open what she sent me. As I read the words on that page, something that I had been missing all week snapped me back to reality. It said, “When you doubt yourself, when you feel the world turning swiftly against you—keep loving. Love so big that you become it, because you are love.” I cried. My client got it, and she gave the gift back to me. I thought of her knowing this, even when I did not. Next week in session, I gulped deeply and said, “Thank you—you gave me a gift last week, and it helped me.” Glossy, tear-filled eyes from both of us. It appears that internalizing my client was as important as the other way around. As we are told by Diana Fosha, client and therapist can and often do exist in the mind of the other.

Therapy as Co-Regulation

My job is to expertly track, monitor, and regulate not only the nervous systems of my clients, but my own as well—to hold two worlds simultaneously together at the same time. As I notice the body language, rhythm, facial expressions, and breathing rate of the people with whom I work, so do I track my own. In turn, my client and I are dancing together with two nervous systems coming in and out of connection—regulating (and sometimes mis-attuning) each other. One time, there was some extremely disappointing news that I had to share with one of my clients, and as I waited for our session, my anxiety was at an all-time high. How was she going to take the news? Was it going to set her back? My heart was in knots. My mind was racing. I was clearly overthinking everything. The session time came, and the second I saw her eyes my anxiety seemed to melt away. I heard myself say, “It’s going to be ok.” It was that quick, that simple, and that magic. I felt safe in our relationship, as did she. There were few words. We didn’t need it. Our nervous systems just knew, and we were both ok.

After that incident I asked myself, “What was that?” I even brought it up in my case consultation that week. I was afraid that I was being self-indulgent or entangled in some mysterious transference/counter-transference fiasco. Allan Schore tells us that psychotherapy entails intersubjective work which is focused more on being with rather than doing for clients, especially during moments of affective stress. In looking back, I realize that moment was not about what was spoken or wasn’t, but rather how we were with one another that made all the difference—for both of us.

“How do you do it?” “How can you not let any of this stuff get to you?” “It must be hard.” These are just a few of the comments and questions I have received from those in my personal life. I am not sure why people think that it doesn’t get to me (us). The fact is that it’s not only ok that it gets to me, it’s necessary. I am not talking about compassion fatigue or vicarious trauma, which can all too well happen if I don’t monitor and take care of my own self as well. I am talking about the actual day-to-day lives of my clients that I am privy to, are a part of, and are engrossed with. How can I “shut it off” when somebody I know intimately tells me a harrowing tale of abuse and neglect—or about when somebody mistreats them—or, conversely, when they start to fall in love and the things that at one time seemed impossible are starting to blossom? These things impact me. I take them with me and carry them as I walk through my day even outside of the therapy room. The resonances that work to create neural circuitry and bond the hearts and minds of our clients do the same for us—if we allow them to.

I’m not going to lie, sometimes I want the buzz in my mind of the two simultaneous worlds, mine and theirs (so many of them!) to shut off, because honestly, I need a break. But as I tell so many of my clients, resisting the natural contours of the mind is part of the problem. If we simply observe and validate that something touched us, and we hold it dear to us, that we are worried, or afraid that we said the wrong thing, then maybe we can all relax in knowing that our hearts and minds are human, too. I am not meant to “shut it off” and be “numb” to my clients’ experiences and stories. I must allow them to change me, move me, and be brave enough to let them know they did.

How Odd Our Profession Is!

As I go about my daily life outside of my office and socialize with friends and family I often find myself catching my words when something reminds me of one of my clients or it relates to what so-and-so said in session. I could be having a rip-roaring girl’s night out with a couple of girlfriends, and when I see one of them wearing a butterfly necklace made of rhinestones, I think to myself, “Oh, Grace (name changed) would love that!” It latches onto the tip of my tongue, ready to spill out. None of my friends know Grace, or the fact that she loves butterflies—but I do, and I immediately think of her. How weird that I can’t really share that, and it’s just a fleeting thought that only I know. How odd our profession is, I think to myself in that moment. It’s like a cozy little secret compartment in a part of my brain that carries all their cobwebs, but nobody in my “real” life really knows how important or special this person is to me—or that they love butterflies. How odd it is indeed.

There are some days that are intensely difficult—when crisis seems to erupt at every turn or the stories seem to be too hard to bear. Having spent some hectic days while working at an IOP/PHP and continuing to do so because most of my clients struggle with complex trauma, there are moments when it feels like I am energetically depleted and exhausted. Talking a client down from the brink of suicide and having them agree to go to a hospital, mediating between difficult family members, or listening to a violent fight as I try to call the police. All in a day’s work. Come home, look forlorn, have my husband ask me if everything is ok and if there is anything he can do. Do I try to explain or just sit with it, do I try to forget it, or tuck it back into the part of my brain that is called “work”? The next day I silently make my coffee in the morning. “You need to find a way to detach, Anna,” my husband says. How easy that is to say—but how hard it is to practice. I see people week after week—some for years. I don’t see some of my friends and family as much as I see my clients. Yet somehow the two worlds have to remain separate, both somewhat hidden from the other.

I open my daily planner and notice one of my scribbles on the back page: “is it my broken heart—Or—yours that I feel?” There are days when I am strangely unsure—but it becomes my job to find out. Giving into the empathic powers that are my work’s calling can be extraordinarily challenging on some days and make me susceptible to compassion fatigue and vicarious trauma. Guilty of both. Holding space for and witnessing suffering opens me up to wounds as well. Another interesting paradox—to truly heal them, we must allow our people to influence us and let them know it, but doing so can open our own cuts as well.

Yet it’s not always so harrowing and serious. In and during therapy, I laugh—a lot. What an often misunderstood part of the work. To go on the journey of pain, I must also find and allow lightness to enter the chambers of healing. I’m not talking about laughter as a defense or a way to deflect shame and fear. When I was a little girl, we had to sit Shiva (a seven day mourning period for Jews) after somebody passed away. Some of the best moments would be spent laughing. Yes, there were tears and anger and irritation as I was stuck with my family for seven days, watching various people coming in and out with tray upon tray of food and reminiscing about our loved one’s demise. It was comforting to spend time with friends and family during the first painful days of loss. But what I recall most is the first time that laughter erupted. It was like somebody allowed us to have that feeling, too. Grief and sadness were making room for joy and the hope that laughter would again find us.

My clients are some of the funniest people I know. They joke, smile, and belly laugh—and they can still do it after unthinkable loss, tragedy, and heartache. What can be more beautiful than that? And I laugh with them, for if I am to hold space for all the bad stuff, there has to be room —lots of room—for the light stuff, too. Laughter can be just as intimate as pain.

The Sharing of Intimacy

Intimacy is closeness between two people that builds over time. Intimacy—real intimacy—is allowing our raw, unrehearsed reality to spill out in front of another and be held in their embrace with resonance, acceptance, and nurturance. I was speaking with a colleague recently about how sometimes it’s hard for our loved ones to understand that “not taking your work personally” can be difficult to maintain. “Don’t you feel like the connections you have with your people is sometimes more intimate than you have with some of your friends and family?” she said. Yes! I know some of these people better than I know some of the closest people in my real life. How peculiar this work is, how incredibly glorious and beautiful in its capacity to let us know the essence of another soul. Yet how divided it often feels from the realm of our everyday life. The intimacy that is created in a therapeutic relationship, if cultivated correctly and appropriately, can change both our lives because part of their journey is ours, too. Here we are traveling together and separately at the same time.

Some days I feel like it’s a lonely road to travel down this path. It makes me go to chambers in my mind that others don’t know exist, thinking about people and things that others know nothing about. I question the real from the imaginary and how these divergent paths meet at a central place and have the capacity to move mountains and change lives. Both theirs and my own. I still get confused by it all. I am learning to accept some of the limitations and unrequited longing that both I as therapist and my clients must live with within this relationship. I am working on finding peace in knowing that my time with my clients doesn’t have to be real to anyone but myself and them to matter. In that respect, I am incredibly lucky to have a bond that has the power to transform, shake me into feeling more alive, and cultivate the ability to give and receive love. That is the legacy I impart to my clients as they embrace the world at large—and perhaps the one they leave me with as well.

Existential-Humanistic Therapy in the Age of COVID-19 in Vulnerable Populations

Challenges

COVID-19 has been a sudden, unexpected, and existentially shattering experience for many individuals, resulting in their questioning their sense of safety and security in the world. Whether facing actual illness or loss, fear of getting sick or infecting others, forced isolation, lack of personal space, or economic hardship, people have now been facing unprecedented stressors for close to a year. With a second wave upon us and new variants emerging, there may be a sense that anyone is vulnerable. While vaccine distribution offers promise for individual immunity, there is protracted uncertainty about the duration of the crisis and its psychological, economic, political, and societal consequences.

These COVID-19 phenomena may exacerbate challenges for individuals with a history of chronic medical conditions and trauma, including feelings of vulnerability, stigma, and lack of control. Having previously confronted and accepted existential truths such as life’s uncertainty, the random nature of events, and the inevitability of death, these individuals may, at the same time, be better equipped to cope with aspects of the pandemic (Gordon, 2020). Existential-Humanistic (E-H) therapy can provide effective therapeutic interventions to aid vulnerable populations in optimizing adjustment, coping, and quality of life during the COVID-19 pandemic.

Existential-Humanistic Therapy

Developed in the 1960s, E-H therapy consolidates central ideas from European existential philosophy—the power of self-reflection, taking responsibility for decisions, and confronting freedom and death—with the American tradition of spontaneity, pragmatism, and optimism (Schneider & Krug, 2017). E-H therapists emphasize several core aims that enable patients and therapists to become more present in the moment: increasing awareness of self-protective patterns that block and restrict presence and personal agency; taking personal responsibility for the construction of one’s life and self-narratives; and choosing or actualizing ways of being in the world that are consistent with values. E-H therapy strives to be a catalyst for individuals to develop their level of curiosity, generate experience that is felt to be enriching, and expand their capacity for personal agency, commitment, and action.

The model emphasizes the “whole-bodied” (e.g., cognitive-affective-kinesthetic) ability to choose, within limits, who one will become, and that fundamental change takes place through experiential learning. Bugental (1987) depicted resistance as analogous to wearing a spacesuit which helps sustain life but also narrows one’s experience of the world. E-H therapists believe that when life-constricting protections are reduced, more meaning, purpose, and joy can emerge. E-H therapists focus on the here-and-now experience of the past as manifested in the present moment, including the patient’s body posture, level and quality of presence, tone or voice, and self-protective patterns.

Viktor Frankl (1992), an Austrian psychiatrist and Holocaust survivor, observed that we do not get to choose our difficulties and challenges, but do have the ability to select our attitudes and responses, decide what we make of them, and maintain a sense of dignity. Rollo May (1985) believed that it takes courage to move forward in life despite adversity.

An E-H theme developed by Irvin Yalom (1980) is the idea that individuals have a basic need to construct meaning through tolerating uncertainty, a passionate engagement in life, and living in the moment. He describes existential anxiety as the result of the confrontation with the givens of existence, including death, freedom, isolation, and meaninglessness. Existential anxiety occurs because of the conflict between these challenges and a desire for its opposite. These universal conflicts include the awareness of death and the desire for immortality, a sense of groundlessness and the wish for structure to provide safety and security, feeling of isolation and the need for connection, and the awareness of meaninglessness of life and the need to construct meaning. As a result of facing death, individuals experience the urgency of time and setting priorities. For Yalom, psychotherapy during times of crisis can heighten existential awareness and help clients put current and ongoing life crises into perspective.

Yalom incorporates the concept of “rippling” into his many writings on existential therapy. This is the notion that we pass parts of our self onto others, even to others we never met, much like the ripples caused by a pebble in a pond—whether a personality trait, an act of kindness, a quote or saying, the impact of our work—which tempers the pain of transiency. Along related lines, Hoffman (2021), guided by the work of Rollo May, discussed the existential guilt that accompanies failure to live up to one’s potential or taking responsibility, while in contrast finding that meaning can transform pain. And finding this meaning, according to Remen (2000), does not require us to live differently, but instead to see our lives differently.

It is in this context of seeing life differently that I ask you, as we might ask our clients, to imagine the consequences of living in a house with only one window. For all intents and purposes, the view from that window will define your reality. Only by experiencing the view from a new window, built perhaps on the other side of the house, will you gradually internalize a degree of perspective and relativity, a sense that vision and meaning involve choice and agency. And with that, I now offer the case of Michael.

The Case of Michael

Michael is a 35-year-old aspiring artist who was referred to me for psychotherapy to develop effective coping skills in his adjustment to his recent diagnosis of Multiple Sclerosis (MS). MS is an autoimmune disease that attacks the central nervous system, which can cause a variety of symptoms, including numbness, fatigue, vision loss, and walking difficulty. He was living with his grandmother and mother and had a strained relationship with his father, whom he had never lived with. He entered therapy three months before COVID-19 rattled the city and shut down services.

At the beginning of treatment, “Michael reported multiple symptoms, frequent incidents of falling and losing his balance, a long-standing history of anxiety and panic attacks, and inhibitions in his ability to commit himself to intimate relationships and professional goals”. Since his adolescence, his anxiety had often resulted in shortness of breath that triggered fears of a heart attack and impending death. He was particularly worried that his physical symptoms would continue to get worse and that he would be totally dependent on others for his physical care.

During his initial sessions, he expressed a great deal of frustration that it took a number of years to get a definitive diagnosis of MS. He felt his family and friends thought he was exaggerating his symptoms to avoid pursuing his educational and vocational goals, which resulted in lack of confidence and trust in expressing his own feelings, needs, and opinions. Even when he was given a definitive diagnosis six months before entering treatment, he experienced others as not fully understanding the impact of his “hidden disability.” He was angry that he developed his medical condition at such an early age, started to doubt his belief that “bad things do not happen to good people,” and felt that he was being punished for his lack of motivation and accomplishments.

Capitalizing on meaning-centered and post-traumatic growth perspectives, therapy began by exploring his strengths—deep-seated values and qualities that did not change due to his medical condition—in order to help him feel more empowered. He identified his compassion for others, creativity, and a sense of humor that could help him cope with his multiple challenges. The only moments when he felt passion in life were when painting or taking pictures of landscapes and city architecture.

In these initial sessions, “Michael was able to express a deep sense of loss and sadness over his physical functioning, as he felt his athleticism had formed a core component of his identity during his adolescence and young adulthood”. He grieved the loss of not being able to play sports with his children, if he became a father in the future. These feelings of sadness triggered memories of his paternal grandfather, who had died of cancer during his adolescence. He was one of the few figures in his life who had confidence in Michael’s talent as an athlete and that he would succeed in the future. Michael identified his grandfather’s resiliency and perseverance in the face of his terminal illness as two of his special qualities. The sessions involved asking Michael open-ended questions, including “What advice would your grandfather give you right now in how to handle your MS?” and “How are you similar to your grandfather?” Michael became more aware of feelings of gratitude toward his grandfather and that he too was a survivor and a determined individual.

When the news of the spread of COVID-19 in March 2020 caused a city-wide lock down, Michael agreed to continue sessions via telehealth. At that time, now on top of his anxiety, panic, and fears of dependency resulting from his medical condition, “he identified the virus as compounding his fears of dying or becoming totally dependent on others”. Shortly after, Michael recalled a series of unsettling dreams. He reported that since his diagnosis of MS approximately nine months before, he had a recurring dream where “Martians shot people and then placed them in upright coffins. They had blank faces and appeared as if in an altered state and could only move their hands in front of them.” Michael’s associations to the dreams were fears of not being able to move, ending up in a wheelchair, and being totally dependent on others. He was asked to retell the dream in the present tense and how he would want the dream to end in order to develop a sense of agency. He said he wanted to be able to fight the Martians like his grandfather had fought his cancer and scare them away.

Two weeks later, Michael reported another frightening dream where he was “trapped in a glass cube in [his] home that was invaded by bad guys who were pumping gas into the cube, and [he] had no way out.” He said he felt terrified of dying and feeling helpless. He was asked to visualize and re-experience how he felt in the dream. He recalled that he felt trapped, his lungs were burning, and he was going to suffocate to death. Michael then spontaneously recalled a memory of escaping from the scene of the World Trade Center Attack. He was at breakfast in a diner across the street and saw the plane hit the building. Michael was numb and could not process what had happened. He was paralyzed by fear, but eventually ran down the street when told to leave by a security guard. He did not remember what happened next, but eventually arrived home covered in ashes and debris, and had difficulty breathing and sleeping for several days. He had not thought about this traumatic event in years.

During this phase of treatment, Michael became more aware of how this traumatic confrontation with the possibility of dying, which occurred shortly after his grandfather’s death, contributed to his panic attacks and fears of dying during his adolescence, which in turn impacted his ability to pursue his educational, vocational, and interpersonal goals. Michael became more aware that his strong needs for safety, security, and protection inhibited his pursuit of taking risks in many aspects of his life. Michael further realized that his avoidance of taking chances and exposing himself to failure and rejection was, as Bugental reminded us, analogous to wearing a spacesuit which is life-affirming but also narrows and inhibits one’s experience of the world.

A major focus of the middle phase of therapy involved his fears of dying and what was meaningful in his life. “Michael acknowledged that part of his death anxiety was that he had wasted many years avoiding pursuing his goals of being an artist and having close relationships”. When asked to project himself a year from now and what new regrets he might accumulate, Michael tearfully stated, “Not completing my college degree and becoming an art teacher, and not living up to Grandfather’s belief in my potential.”

This was a pivotal point in Michael’s treatment, which brought him to enroll in a local college, where he took and succeeded in a number of online courses. He continued to realize on a more experiential level that he had been fearful of taking risks and failing since his adolescence, but that he was paying a significant price for pursuing his strong need for security. When asked “What have you discovered about yourself through the challenge of the pandemic?” Michael reflected that, while the pandemic had added new layers of anxiety, it also had provided him with the space to step back and evaluate what really mattered to him. Rather than continuing his past patterns of avoidance, self-doubt, and comparing himself unfavorably to others, he was determined to focus on his creativity and having an impact on others through teaching. He also realized that his previous contemplation of death anxiety and perseverance in coping with his MS served as protective factors in dealing with COVID-19.

Within a few months, Michael transitioned from feeling overwhelmed and vulnerable in the storm of his MS symptoms and COVID-19 threat to feeling more focused, determined, and resilient. Although he had to maintain cautiousness due to his medical condition and COVID-19, he was able to take the initial steps in pursuing a meaningful career that was consistent with his values and identification with his grandfather. Through the therapeutic process, he came to recognize his own power to choose how he wanted to view and respond to life’s major challenges, including his MS.

Concluding Thoughts

This essay describes my flexible application of E-H approach to psychotherapy when working with a patient with a chronic medical condition and a history of trauma during COVID-19. The case vignette highlights different aspects of the E-H approaches, including cultivating presence in the moment, choosing one’s attitude toward challenge and adversity, increasing awareness of what is most meaningful in life, living in manner consistent with one’s values, and expressing gratitude toward others.

For patients who have chronic and life-threatening medical conditions and a history of trauma, COVID-19 may increase their level of anxiety, fear, vulnerability, and social isolation. On the other hand, “these individuals may have developed a degree of psychological protection and resiliency in having already experienced a prolonged sense of insecurity and uncertainty” involving fears of body integrity and mortality.

In my therapeutic work, E-H therapy provides a safe place for patients to reflect on how COVID-19, while frightening and potentially traumatic, is changing them in unanticipated positive ways, including living life with greater meaning, purpose, and sense of urgency. It is my hope that in reading this, that you may experience this new context as an opportunity to explore existential issues such as uncertainty, vulnerability, meaning in life, and death anxiety with patients in deeper ways than before.

References

Bugental, J. F. T. (1987). The art of the psychotherapist. Norton. https://doi.org/10.1037/h0085349

Frankl, V. (1992). Man’s search for meaning (4th Ed.). Beacon Press.

Gordon, R. M., Dahan, J. F., Wolfson, J. B., Fults, E., Lee, Y. S. C., Smith-Wexler, L., Liberta, T. A., & McGiffin, J. N. (2020). Existential-humanistic and relational psychotherapy during COVID-19 with patients with preexisting conditions. Journal of Humanistic Psychology. Published online: November 2020, https://doi.org/10.1177/0022167820973890

Hoffman. L. (2021). Existential-Humanistic therapy and disaster response: Lessons from the COVID-19 pandemic. Journal of Humanistic Psychology, 61, 33-54. http://doi.org/10.1177/0022167820931987

May, R. (1985). The courage to create. Bantam Books.

Remen, R. N. (2000). My grandfather’s blessings: Stories of strength, refuge, and belonging. Riverhead Books.

Schneider, K. J. & Krug, O. T. (2017). Existential-humanistic therapy (2nd Edition). American Psychological Association. http://dx.doi.org/10.1037/0000042-000

Yalom, I. D. (1980). Existential psychotherapy. Basic Books. 

How to Master the Art of Developing Your Therapeutic Voice

Becoming an Artist

Surrounded by a sea of attendees at Psychotherapy Networker’s annual conference, I waited to ask my hero the question that had been burning inside. One man, with an uncanny resemblance to Sigmund Freud, entranced us yet again with a story of the work we’d all been celebrating and emulating in our own offices for so many years. Our master clinician and storyteller, group therapy guru, and most importantly, the single most generous and open discloser of his clinical process, Irvin Yalom was reflecting on his lifetime contributions.

It was now our turn to ask him questions. “Dr. Yalom, you’ve shown us how to embrace the process, and as the poet Rilke advised, to: ‘be patient toward all that is unsolved in your heart and try to love the questions themselves.’” Was I even talking into the microphone? The notes on my phone bounced out of focus, but I pressed on.

“Like jazz musicians, you’ve reminded us to enjoy the dissonances and savor the surprises we find within them. Can you talk about that, the role and importance of being an artist in our field?” I was grateful when he acknowledged that yes, he had thought of calling his book Letters to a Young Therapist after Rilke’s famous missives. “Even though I idolized so many, no, no, I never thought of myself as an artist. Even though I had wanted to be one, it wasn’t me!” It was like I had framed the wrong man. With him ready to quickly move on, I was stunned, stung, crestfallen. If Yalom couldn’t recognize being an artist, how could any of us?

Luckily for me — and us — Sue Johnson, the puckish British couples therapist and our evening’s interviewer, held him up a minute to take stock of his knee-jerk demurral. Wasn’t his work — its graceful storytelling and open embrace of the therapeutic process a testament to the power of our art to heal and enlarge? Was this any less artistic than the poet, musician, or actor’s craft?

Yalom’s initial objection ripened into delight on stage, and after the conference, in a private email, he thanked me, stating simply, “I’ll remember your comment for a very, very long time.” That’s what this essay is about: the artistry of our work and how we develop a therapeutic voice to help us get there. This is vital not only for ourselves and our supervisees, but even more so for our clients, who cultivate their own voice in the interplay with ours. Happily, there is ample scientific and empirical support for this artistic venture and cultivation of the voice, and I will use it to contextualize and illuminate our journey along the way.

Finding Our Voice

All artists — whether writers, musicians, or actors — must develop a voice, that hard-to-define yet distinctive style which runs like an invisible thread through their work, opening a space of creative possibility between their art and audience. As a supervisor of beginning therapists, I view this as essential, and liken it to the process we see on television each week on the show “The Voice.”

Just as Kelly Clarkson, Blake Shelton, and Adam Levine compassionately and thoughtfully mold, mentor, and inspire young talent, so too must we as supervisors help our beginning clinicians. Each has their own music and style they come in playing, and supervisors help them draw out their raw talent, experiment with new genres, and ultimately learn about how to make music that is, as Duke Ellington said, “beyond category.” This is therapy that transcends theoretical orientations, becoming a unique blend of the clinician’s theoretical and empirical knowledge, their personality, and emerging therapeutic repertoire.

There is a yin and yang here that, when in proper balance and harmony, lead to a fully developed artistic voice. This voice not only serves the therapist but promotes the opening and expansion of the patient’s own voice, becoming the driving force of creative therapeutic work. This also forms the basis for a lifetime of creating art. Yes, all of us therapists (veterans too!) do this daily, in the poetic and musical lines we shape in what others easily pass over as ordinary prose. Freud had it right from the beginning when he suggested, “When we can share that is poetry in the prose of life.”

Wouldn’t it be inspiring if all of us — beginning and veteran clinicians alike, supervisors and supervisees — could embrace the artistry of our everyday work? Wouldn’t it be illuminating if we had a working model of how to cultivate and deepen this?

Building a Voice

The model that I’ve arrived at is both simple yet expansive. A therapeutic voice is the combination and interplay of therapeutic presence and therapeutic authority, the complementary and seemingly contradictory elements that like yin and yang, enable us to create a three-dimensional picture of our patients and ourselves. Think of it like how our two eyes, each with their independent perspectives, magically create depth perception.

An ambitious supervisee recently confessed to me, “I have to anticipate everything before our session, and know exactly where I am taking my clients. I feel like a white-water rafting guide who’s one turn away from taking the whole crew down with me!”

This supervisee, like so many others, is proficient at being directive, setting goals, and moving quickly towards intervention. Unfortunately, they don’t offer enough room for the patient to openly explore and steep in their feelings or draw on the relational process to entertain new possibilities, which is why they so often feel up a creek without a paddle.

Therapeutic Presence

What they need more of is the yin of therapeutic voice, therapeutic presence — the capacity to be receptive, mindfully attentive, emotionally available, nonjudgmental and resonant with the client’s unfolding experience (1). Freud originated this concept in his earliest recommendation for practicing therapists in 1912, underscoring the vital importance of “evenly hovering attention.” Like a koan, the therapist should “simply listen and not bother about whether he is keeping anything in mind.”

Considered the foundation for tuning in to the patient’s unconscious, it provided a potent tool for opening one’s mind and heart to new possibilities for understanding and engaging the patient’s psyche. Like the Zen Buddhist notion of “beginner’s mind,” or mindfulness itself, therapeutic presence comes from the framework of “not knowing” in the service of creativity. To paraphrase the Nobel prize-winning poet Wislawa Szymborska, the point — like the poet’s main task — is to say I don’t know and keep on going. It’s to wonder aloud!

Therapeutically present therapists are understanding, open-minded, and comfortable with a range of different feelings and perspectives.These therapists have internalized Robert Frost’s prescient quip, “No surprise for the writer. No surprise for the reader!” Patients feel a sense of safety, trust, and warmth in their company. The space seems to open with them. This disarming quality makes it easy for patients to explore new subplots and turns in their stories. They find themselves surprised at how much they are saying and learning in just the telling itself.

Therapists who practice this kind of presence don’t have to know immediately and aren’t bothered by the ambiguity or complexity of what they are hearing; they “dwell in possibility,” as Emily Dickinson said, a “fairer house than prose.” They allow patients to be in the driver’s seat so that they can show them the territory first, and in so doing, instruct their therapist how to best be of service. This openness allows patients to take more risks in therapy, to deepen the exploration of their thoughts and feelings, and to get to genuinely enjoy the deeper waters of the psyche, even providing modeling for them to be more open to the various and contradictory sides of themselves! In short, to paraphrase Whitman, they are reminded that, “We are large. We contain multitudes!”

Owning A Voice

Plopping down in my office chair, and letting out a formidable sigh, another supervisee recently lamented: “Sometimes I feel like I’m taking it all in but then can’t get a word in edgewise, and I’m not even sure if what I’m thinking even makes sense. Am I really helping them at all, or are my own mixed-up feelings just getting in the way of making any headway?”

I know many fantastic supervisees who excel at being empathic, reflective, and thoughtful with their patients, but lack the confidence to make discriminating interpretations that take into account their valuable instincts and intuition regarding new creative possibilities.

These supervisees, understandably, worry that if they use too much of their authority, they will overwhelm or possibly hurt their clients.

They need more of the yang of the voice of therapeutic authority — which I define as the command of theory and technique and a discriminating awareness of how to put these into practice. It is the confidence to properly select, apply, time, and adjust one’s interventions in a multicultural and relationally sensitive manner (by relying on the yin of therapeutic presence, of course!).

The clinician with therapeutic authority is happy to show patients how to blaze a new trail and empower them to sort through the various aspects of their experience to find bigger patterns and new possibilities. Like an artist mentoring a new student, they can see the bigger and smaller picture and can help with the difficult passages encountered in putting new skills and pieces together. Most importantly, the therapist with a balanced dose of therapeutic authority knows how to do this with proper timing, tact and empathy. They are not going to break patients down like a military drill sergeant, but instead are going to be thoughtfully discriminating and penetrate deeper into problems and their implied solutions.

Supervisory Support

It is vital for supervisors to support beginning clinicians in developing their clinical intuition and instincts, the confident application of their theoretical and empirical knowledge, and a sense for having the “authority” to make therapeutic moves. Just as a singer needs to take risks with trying out new ways to expand their interpretation of a song, so too does the beginning clinician, and as supervisors, we are right behind them to encourage it!

Supervisors also need to model how to both be comfortable with and to chase the kind of not-knowing that makes creative therapeutic work possible. Like Yoda to Luke Skywalker, we help emerging clinicians to learn how to use “The Force,” showing them that, paradoxically, it is only by surrendering and letting go that we truly open the space for something new to emerge.

Just like our young poet needed Rilke to learn how to become an artist (and Rilke in turn was mentored by the great sculptor Auguste Rodin), so too do our beginning clinicians need us to illustrate how they can be balanced and integrated in their own unique therapeutic voice by uniting these two crucial faculties. And it turns out that all of us, no matter what level we are at, need to remember that we are always cultivating and expressing this artistry!

Empirically Supported Artistry

Art never needs more than its own justification, but as a scientist practitioner, you might need to be reminded of the scientific support for viewing therapy as an artistic enterprise. Look no further than Neuroscientist Antonio Damasio’s recent book, The Strange Order of Things, which eloquently showcases the way in which our “right-brained” feeling comes first, inspiring and motivating our greatest cultural innovations and products, and that joined together with the logic and language of our left-brains, becomes something truly extraordinary. Daniel Pink in In a Whole New Mind illustrates the 21st century’s cultural sea change from a left-brained leaning computer age, to a right-brained leaning conceptual age that integrates right and left to make the best of both worlds.

In my model, therapeutic presence is the right-brain dominant aspect of our therapeutic artistry, and therapeutic authority is the left-brain pilot, so to speak. Therapeutic presence is at once dreamlike and free-associative, holistic and big-picture, image and metaphor centered, and largely implicit and nonverbal. It undergirds the profound empathic connection between us and our patients, especially to those sides of our clients that have experienced trauma and yet still long for—even in secret — a more redemptive narrative.

Therapeutic authority flows from the language and logic-based sides of our brain with its highly developed executive functioning. More largely conscious and deliberate, this side enables us to zero in and edit the many clinical possibilities before us so that we can work with true specificity and discernment, tailoring our treatment for the unique person sitting across from us, and getting to the heart of the matter.

A 19th century poem by Frances Cornford sums up this lovely process best. Entitled “The Guitarist Tunes Up”, we learn that this musician leans into their instrument with ‘attentive courtesy’:

Not as a lordly conqueror who could

Command both wire and wood,

But as a man with a loved woman might,

Inquiring with delight

What slight essential things she had to say

Before they started, he and she, to play.

For a visual of this interplay, we can look to none other than that famous Renaissance man — Da Vinci and his iconic drawing of his Vitruvian Man. It is only by integrating the square of our logic with the circle of our feeling do we become something truly divine — artists in our own right.

Learning & Teaching from Art

If we are to find and develop a therapeutic voice, we must first look at how therapy itself connects to the arts and how, as supervisors and supervisees, we can attend to these important dimensions. We’ll look specifically to poetry and music as starting points.

Poetry Lessons

A poem, such as a sonnet, compresses a question or problem, its exploration, and a final statement of some revelation or new understanding into 14 lines. In Shakespeare’s famous sonnet, “Shall I compare thee to a summer’s day?” the speaker wrestles back and forth with how his love is and is not like summer. Initially, it seems very fitting to compare her to the beauty and splendor of the season, but upon further inspection, new ideas emerge. Among other things, she is much more constant, evenly tempered, reliable, and more lovely than the summer months.

Much like Shakespeare’s speaker, we wrestle with our initial diagnostic impressions of our patients: Shall I compare thee to a borderline personality, a depressive, or an adjustment disorder? It is not immediately clear, and so many of our first sessions entail testing out various hypotheses to determine who the patient is and is not.

As Shakespeare’s poem continues, surprises and new discoveries emerge and toward the final turn of the poem, the poet concludes that his love will be eternal as a result of the poetic act itself: “So long as men can breathe or eyes can see/so long lives this, and this gives life to thee.” This is the aim of a transformative therapeutic process. Much like a sonnet, by the end of the therapeutic experience, a patient will be able to make a few “turns” and come to a way of internalizing the therapeutic process so that it too will become eternal.

Music Lessons

Beethoven’s fifth symphony provides an immediately recognizable compressed musical idea. In only four notes, a focal theme is established that is explored, varied, and reharmonized much in the same way that occurs in therapy. The capacity of the therapist to articulate that melody — the dominant trend or relational pattern that pulls the various strands of a patient’s story together —goes very far in clarifying what has been troubling patients while it points them in the direction of how they can move forward. Much of the time, patients are playing the notes of their issues but are not aware of the melody and cannot synthesize it into a focal theme. They bring us their own invisible scores and hope we will give them feedback to recognize their own music.

About seven and a half minutes into the third movement of Rachmaninov’s Symphony in E minor, we hear the main theme played by the French horn, in the manner that a patient initially expresses when it is recognized by the counselor: “You hear me! This is the song I didn’t know I was singing.” Shortly after, the theme gets played by the violin with a melancholy poignancy: “I have been waiting a long time suffering with this alone.” This is the sense of sadness and mourning that the patient feels for having had to sequester this aspect of self in the service of protection and adaptation.

As the theme gets worked upon and elaborated, new instruments, such as the oboe and flute, come in to take on the line, with hope gathering. Calmer and with greater poise, a certain pride and expressiveness opens now that this very significant idea can be incorporated into the larger musical narrative of the patient’s story.

Let’s see how this artistry translates to a representative case and get a preview of putting all the pieces together.

A Case of You

I’ve named this “A Case of You” as a nod to Joni Mitchell’s heartbreakingly beautiful song because this patient seemed at first blush like she was too much to handle. Pretty quickly into our first session, I realized that, like for so many of our cases, the following lyrics truly applied:

“You’re in my blood, you’re my holy wine, you’re so bitter and so sweet, oh I could drink a case of you, and I’d still be on my feet!”

A student came to her intake appointment complaining that her friends did not understand her, that she couldn’t fathom why they were so turned off by the razor blade that she kept on her desk as a reminder that she could cut herself, and that she had been told to come to counseling many times, but it had never been helpful in the past. She asked, why should she bother now?

Previous counselors told her that she needed a higher level of care than they could provide, and those appointments left the student feeling misunderstood and blamed for troubles she could not fathom. She also felt a sense of hopelessness at not being able to make true contact, just as she had not with family and friends. Aiming right for the jugular, she also scoffed at me: “Counselors are incompetent and don’t really understand me. You probably won’t either!”

In addition to feeling interpersonally rejected on several fronts, as a first-generation college student, she experienced the pressure of well-meaning parents who hoped to see the family’s metaphorical stock rise with her success. At the same time, her family expected her to be at the ready when they called her to take care of her younger siblings. She was a painter who loved the darkest colors of her palette, with her works centering on Hopperesque misfits wandering in the night.

Initially, her cutting was a regular strategy to express and modulate her emotions, combined with a preoccupation with death, and the ways in which friends and other therapists had been repelled by her behavior made me wonder whether this student had borderline personality disorder. Like in Shakespeare’s poem, though, I was not sure whether this comparison truly fit.

Here we see the internal wrestling of therapeutic authority and presence. The first stab at therapeutic authority can have us all too quickly categorize or even pathologize what we are seeing before we get the full story. At the same time, this discriminating faculty provides crucial information that we really need to follow. Like a samurai warrior, psychologically speaking we need to forge the sword and learn how to use it appropriately. Toggling back and forth between this function and therapeutic presence — the open and receptive Buddha nature — allows us to see the big picture clearly while also focusing keenly on the supporting details that we need to assess and intervene incisively.

As I got to know more about the patient’s relational backdrop and leaned into my therapeutic presence, things looked a bit different. I learned about her parents’ difficulty tolerating fear, anger, and sadness, and their own struggles with managing chronically high levels of stress. I also learned about my client’s repeated experiences of the family being unable to acknowledge or stay with her emotional experience.

Just as the subject of the Shakespearian poem was no longer so much like the summer, it seemed more and more that she was no longer like a patient with a borderline organization and instead more like one with a neurotic organization or a possible adjustment disorder. She appeared to be in a conflict that could not be acknowledged squarely as she was in the midst of an important developmental transition, both issues coloring each other and placing her in an ever-tightening Gordian knot.

By trusting my therapeutic authority, a focal theme emerged. When this patient expressed negative emotions, people could not tolerate them and emotionally and physically abandoned her. This pattern was consistent with her emerging friendships — others were not interested in hanging out with her despite her charm and intelligence — and extended to her early family experience, in which her parents subjected her to the silent treatment for days whenever her emotions ran too hot. Taken together, the patient internalized a message that her emotions were problematic and disruptive and that they must be put aside and suppressed. In other words, they became “not-me” and funneled into the dissociative symptom of cutting.

Until I was able to home in on a focal theme, I, like the therapists before me, was part of the problem, imagining in my countertransference that it was the patient who had the major issue. Internally, I underestimated how much my feelings were part of an enactment, containing only a small piece of the story. Initially, I was bracing myself for difficult work, assuming that the student had a great deal of pathology and would make little movement. In a way, I was reenacting the dynamic of the student’s relational backdrop, finding her issues disruptive to my sense of authority just like her parents and her prior therapists had — “it is not me, it is her.” By maintaining a therapeutically present stance, I was able to observe this crucial dynamic and incorporate it into a new understanding and relationship with the client.

Therapeutic authority led me to a focal theme that helped me see that it was totally understandable for her to shy away from sharing her intense feelings and need to hide and express them in her not-so-secret ritual of cutting. She was protecting both myself and herself from “not-me” and letting the world know, with what seemed to be twisted pride, that cutting was her right and a very valuable part of her emotional life. Looking back on that detail now, it was very prescient in the way it encapsulated her attempt to express and independently resolve her bind.

Reading and Tracking Changes

Guided by a mindful application of therapeutic presence and a discriminating use of therapeutic authority, the student went through the kind of musical sequence referenced above. Initially, having a therapist who was able to respect and receive the fullness of her experience without mistreating or abandoning her by becoming critical or explosive or falling apart was a tremendous step toward a new relational experience. The recognition that her focal theme was understandable and heard enabled her to begin to speak of it without the kind of shame and dissociation that often accompanies a “not-me” experience. It also enabled her to begin to trust and hope again.

She became inwardly and outwardly relaxed so that she could begin to examine the many facets of her current and past experience and thus begin the riffing that is essential to the jazz improvisation that is therapy. In short, she began to find and develop her own voice as a patient!

The patient could view her behaviors as more comprehensible and expressive of the hidden conflicts she had been harboring and that had been left unformulated and disconnected. This expanding sense of self-compassion became an important antidote to her cutting behavior and provided an alternative avenue for exploring and containing her emotional experience. Interpersonally, she became less defensive and fearful of others abandoning her, having had a transformative set of experiences in which she felt the consistent presence of a reliable other. She began to show her pain not only in her words but in the artwork, she did as a painter.

When a poetic turn or musical theme has been established, shifts can immediately be seen in the patient and felt in the relationship. These can occur simply in the change of posture (often, a straightening of the back and sitting up in one’s chair), a richer tone of voice, a feeling of newfound connection and space in the therapeutic relationship, or in the spontaneity and flow of narrative or images that emerge in the therapeutic interplay

In the first session, trust was developed as the student began to see me as a figure who could understand and appreciate the depth of her pain and recognize the myriad ways in which she had been misjudged and pigeonholed by her family, friends and, most notably, other therapists. We also developed a focal theme centering on how this rejection led her to suppress and negate her important and precious feelings. Taken together, I believe that these turns led to decreased scores in hostility and emotional distress, each indicative of the fact that she was feeling more trusting, less defensive, and relieved at being able to begin to experience her emotions more directly.

These scores continued to remain significantly lower than baseline for the next few sessions, whereupon we worked on developing ways of shifting patterns in her relationships with friends and family. At around session five, the student’s depression scores started to decrease as she began to feel greater self-efficacy and agency in being able to affect change in her life inside and outside of the therapy space. Simultaneously, her levels of anxiety followed suit as they made a statistically significant drop from baseline in our final session of the semester. Our work together concretized the notion of making a more poetic and musical line in our therapeutic work, and the importance of drawing on artistic metaphors to inform treatment and expand both the therapist’s and the patient’s voice in that process.

A New Slant on Working Dynamically

We are very accustomed as clinicians to thinking vertically, troubling ourselves over quick diagnoses and assessments, especially given the limited time we often have. At some points, this may take away from focusing horizontally on the musical line and the movement of the intervention. In music, in order to play or sing a melody successfully, one needs to be as attentive to the horizontal motion of the notes carrying a melodic line forward as to the vertical axis of hitting the note itself.

In clinical practice, one can analogize the horizontal forward motion to the momentum of an intervention, the movement toward a new relational experience. The vertical playing of the note is the clinical equivalent of ensuring you understand the patient’s experience correctly and getting a proper diagnostic read. This horizontal motion is informed by therapeutic presence just as, conversely, the vertical movement is guided by therapeutic authority. Both are essential, and they need to be worked in concert to turn notes into music.

This musical way of approaching relational work helps us to be more efficient, fluid, and creative, focusing simultaneously on how to skillfully assess and intervene in our fast-paced culture. Moreover, it enables us to carry the themes of the patient’s past into new orchestrations and harmonizations in the present, providing a model for continued transformative possibilities in the future. Through this process, patients internalize working creatively with their own themes and then take us into new melodic and harmonic territory, stimulating further treatment progress and development. Taken together, this fosters a positive feedback loop in the creative matrix between patient and therapist, and from this synergy, transformative changes quickly follow. This is precisely what a well-tuned therapeutic voice does for the clinician and their client.

References

Cornfeld, F. D. (1965). Collected poems. Cresset Press.

Questions for Thought and Discussion

Who inspired you to find your voice?

What are some of the unique attributes of your therapeutic voice?

Which of your clients helped you to find your therapeutic voice?

In what ways do you compare psychotherapy to an art?

Working with Teens: The Good, the Bad and the Ugly

“I never set out to work with teens.” For many years after I started my private practice, people would ask, “what is your specialty?” and I would demure. I thought it was pretentious to say I’m a “specialist.” I didn’t feel like a “specialist.” I also thought it would be boring if I specialized. I wanted to mix it up (a little ADHD?). But I soon found myself gravitating to adolescents and young adults, and them to me. Given my years of training in family therapy, it started to feel natural that I would work with this population, those not-quite-children but not-quite-adult people who most therapists feared. And then I had two teen girls of my own; one now 20. What better breeding ground for insight could there be, I thought. Boy, or should I say girl, was I wrong!

Girls Will Be Girls

A therapist can no more easily treat herself and her family than a doctor can heal herself. As far as I can tell, my own family problems stem back generations. Mark Wolynn’s recent book called, It Didn’t Start with You: How Inherited Family Trauma Shapes Who We Are and How to End the Cycle lends some credence to this assertion. Jewish-check, anxiety-check, narcissism-check, mental illness-check. And the list goes on!

“I sought to correct all that with my girls. Clearly, I overreached.” Not only did it not help to hold myself to exacting, unrealistic and perfectionistic standards; it was in fact, impossible. Fast forward to last weekend, my girls now 20 and 17, fistfighting (I kid you not) over a sweatshirt.

My sense of failure runs deep but I am thankful that I was blessed with pure luck with these two. My insights are largely useless. My husband, however, excels at mediation (he’s a lawyer after all), and he has filled in the missing pieces on numerous occasions. We make a good team. Nevertheless, my girls have taught me a number of key things:

1. Each kid is different.
2. They teach you.
3. The “0-60” phenomenon of the teen brain is alive and well.
4. Use humor.
5. Be strong. If you are emotionally weak, they will have no one to push against, leading to a failure to launch.
6. No matter the age and stage, be patient. As soon as you master it, it changes.

Mary and her Parents

There are some cases that make me feel like a complete idiot. Take the case of Mary. She never wanted to be there. My first tenet of teen therapy is that they have to own it. It’s their life. If I am doing all the work, something is wrong. It took me a long time to realize this one. It’s great to get them when they’re young enough to change but old enough to understand, which I’d put at 17– a beautiful age! Raring to go to college yet clinging at will to parents, kids this age are a pleasure to help. Change comes fast and furiously and if you’re lucky you’ll get hugs in there too! They go off bolstered by the therapy, and they don’t come back. On the other hand, if they are there against their will it’s a different story. We know this. No therapy is going to work by force.

Mary had a history of acting out and strict, somewhat eccentric parents who did not understand her difficulties (see “Far from the Tree” by Andrew Solomon). With this mismatch, things got off to a miserable start. She was returning from a multi-thousand-dollar wilderness program of questionable long-term repute. “Please fix her from here,” her parents dumped on me. And so I did, sort of. She continued awful acting out, rages, mood-swings, and long before I knew it there was a team of professionals all over the case. No problem. We continued to integrate her back to home. But the back-to-family part never happened. You see, the parents were the problem. This is hardly uncommon. Now they were avoiding me. They were done. I tried to explain to no avail that their participation would be key. More avoidance. So, we continued weekly until the girl simply said “this entire enterprise is futile. I give up.” What a sad case indeed when parents induce helplessness in their teens. Where will all her energy go, I wondered sadly. The case had fizzled out before my eyes. After questioning my abilities, I concluded that this was case was doomed from the start. Her only channel was anger and that wasn’t a channel I was on. Thankfully there was group therapy to warm the soul and I gladly referred her to the care of another clinician.

Group Therapy with Teens

Witness however, Cecilia. Her case was the best! Coming from a childhood of unspeakable trauma, she was rescued by a relative and set on another course. When she came to group therapy, she was literally an outcast from school, home and family. The group embraced her. She lit up each week. In my group there are no restrictions except on gossiping and phone use. I actually pretend that I am the most casual and chill person on earth so that they talk as freely as possible. It’s like when you’re driving your kids to the mall and they’re in the back seat, with no eye contact, finally telling you the most important thing they ever shared. That is my posture in the group. The more I lay back, the more they seem to talk. These kids have no other avenue to ask questions about sex, drugs, birth control, family, siblings, mental illness, physical issues, sexism, racism and relationships. They even accept academic support from me. I become like a big sister in the group, and it works. Cecilia grew to become her class president. She vented for a solid two years about her childhood. She was made to feel normal. She heard from other kids of all backgrounds. They all became “normal” together- normalized by the group process. Who doesn’t have a crazy mother/father/sibling/uncle/friend/teacher? My god, they were normal! Just the celebration of that became the group creed. We welcomed newcomers with near joy. Parents waiting outside would never have believed it. Their angst-filled, moody, belligerent offspring had finally shed their shells. I almost never told anyone my secret. Do you want to know the secret to teen group therapy? Pretend you’re not there, do not wince at disgusting revelations about sex, and by all means allow cursing of all stripes and colors.

As the “core group” began to solidify I worried if I was being effective and compulsively tried to “deepen” the conversation. As I began to relax, they were able to tell me that they liked the group just the way it was. Just talking, venting, sharing and taking turns. It soon became clear that my need to control and get it right and my own insecurities still plaguing me after all these years of experience were beside the point. The group had sustained itself. Nevertheless, the interventions I made aimed to reinforce the shared group values and purpose, the universal nature of the teenager experience and the shepherding of the inner self to the surface despite fear. I also increasingly pushed the more reticent members to link up their past with their present, thus gaining insight for the first time. Finally, I was “motherly” in that I could see from where I sat that life would ultimately deal them their share of traumas, yet I knew they could withstand it by holding that space for them, quieting down my own thoughts. By testing their judgment or lack thereof with their peers, they gained the self-knowledge to withstand pain rather than avoid it.

Teens and Divorce

Parents have often asked me what the best/worst age for a child to be at the time of divorce. There are many answers to this. First off, it depends not only on the age at divorce but rather on how the parents handle the divorce that really matters. Second, all ages suck, period, end of story. But divorce in the teen years royally sucks. Social/emotional development is significantly impacted. What the research says is not pretty: not only does the effect of divorce on teens have a huge impact for years, but also, it lasts forever and ever. The researcher Judith Wallerstein has asserted that unlike a parent’s death which has a beginning, middle and end, divorce just goes on and on. Once again, the teen brain, volatile as it is, is not prepared and will surely rebound with rage, defiance, profound risk behavior, testing limits and all the things you tried as a teen but on steroids (social media strikes again). So, buckle your seatbelts on this one and seek help early and often.

“One of my teen clients of divorce casually sent a nude photo to a boy in 10th grade”. The next day, it traveled around the school with the speed of rumor and she found herself in the hospital dealing with a new diagnosis- humiliation. With one parent working round the clock and the other nowhere to be found, she did what anyone in that situation would do, she went underground. The numbing, cutting and sheer embarrassment got worse. She started cutting school too. Each setback snowballed mercilessly. We had to get her back to herself. The therapy consisted of gradually starting her activities again, putting it behind her and structured-only phone use. To this day, she calls me every year on my birthday and says, “if it wasn’t for you, I’d be dead.” She is now a successful hairdresser hoping to open her very own shop. Her parents’ divorce was the hardest step from teen to adult, but she got by because she persisted, used her strengths and had a passion.

Older teens feel lost, insecure and socially stigmatized after divorce. The post-divorce financial uncertainty adds to the overall stress. College plans can change. One divorce created a situation with the parents telling their twins in my office, “surprise, we can no longer pay…” Plus, shuttling between two homes can be disorienting, to say the least (or in the case of my own parents’ divorce, jetting between two coasts). Parents often dwell on how and when to tell their children that they are getting divorced, rather than the aftermath. Just like birth plans, divorce plans go awry. Better to sort it out for the long-haul than have it scripted in the short.

I try to help the teens in therapy by “joining” with their rage. Damn straight your parents suck. They are the ones who should be here! Once I do that, and establish trust, rapport and confidentiality, it is easy to win their hearts and minds. I provide gentle support and strategies for coping and self-care while reminding parents that part of the confusion is normal teen angst. If parents make the common error of ascribing all behavior to the divorce, then guilt steps in and over-compensates in many forms including the of throwing money at the child, which rarely helps.

More times than not, my job is to mitigate confusion. You cannot believe what’s in these kids’ heads. For younger kids, they go right to the most concrete –will my room be pink at Mom’s house still? Can I have two stuffed animals-one for each house? If my parents separate, will I ever see dad again? Are my grandparents still going to be my grandparents? For teenagers and young adults, it can be far more morose, as it was for me with my own parents’ divorce. “Why why why?” is one refrain. The other is a lurking sense of doom some might call dysthymia. As soon as I labeled that for myself as an adult, I started to get help, including antidepressants. The clinicians’ definition of the word would be a “low-grade depression.” I call it, the lowering of expectations, always second-guessing myself. Demystifying the wild ideas kids and teens formulate goes a long way toward alleviating crippling anxiety and dread. It’s hard enough to grow up without constant stress in this world, let alone have your parents fighting all the time. One family was fighting so badly about the kids’ shoes at each house that I offered to go to Payless and buy them a second set of sneakers.

I now run a successful teen support group for kids between the ages of 13-19. I remember how my losses haunted me at that stage, but I never had the words to feel and let go–I was constantly grasping for meaning or truth that didn’t exist. I tortured myself to figure something out about my family. But all that I got in return were meaningless intellectual insights that couldn’t sustain me. Nevertheless, I did rebound. I got many degrees and certificates, had scores of talented friends and married the love of my life. Economic times have since hit us hard, but our fortitude is paramount. “I model this resilience to my patients through gentle wit, disclosing when necessary that I “get it.”” Then reminding them there is no one path; there is no perfect; there is only you, open to the ups and downs, or as my yoga teacher would say, “meeting each moment as a friend.”

It All Adds Up

A perfect case to illustrate when all cylinders are firing in teen therapy is Megan. This teen came in with what I call the “break up story.” Megan, like many other girls with whom I have worked, was a ruminator. So, the task is how to utilize all the teen’s strengths just to make it to another day. Why? The phone (you didn’t think I would forget the social media part, did you?). Because I was an “early adopter” of the internet age and even worked in the field of online production and community building in its heyday, I have always taken a favorable view of technology. That said, if my daughter doesn’t unwrap her phone from her head soon I’m going to throw it into the Hudson River. It is her permanent appendage. There is no doubt in my mind that she would benefit from a screen break. But instead of being that mom who limited screen time, I was actually the mom who was the first on the block to get the kids a phone. That did not make me popular among the neighborhood parents. I prefer to know where they are. On the other hand, I have friends who have their adult kids on “find my friends” which would literally put me in a full-time state of panic. There must be balance.

Megan started cutting in 9th grade because she already had a family history of poor emotional regulation combined with an awkward style and no real avenues for getting her feelings straight. Her father was absent and alcoholic. Her mother was a determined and high functioning administrator who was always on the brink of a breakdown, and who could blame her? Therefore, Megan was accustomed to caretaking not care-receiving, which she desperately needed. In therapy, she was able to use her intellect and motivation for good. I encouraged her to think of things in a less catastrophic/dramatic, black and white and exaggerated way. “My boyfriend friended his ex on Twitter” she would say. “So what!” I would chime. “I’m stalking him. I see he’s online at 3am. I saw him with her. She liked his status.” It goes on. Yes, this goes to his character of questionable trustworthiness. But does it REALLY matter? Growing up in the 70’s and 80’s has made me a bit cynical to what real love is (memories of Kramer versus Kramer dance through my brain). I try to get them from point A- everything matters, to point B- nothing matters. “The therapeutic technique most attuned to this might be called Freud-light”. What is getting in your way of allowing this process to work? What is coming up as a trigger/resistance? What can we work through/process/vent/feel/release/analyze or simply let go of to move forward? Nevertheless, the point is the phone doesn’t matter! What matters is can he be at the right place at the right time, can he talk and communicate, can you be friends first and foremost, do you even know him, can he get off his phone…? Megan started putting herself first. She got into the college of her choice. A big girl with body-image issues, she bought herself the shiniest red prom dress I have ever seen and danced right through to morning!

What’s my Theory?

Lest you think that I’m just flying by the seat of my pants, there is plenty of theory to support my approaches. I rely on several methods and philosophies, yet I’m not married to one. I lean toward mind/body (Van Der Kolk, Levine), existential, person-centered (Rogers) and family systems (Haley, Minuchin, Bowen), and group (Yalom.) Much of my work is based on the idea that anyone can relieve anxiety by allowing it to flow through you. Just like going to the gym, anxiety is a habit of mind that if practiced will be reinforced. It’s the faulty circuit of fight or flight. It’s the mammalian brain. The goal (CBT and DBT) is to allow yourself to practice a better way of coping. A way with ease and equanimity; a way with kindness and support. A middle way, a way that allows you to press the pause button while you cool off. Getting flooded by one’s emotions is useless, so learning CBT (“I’m a mess and everything is a mess” to “I made a mistake; humans make mistakes and learn from them” makes good sense.” With DBT, “let me calm down for a second–getting worked up is totally unproductive. I’m just going to breathe and let it pass,” you will most likely get results. What I have not done more of until recent years is appreciate the role of trauma in that it can completely derail or retard the above process to the point of paralysis.

Lessons Learned

Therapists may turn away from working with teens because of their volatility and the resultant risks involved in their care. They flake out of appointments, come late, walk out, don’t return calls, and show up high and hungover. Their parents are often difficult, defensive and in denial. Sessions have to be coordinated with who can drive when, a logistical nightmare from volleyball to work to therapy and back all after a parent has put in a full day’s work. In short, it’s a pain in the butt. Nevertheless, teens are fast learners, quick to laugh out loud, they can cry their hearts out one week and the next week show up like nothing happened. They leave you with all the debris while they move on. My kids started doing this in daycare. Sobbing when I left, then an hour later, having the time of their lives. You simply can’t take it all personally. This takes a concentrated effort on the part of you, the therapist and mom, to feel as deeply and sensitively as they do, and then drop the whole damn thing. Only time can teach you that.

What it has taken me my whole adult life to learn is that there is no absolute answer. There is no one truth. There is no lasting stability. There is only you, open to the shattering of reality, embracing the change; knowing that change is the only constant. My history of loss/resilience/loss makes my therapy genuine. My genuine interest in teens, my blessed gifts from my parents, and my profound belief in being curious is what helps the therapy. It’s the turbulence, the roller-coaster, the deep pain and sorrow, and even the helpless confusion that instructs me how to remain flexible, less anxious, more prepared and physically more resilient (Yoga!). I still crave stability, but I have learned to create it for myself both inside and outside of the therapy office.

Becoming Myself: A Psychiatrist’s Memoir

Editor's Note: The following is excerpted from Becoming Myself: A Psychiatrist's Memoir by Irvin Yalom. Published by Basic Books © 2017. Reprinted by permission of the publisher.


Chapter One, The Birth of Empathy


I awake from my dream at 3 a.m., weeping into my pillow. Moving quietly, so as not to disturb Marilyn, I slip out of bed and into the bathroom, dry my eyes, and follow the directions I have given to my patients for fifty years: close your eyes, replay your dream in your mind, and write down what you have seen.

I am about ten, perhaps eleven. I am biking down a long hill only a short distance from home. I see a girl named Alice sitting on her front porch. She seems a bit older than me and is attractive even though her face is covered with red spots. I call out to her as I bike by, “Hello, Measles.”

Suddenly a man, exceedingly large and frightening, stands in front of my bicycle and brings me to a stop by grabbing my handlebars. Somehow I know that this is Alice’s father.

He calls out to me: “Hey, you, whatever your name is. Think for a minute—if you can think—and answer this question. Think about what you just said to my daughter and tell me one thing: How did that make Alice feel?”

I am too terrified to answer.

“Cummon, answer me. You’re Bloomingdale’s kid [My father’s grocery store was named Bloomingdale Market and many customers thought our name was Bloomingdale] and I bet you’re a smart Jew. So go ahead, guess what Alice feels when you say that.”

I tremble. I am speechless with fear.

“All right, all right. Calm down. I’ll make it simple. Just tell me this: Do your words to Alice make her feel good about herself or bad about herself?”

All I can do is mumble, “I dunno.”

“Can’t think straight, eh? Well, I’m gonna help you think. Suppose I looked at you and picked some bad feature about you and comment on it every time I see you?” He peers at me very closely. “A little snot in your nose, eh? How about ‘snotty’? Your left ear is bigger than your right. Supposed I say, ‘Hey, “fat ear”’ every time I see you? Or how about ‘Jew Boy’? Yeah, how about that? How would you like that?”

I realize in the dream that this is not the first time I have biked by this house, that I’ve been doing this same thing day after day, riding by and calling out to Alice with the same words, trying to initiate a conversation, trying to make friends. And each time I shouted, “Hey, Measles,” I was hurting her, insulting her. I am horrified—at the harm I’ve done, all these times, and at the fact that I could’ve been so blind to it.

When her father finishes with me, Alice walks down the porch stairs and says in a soft voice, “Do you want to come up and play?” She glances at her father. He nods.

“I feel so awful,” I answer. “I feel ashamed, so ashamed. I can’t, I can’t, I can’t . . . ”


Since early adolescence, I’ve always read myself to sleep, and for the past two weeks I have been reading a book called Our Better Angels by Steven Pinker. Tonight, before the dream, I had read a chapter on the rise of empathy during the Enlightenment, and how the rise of the novel, particularly British epistolary novels like Clarissa and Pamela, may have played a role in decreasing violence and cruelty by helping us to experience the world from another’s viewpoint. I turned out the lights about midnight, and a few hours later I awoke from my nightmare about Alice.

After calming myself, I return to bed, but lie awake for a long time thinking how remarkable it was that this primeval abscess, this sealed pocket of guilt now seventy-three years old, has suddenly burst. In my waking life, I recall now, I had indeed bicycled past Alice’s house as a twelve-year-old, calling out “Hey, Measles,” in some brutish, painfully unempathic effort to get her attention. Her father had never confronted me, but as I lie here in bed at age eighty-five, recovering from this nightmare, I can imagine how it must have felt to her, and the damage I might have done. Forgive me, Alice.

***

Chapter Three, I want Her Gone

I have a patient, Rose, who lately had been talking mostly about her relationship with her adolescent daughter, her only child. Rose was close to giving up on her daughter, who had enthusiasm only for alcohol, sex, and the company of other dissipated teenagers.


In the past Rose had explored her own failings as a mother and wife, her many infidelities, her abandoning the family several years ago for another man and then returning a couple of years later when the affair had run its course. Rose had been a heavy smoker and had developed crippling advanced emphysema, but, even so, she had for the past several years tried hard to atone for her behavior and devoted herself anew to her daughter. Yet nothing worked. I strongly advocated family therapy, but the daughter refused, and now Rose had reached her breaking point: every coughing fit and every visit to her pulmonary doctor reminded her that her days were limited. She wanted only relief: “I want her gone,” she told me. She was counting the days until her daughter would graduate from high school and leave home—for college, a job, anything. She no longer cared which path her daughter would take. Over and again she whispered to herself and to me: “I want her gone.”

I do all I can in my practice to bring families together, to heal rifts between siblings and between children and parents. But I had grown fatigued in my work with Rose and lost all hope for this family. In past sessions I had tried to anticipate her future if she cut her daughter off. Would she not feel guilty and lonely? But that was all to no avail, and now time was running out: I knew that Rose did not have long to live. After referring her daughter to an excellent therapist, I now attended only to Rose and felt entirely on her side. More than once she said, “Three more months till she graduates from high school. And then she is out. I want her gone. I want her gone.” I began to hope she would get her wish.

As I took my bicycle ride later that day, I silently repeated Rose’s words—“I want her gone. I want her gone”—and before long I was thinking of my mother, seeing the world through her eyes, perhaps for the very first time. I imagined her thinking and saying similar words about me. And now that I thought about it, I recalled no maternal dirges when I finally and permanently left home for medical school in Boston. I recalled the farewell scene: my mother on the front step of the house waving goodbye as I drove away in my fully packed Chevrolet, and then, when I vanished from view, stepping inside. I imagine her closing the front door and exhaling deeply. Then, two or three minutes later, she stands erect, smiles broadly, and invites my father to join her in a jubilant “Hava Nagila” dance.

Yes, my mother had good reason to feel relieved when I, at twenty-two, left home for good. I was a disturber of the peace. She never had a positive word for me, and I returned the favor. As I coast down a long hill on my bicycle, my mind drifts back to the night when I was fourteen and my father, then age forty-six, awoke in the night with severe chest pain. In those days, doctors made home visits, and my mother quickly called our family doctor, Dr. Manchester. In the quiet of the night, we three—my father, my mother, and I—waited anxiously for the doctor to arrive. (My sister, Jean, seven years older, had already left home for college.)

Whenever my mother was distraught, she reverted to primitive thinking: if something bad happened, there must be someone to blame. And that someone was me. More than once that evening, as my father writhed with pain, she screamed at me, “You—you killed him!” She let me know that my unruliness, my disrespect, my disruption of the household—all of this—had done him in.

Years later, when on the analytic couch, my description of this event resulted in a rare, momentary outburst of tenderness from Olive Smith, my ultraorthodox psychoanalyst. She clucked her tongue, tsk, tsk, leaned toward me, and said, “How awful. How terrible that must have been for you.” She was a rigid training analyst in a rigid institute that valued interpretation as the singular effective action of the analyst. Of her thoughtful, dense, and carefully worded interpretations, I remember not a one. But her reaching out to me at that time, in that warm manner—that I cherish even now, almost sixty years later.

“You killed him, you killed him.” I can still hear my mother’s shrill voice. I remember cowering, paralyzed with fear and with fury. I wanted to scream back, “He’s not dead! Shut up, you idiot.” She kept wiping my father’s brow and kissing his head as I sat on the floor curled up in a corner until, finally, finally, about 3 a.m., I heard Dr. Manchester’s big Buick crunching the autumn leaves in the street and I flew downstairs, three steps at a time, to open the door. I liked Dr. Manchester very much, and the familiar sight of his large round smiling face dissolved my panic. He put his hand on my head, tousled my hair, reassured my mother, gave my father an injection (probably morphine), held his stethoscope to my father’s chest, and then let me listen as he said, “See, Sonny, it’s ticking away, strong and regular as a clock. Not to worry. He’s going to be all right.”

That night I witnessed my father drawing close to death, felt, as never before, my mother’s volcanic rage, and made a self-protective decision to shut the door on her. I had to get out of this family. For the next two to three years I barely spoke to her—we lived like strangers in the same house. And, most of all, I recall my deep, expansive relief at Dr. Manchester’s entrance into our home. No one had ever given me such a gift. Then and there I decided to be like him. I would be a doctor and pass on to others the comfort he had offered me.

My father gradually recovered, and though he had chest pain thereafter with almost any exertion, even walking a single block, and immediately reached for his nitroglycerin and swallowed a tablet, he lived another twenty-three years. My father was a gentle, generous man whose only fault, I believed, was his lack of courage in standing up to my mother. My relationship with my mother was an open sore all my life, and yet, paradoxically, it is her image that passes through my mind almost every day. I see her face: she is never at peace, never smiling, never happy. She was an intelligent woman, and though she worked hard every day of her life, she was entirely unfulfilled and rarely uttered a pleasant, positive thought. But today, on my bicycle rides, I think about her in a different way: I think of how little pleasure I must have given her while we lived together. I am grateful I became a kinder son in later years.

Creatures of a Day

The following is excerpted from Irvin Yalom's new book, Creatures of a Day: And Other Tales of Psychotherapy, with permission from the author. Available from Amazon.

All of us are creatures of a day; the rememberer and the remembered alike. All is ephemeral—both memory and the object of memory. The time is at hand when you will have forgotten everything; and the time is at hand when all will have forgotten you. Always reflect that soon you will be no one, and nowhere.

—Marcus Aurelius, "The Meditations"

The Crooked Cure

Dr. Yalom, I would like a consultation. I’ve read your novel, When Nietzsche Wept, and wonder if you’d be willing to see a fellow writer with a writing block.

—Paul Andrews

No doubt Paul Andrews sought to pique my interest in his email. And he succeeded: I’d never turn away a fellow writer. As for the writing block, I feel blessed by not having been visited by one of those creatures, and I was keen to help him tackle it. Ten days later Paul arrived for his appointment. I was startled by his appearance. Somehow I had expected a frisky, tormented, middle-aged writer, yet entering my office was a wizened old man, so stooped over that he appeared to be scrutinizing the floor. As he inched slowly through my doorway, I wondered how he had possibly made it to my office at the top of Russian Hill. Almost able to hear his joints creaking, I took his heavy battered briefcase, held his arm and guided him to his chair.

“Thankee, thankee, young man. And how old are you?

“Eighty years old,” I answered.

“Ahhh, to be eighty again.”

“And you? How many years do you have?”

“Eighty-four. Yes, that’s right, eighty-four. I know that startles you. Most folks guess I’m in my thirties.”

I took a good look at him and, for a moment, our gazes locked. I felt charmed by his elfish eyes and the wisp of a smile playing on his lips. As we sat in silence for a few moments looking at one another, I imagined we basked in a glow of elder comradeship, as though we were travelers on a ship who, one cold foggy night, fell into conversation on the deck and discovered we had grown up in the same neighborhood. We instantly knew one another: our parents had suffered through the great depression, we had witnessed those legendary duels between DiMaggio and Ted Williams, and remembered rationing cards for butter and gasoline, and VE day, and Steinbeck’s Grapes of Wrath, and Farrell’s Studs Lonigan. No need to speak of any of this: we shared it all and our bond felt secure. Now it was time to get to work.

“So Paul, if we may use first names—”

He nodded, “Of course.”

“All I know about you comes from your short email. You wrote that you were a fellow writer, you’ve read my Nietzsche novel, and you have a writing block.”

“Yes, and I’m requesting a single consultation. That’s all. I’m on a fixed income and can’t afford more.”

“I’ll do what I can. Let’s start immediately and be as efficient as possible. Tell me what I should know about the block.”

“If it’s all right with you, I’ll give you some personal history.”

“That’s fine.”

“I have to go back to my grad school days. I was in philosophy at Princeton writing my doctorate on the incompatibility between Nietzsche’s ideas on determinism and his espousal of self-transformation. But I couldn’t finish. I kept getting distracted by such things as Nietzsche’s extraordinary correspondence, especially by his letters to his friends and fellow writers like Strindberg. Gradually I lost interest altogether in his philosophy and valued him more as an artist. I came to regard Nietzsche as a poet with the most powerful voice in history, a voice so majestic that it eclipsed his ideas and soon there was nothing for me to do but to switch departments and do my doctorate in literature rather than philosophy. The years went by, my research progressed well, but I simply could not write. Finally I arrived at the position that it was only through art that an artist could be illuminated and I abandoned the dissertation project entirely and decided instead to write a novel on Nietzsche. But the writing block was neither fooled nor deterred by my changing projects. It remained as powerful and unmovable as a granite mountain. No progress was possible. And so it has continued until this very day.”

I was stunned. Paul was eighty-four now. He must have begun working on his dissertation in his mid twenties, sixty years ago. I had heard of professional students before, but sixty years? His life on hold for sixty years? No, I hoped not. It couldn’t be.

“Paul, fill me in about your life since those college days.”

“Not much to tell. Of course the university eventually decided I had stayed overtime, rang the bell and terminated my student status. But books were in my blood and I never strayed far from them. I took a job as a librarian at a state university where I stayed put until retirement trying, unsuccessfully, to write all these years. That’s it. That’s my life. Period.”

“Tell me more. Your family? The people in your life?”

Paul seemed impatient and spat his words out quickly, “No siblings. Married twice. Divorced twice. Mercifully short marriages. No children, thank God.”

This is getting very odd, I thought. So affable at first, Paul now seemed intent on giving me as little information as possible. What’s going on?

I persevered. “Your plan was to write a novel about Nietzsche and your email mentioned that you had read my novel, When Nietzsche Wept. Can you say some more about that?”

“I don’t understand your question.”

“What feelings did you have about my novel?”

“A bit slow going at first, but it gathered steam. Despite the stilted language and the stylized, improbable dialogue, it was, overall, not an unengrossing read.”

“No, no, what I meant was your reaction to that novel appearing while you, yourself, were striving to write a novel about Nietzsche. Some feelings about that must have arisen.”

Paul shook his head as though he did not wish to be bothered with that question. Not knowing what else to do, I continued on.

“Tell me, how did you get to me? Was my novel the reason you selected me for a consultation?”

“Well, whatever the reason, we’re here now.”

Things grow stranger by the minute, I thought. But if I were to offer him a useful consultation, I absolutely had to learn more about him. I turned to ‘old reliable,’ a question that never fails to provide heaps of information: “I need to know more about you, Paul. I believe it would help our work today if you’d take me through, in detail, a typical 24-hour day in your life. Pick a day earlier this week and let’s start with your waking in the morning.” I almost always ask this question in a consultation as it provides invaluable information about so many areas of the patient’s life. Sleep, dreams, eating and work patterns, but most of all I learn how the patient’s life is peopled.

Failing to share my investigative enthusiasm, Paul merely shook his head slightly as though to brush my question away. “There’s something more important for us to discuss. For many years I had a long correspondence with my dissertation director, Professor Claude Mueller. You know his work?”

“Well, I’m familiar with his biography of Nietzsche. It’s quite wonderful.”

“Good. Very good, I’m exceptionally glad you think that,” Paul said, as he reached into his briefcase and extracted a ponderous binder. “Well, I’ve brought that correspondence with me and I’d like you to read it.”

“When? You mean now?”

“Yes, there is nothing more important that we could do in this consultation.”

I looked at my watch. “But we have only this one session and reading this would take an hour or two and it is so much more important that we—”

“Dr. Yalom, trust me, I know what I’m asking. Make a start. Please.”

I was flummoxed. What to do? He is absolutely determined. I’ve reminded him of our time constraints and he is fully aware he has only this one meeting. On the other hand, perhaps Paul knows what he is doing. Perhaps he believes that this correspondence would supply all the information about him that I needed. Yes, yes, the more I think about it the more certain I am: this must be it.

“Paul, I gather you’re saying that this correspondence provides the necessary information about you?”

“If that assumption is necessary for you to read it, then the answer is ‘yes.’”

Most unusual. An intimate dialog is my profession, my home territory. It’s where I am always comfortable and yet in this dialog everything feels askew, out of joint. “Maybe I should stop trying so hard and just go with the flow. After all, it’s his hour. He’s paying for my time.” I felt a bit dizzy but acquiesced and held out my hand to accept the manuscript he proffered.

As Paul passed me the massive three-ring binder, he told me the correspondence extended over forty-five years and ended with Professor Mueller’s death in 2002. I began by flipping the pages to familiarize myself with the project. Much care had gone into this binder. It seemed that Paul had saved, indexed, and dated everything that passed between them, both short casual notes and long discursive letters. Professor Mueller’s letters were neatly typed with his small exquisitely fashioned closing signature, while Paul’s letters—both the early carbon copies and the latter photocopies—ended simply with the letter ‘P.'

Paul nodded toward me, “Please start.”

I read the first several letters and saw that this was a most urbane and engaging correspondence. Though Prof Mueller obviously had great respect for Paul, he chided him for his infatuation with wordplay. In the very first letter he said, “I see that you’re in love with words, Mr. Andrews. You enjoy waltzing with them. But words are just the notes. It’s the ideas that form the melody. It’s the ideas that give our life structure.”

“I plead guilty,” retorted Paul in the ensuing letter. “I don’t ingest and metabolize words, I love to dance with them. I greatly hope to be always guilty of this offense.” A few letters later, despite the roles and the half-century dividing them, they had dropped formal titles of Mister and Professor and used their first names, Paul and Claude.

In another letter, my eye fell on an important statement written by Paul: “I never fail to perplex my companions.” So, I had company. Paul continued, “Hence, I shall always embrace solitude. I know I make the error of assuming that others share my passion for great words. I know I inflict my passions onto them. You can only imagine how all creatures flee and scatter when I approach them.” That sounds important, I thought. ‘Embracing solitude’ is a nice cosmetic touch and puts a poetic spin on it, but I imagine he is a very lonely old man.

And then, a couple of letters later, I had an ‘aha’ moment when I came upon a passage that possibly offered the key to understanding this entire surreal consultation. Paul wrote, “So you see, Claude, what is there left for me but to look for the nimblest and noblest mind I can find. I need a mind likely to appreciate my sensibilities, my love of poetry, a mind incisive and bold enough to join me in dialog? Do any of my words quicken your pulse, Claude? I need a light-footed partner for this dance. Would you do me the honor?”

A thunderclap of understanding burst in my mind. Now I knew why Paul insisted I read the correspondence. It’s so obvious. How had I missed it? Professor Mueller died fifteen years ago and Paul is now trolling for another dance partner! That’s where my novel about Nietzsche comes in! No wonder I was so confused. I thought I was interviewing him whereas, in reality, he was interviewing me. That must be what is going on.

I looked at the ceiling for a moment wondering how to express this clarifying insight when Paul interrupted my reverie by pointing to his watch and remarking, “Please Dr. Yalom, our time passes. Please continue reading.” I followed his wishes. The letters were compelling and I gladly dived back into them.

In the first dozen letters there seemed a clear student-teacher relationship. Claude often suggested assignments, for example, “Paul, I’d like you to write a piece on comparing Nietzsche’ misogyny with Strindberg’s misogyny.” I assumed Paul completed such assignments but saw no further mention of them in the correspondence. They must have discussed his assignments face to face. But gradually, halfway through the year, the teacher-student roles began to dissolve. There was little mention of assignments and, at times, it was difficult to discern who was the teacher and who the pupil. Claude submitted several of his own poems seeking Paul’s commentary and Paul’s responses were anything but deferential as he urged Claude to turn off his intellect and pay attention to his inner rush of feelings. Claude, on the other hand critiqued Paul’s poems for having passion but no intelligible content.

Their relationship grew more intimate and more intense with each exchange of letters. I wondered if I held in my hands the ashes of the great love, perhaps the only love, of Paul’s life. Maybe Paul is suffering from chronic unresolved grief. Yes, yes—certainly that’s it. That’s what he’s trying to tell me by asking me to read these letters to the dead.

As time went on I entertained one hypothesis after another but, in the end, none offered the full explanation I sought. The more I read, the more my questions multiplied. Why had Paul come to see me? He labeled a writing block as his major problem, yet why did he show no interest whatsoever in exploring his writing block? Why did he refuse to give me details of his life? And why this singular insistence that I spend all our time together reading these letters of long ago? We needed to make sense of it. I resolved to broach all these issues with Paul before we parted.

Then I saw an exchange of letters that gave me pause. “Paul, your excessive glorification of sheer experience is veering in a dangerous direction. I must remind you, once again, of Socrates’s admonition that the unexamined life is not worth living.”

‘Good going, Claude!’ I silently rooted. ‘My point exactly. I identify entirely with your pressing Paul to examine his life.’

But Paul retorted sharply in his next letter, “Given the choice between living and examining, I’ll choose living any day. I eschew the malady of explanation and urge you to do likewise. The drive to explain is an epidemic in modern thought and its major carriers are contemporary therapists: every shrink I have ever seen suffers from this malady, and it is addictive and contagious. Explanation is an illusion, a mirage, a construct, a soothing lullaby. Explanation has no existence. Let’s call it by its proper name, a coward’s defense against the white-knuckled, knee-knocking terror of the precariousness, indifference and capriciousness of sheer existence.” I read this passage a second and third time and felt destabilized. My resolve to posit any of the ideas fermenting in my mind wavered. I knew that there was zero chance that Paul would accept my invitation to dance.

Every once in a while I looked up and saw Paul’s eves riveted on me, taking in my every reaction, signaling me to go on reading. But, finally, when I saw there were only ten minutes left, I closed the folder and firmly took charge.

“Paul we’ve little time left and I have several things I want to discuss with you. I’m uncomfortable because we’re coming to the end of our session and I’ve not really addressed the very reason you contacted me – your major complaint, your writing block.”

“I never said that.”

“But in your email to me you said … here, I have it printed out…” I opened my folder but, before I could locate it, Paul responded:

“I know my words: I would like a consultation. I’ve read your novel, When Nietzsche Wept, and wonder if you’d be willing to see a fellow writer with a writing block.

I looked up at him expecting a grin but he was entirely serious. He had said he had a writing block but had not explicitly labeled it as the problem for which he wanted help. It was a word-trap and I fought back irritation at being trifled with. ““I’m accustomed to helping folks with problems. That’s what therapists do. So one can easily see why I made that assumption.””

“I understand entirely.”

“Well then, let’s make a fresh start, ‘tell me, how can I be of help to you?’”

“Your reflections on the correspondence?”

“Can you be more explicit? It would help me frame my comments.”

“Any and every observation would be most helpful to me.”

“All right.” I opened the notebook and flipped through the pages, “As you know, I had time to read only a small portion, but overall I was captivated by it, Paul, and found it brimming with intelligence and erudition at the highest level. I was struck by the shift in roles. At first you were the student and he the teacher. But obviously you were a very special student and within a few months this young student and this renowned professor corresponded as equals. There was no doubt he had the greatest respect for your comments and your judgments. He admired your prose, valued your critique of his work, and I can only imagine that the time and energy he gave to you must have far exceeded what he could possibly have provided the typical student. And, of course, given that the correspondence continued long after your tenure as a student, there is no doubt that you and he were immensely important to one another.”

I looked at Paul. He sat motionless, his eyes filling with tears, eagerly drinking in all that I said, obviously thirsting for yet more. Finally, finally, we had had an encounter. Finally, I had given him something. I could bear witness to an event of extraordinary importance to Paul. I, and I alone, could testify that a great man deemed Paul Andrews to be significant. But the great man had died years ago and Paul had now grown too frail to bear this fact alone. He needed a witness, someone of stature, and I had been selected to fill that role. Yes, I had no doubt of this. This explanation had the aroma of truth.

Now to convey some of these thoughts that would be of value to Paul. As I looked back on all my many insights and at the few minutes remaining to us, I was uncertain where to begin and ultimately decided to start with the most obvious: “Paul, what struck me most strongly about your correspondence was the intensity and the tenderness of the bond between you and Professor Mueller. It struck me as a deep love. His death must have been terrible for you. I wonder if that painful loss still lingers and that is the reason you desired a consultation. What do you think?”

Paul did not answer. Instead he held out his hand for the manuscript and I returned it to him. He opened his briefcase, packed the binder of correspondence away, and zippered it shut.

“Am I right, Paul?”

“I desired a consultation with you because I desired it. And now I’ve had the consultation and I obtained precisely what I wished for. You’ve been helpful, exceedingly helpful. I expected nothing less. Thank you.”

“Before you leave, Paul, one more moment, please. I’ve always found it important to understand what helps. Could you expound for a moment on what you received from me. I believe that some greater clarification of this will serve you well in the future, and might be useful for me and my future clients.”

“Irv, I regret having to leave you with so many riddles but I’m afraid our time is up.” He tottered as he tried to rise. I reached out and grabbed his elbow to steady him. Then he straightened himself, reached to shake my hand and, with an invigorated gait, strode out of my office.


 

The Spinoza Problem: An Excerpt

Prologue

Spinoza has long intrigued me, and for years I’ve wanted to write about this valiant seventeenth-century thinker, so alone in the world—without a family, without a community—who authored books that truly changed the world. He anticipated secularization, the liberal democratic political state, and the rise of natural science, and he paved the way for the Enlightenment. The fact that he was excommunicated by the Jews at the age of twenty-four and censored for the rest of his life by the Christians had always fascinated me, perhaps because of my own iconoclastic proclivities. And this strange sense of kinship with Spinoza was strengthened by the knowledge that Einstein, one of my first heroes, was a Spinozist. When Einstein spoke of God, he spoke of Spinoza’s God—a God entirely equivalent to nature, a God that includes all substance, and a God “that doesn’t play dice with the universe”—by which he means that everything that happens, without exception, follows the orderly laws of nature.

I also believe that Spinoza, like Nietzsche and Schopenhauer, on whose lives and philosophy I have based two earlier novels, wrote much that is highly relevant to my field of psychiatry and psychotherapy—for example, that ideas, thoughts, and feelings are caused by previous experiences, that passions may be studied dispassionately, that understanding leads to transcendence—and I wished to celebrate his contributions through a novel of ideas.

But how to write about a man who lived such a contemplative life marked by so few striking external events? He was extraordinarily private, and he kept his own person invisible in his writing. I had none of the material that ordinarily lends itself to narrative—no family dramas, no love affairs, jealousies, curious anecdotes, feuds, spats, or reunions. He had a large correspondence, but after his death his colleagues followed his instructions and removed almost all personal comments from his letters. No, not much external drama in his life: most scholars regard Spinoza as a placid and gentle soul—some compare his life to that of Christian saints, some even to Jesus.

So I resolved to write a novel about his inner life. That was where my personal expertise might help in telling Spinoza’s story. After all, he was a human being and therefore must have struggled with the same basic human conflicts that troubled me and the many patients I’ve worked with over the decades. He must have had a strong emotional response to being excommunicated, at the age of twenty-four, by the Jewish community in Amsterdam—an irreversible edict that ordered every Jew, including his own family, to shun him forever. No Jew would ever again speak to him, have commerce with him, read his words, or come within fifteen feet of his physical presence. And of course no one lives without an inner life of fantasies, dreams, passions, and a yearning for love. About a fourth of Spinoza’s major work, Ethics, is devoted to “overcoming the bondage of the passions.” As a psychiatrist, I felt convinced that he could not have written this section unless he had experienced a conscious struggle with his own passions.

Yet I was stumped for years because I could not find the story that a novel requires—until a visit to Holland five years ago changed everything. I had come to lecture and, as part of my compensation, requested and was granted a “Spinoza day.” The secretary of the Dutch Spinoza Association and a leading Spinoza philosopher agreed to spend a day with me visiting all the important Spinoza sites—his dwellings, his burial place, and, the main attraction, the Spinoza Museum in Rijnsburg. It was there I had an epiphany.

I entered the Spinoza Museum in Rijnsburg, about a forty-five-minute drive from Amsterdam, with keen anticipation, looking for—what? Perhaps an encounter with the spirit of Spinoza. Perhaps a story. But entering the museum, I was immediately disappointed. I doubted that this small, sparse museum could bring me closer to Spinoza. The only remotely personal items were the 151 volumes of Spinoza’s own library, and I turned immediately to them. My hosts permitted me free access, and I picked up one seventeenth-century book after another, smelling and holding them, thrilled to touch objects that had once been touched by Spinoza’s hands.

But my reverie was soon interrupted by my host: “Of course, Dr. Yalom, his possessions—bed, clothes, shoes, pens and books—were auctioned off after his death to pay funeral expenses. The books were sold and scattered far and wide, but fortunately, the notary made a complete list of those books prior to the auction, and over two hundred years later a Jewish philanthropist reassembled most of the same titles, the same editions from the same years and cities of publication. So we call it Spinoza’s library, but it’s really a replica. His fingers never touched these books.”

I turned away from the library and gazed at the portrait of Spinoza hanging on the wall and soon felt myself melting into those huge, sad, oval, heavy-lidded eyes, almost a mystical experience—a rare thing for me. But then my host said, “You may not know this, but that’s not really Spinoza’s likeness. It’s merely an image from some artist’s imagination, derived from a few lines of written description. If there were drawings of Spinoza made during his lifetime, none have survived.”

Maybe a story about sheer elusiveness, I wondered.

While I was examining the lens-grinding apparatus in the second room—also not his own equipment, the museum placard stated, but equipment similar to it—I heard one of my hosts in the library room mention the Nazis.

I stepped back into the library. “What? The Nazis were here? In this museum?”

“Yes—several months after the blitzkrieg of Holland, the ERR troops drove up in their big limousines and stole everything—the books, a bust, and a portrait of Spinoza—everything. They carted it all away, then sealed and expropriated the
museum.”

“ERR? What do the letters stand for?”

“Einsatzstab Reichsleiter Rosenberg. The taskforce of Reich leader Rosenberg—that’s Alfred Rosenberg, the major Nazi anti-Semitic ideologue. He was in charge of looting for the Third Reich, and under Rosenberg’s orders, the ERR plundered all of Europe—first, just the Jewish things and then, later in the war, anything of value.”

“So then these books are twice removed from Spinoza?” I asked. “You mean that books had to be purchased again and the library reassembled a second time?”

“No—miraculously these books survived and were returned here after the war with just a few missing copies.”

“Amazing!” There’s a story here, I thought. “But why did Rosenberg even bother with these books in the first place? I know they have some modest value—being seventeenth-century and older—but why didn’t they just march into the Amsterdam Rijksmuseum and pluck a single Rembrandt worth fifty times this whole collection?”

“No, that’s not the point. The money had nothing to do with it. The ERR had some mysterious interest in Spinoza. In his official report, Rosenberg’s officer, the Nazi who did the hands-on looting of the library, added a significant sentence: ‘They contain valuable early works of great importance for the exploration of the Spinoza problem.’ You can see the report on the web, if you like—it’s in the official Nuremberg documents.”

I felt stunned. “‘Exploration of the Nazis’ Spinoza problem’? I don’t understand. What did he mean? What was the Nazi Spinoza problem?”

Like a mime duo, my hosts hunched their shoulders and turned up their palms.

I pressed on. “You’re saying that because of this Spinoza problem, they protected these books rather than burn them, as they burned so much of Europe?”

They nodded.

“And where was the library kept during the war?”

“No one knows. The books just vanished for five years and turned up again in 1946 in a German salt mine.”

“A salt mine? Amazing!” I picked up one of the books—a sixteenth-century copy of the Iliad—and said, as I caressed it, “So this old storybook has its own story to tell.”

My hosts took me to look at the rest of the house. I had come at a fortunate time—few visitors had ever seen the other half of the building, for it had been occupied for centuries by a working-class family. But the last family member had recently died, and the Spinoza Society had promptly purchased the property and was just now beginning reconstruction to incorporate it into the museum. I wandered amid the construction debris through the modest kitchen and living room and then climbed the narrow, steep stairway to the small, unremarkable bedroom. I scanned the simple room quickly and began to descend, when my eye caught sight of a thin, two-by-two-foot crease in a corner of the ceiling.

“What’s that?”

The old caretaker climbed up a few stairs to look and told me it was a trap door that led to a tiny attic space where two Jews, an elderly mother and her daughter, were hidden from the Nazis for the entire duration of the war. “We fed them and took good care of them.”

A firestorm outside! Four out of five Dutch Jews murdered by the Nazis! Yet upstairs in the Spinoza house, hidden in the attic, two Jewish women were tenderly cared for throughout the war. And downstairs, the tiny Spinoza Museum was looted, sealed, and expropriated by an officer of the Rosenberg task force, who believed that its library could help the Nazis solve their “Spinoza problem.” And what was their Spinoza problem? I wondered if this Nazi, Alfred Rosenberg, had also, in his own way, for his own reasons, been looking for Spinoza. I had entered the museum with one mystery and now left it with two.

Shortly thereafter, I began writing.

Chapter One

AMSTERDAM—APRIL 1656
As the final rays of light glance off the water of the Zwanenburgwal, Amsterdam closes down. The dyers gather up their magenta and crimson fabrics drying on the stone banks of the canal. Merchants roll up their awnings and shutter their outdoor market stalls. A few workers plodding home stop for a snack with Dutch gin at the herring stands on the canal and then continue on their way. Amsterdam moves slowly: the city mourns, still recovering from the plague that, only a few months earlier, killed one person in nine.

A few meters from the canal, at Breestraat No. 4, the bankrupt and slightly tipsy Rembrandt van Rijn applies a last brushstroke to his painting Jacob Blessing the Sons of Joseph, signs his name in the lower right corner, tosses his palette to the floor, and turns to descend his narrow winding staircase. The house, destined three centuries later to become his museum and memorial, is on this day witness to his shame. It swarms with bidders anticipating the auction of all of the artist’s possessions. Gruffly pushing aside the gawkers on the staircase, he steps outside the front door, inhales the salty air, and stumbles toward the corner tavern.

In Delft, seventy kilometers south, another artist begins his ascent. The twenty-five-year-old Johannes Vermeer takes a final look at his new painting, The Procuress. He scans from right to left. First, the prostitute in a gloriously yellow jacket. Good. Good. The yellow gleams like polished sunlight. And the group of men surrounding her. Excellent—each could easily stroll off the canvas and begin a conversation. He bends closer to catch the tiny but piercing gaze of the leering young man with the foppish hat. Vermeer nods to his miniature self. Greatly pleased, he signs his name with a flourish in the lower right corner.

Back in Amsterdam at Breestraat No. 57, only two blocks from the auction preparations at Rembrandt’s home, a twenty-three-year-old merchant (born only a few days earlier than Vermeer, whom he would admire but never meet) prepares to close his import-export shop. He appears too delicate and beautiful to be a shopkeeper. His features are perfect, his olive skin unblemished, his dark eyes large, and soulful.

He takes a last look around: many shelves are as empty as his pockets. Pirates intercepted his last shipment from Bahia, and there is no coffee, sugar, or cocoa. For a generation, the Spinoza family operated a prosperous import-export wholesale business, but now the brothers Spinoza—Gabriel and Bento—are reduced to running a small retail shop. Inhaling the dusty air, Bento Spinoza identifies, with resignation, the fetid rat droppings accompanying the odor of dried figs, raisins, candied ginger, almonds, and chickpeas and the fumes of acrid Spanish wine. He walks outside and commences his daily duel with the rusted padlock on the shop door. An unfamiliar voice speaking in stilted Portuguese startles him.

“Are you Bento Spinoza?”

Spinoza turns to face two strangers, young weary men who seem to have traveled far. One is tall, with a massive, burly head that hangs forward as though it were too heavy to be held erect. His clothes are of good quality but soiled and wrinkled. The other, dressed in tattered peasant’s clothes, stands behind his companion. He has long, matted hair, dark eyes, a strong chin and forceful nose. He holds himself stiffly. Only his eyes move, darting like frightened tadpoles.

Spinoza offers a wary nod.

“I am Jacob Mendoza,” says the taller of the two. “We must see you. We must talk to you. This is my cousin, Franco Benitez, whom I’ve just brought from Portugal. My cousin,” Jacob clasps Franco’s shoulder, “is in crisis.”

“Yes,” Spinoza answers. “And?”

“In severe crisis.”

“Yes. And why seek me?”

“We’ve been told that you’re the one to render help. Perhaps the only one.”

“Help?”

“Franco has lost his faith. He doubts everything. All religious ritual. Prayer. Even the presence of God. He is frightened all the time. He doesn’t sleep. He talks of killing himself.”

“And who has misled you by sending you here? I am only a merchant who operates a small business. And not very profitably, as you see.” Spinoza points at the dusty window through which the half-empty shelves are visible. “Rabbi Mortera is our spiritual leader. You must go to him.”

“We arrived yesterday, and this morning we set out to do exactly that. But our landlord, a distant cousin, advised against it. ‘Franco needs a helper, not a judge,’ he said. He told us that Rabbi Mortera is severe with doubters, that he believes all Jews in Portugal who converted to Christianity face eternal damnation, even if they were forced to choose between conversion and death. ‘Rabbi Mortera,’ he said, ‘will only make Franco feel worse. Go see Bento Spinoza. He is wise in such matters.’”

“What talk is this? I am but a merchant—”

“He claims that if you had not been forced into business because of the death of your older brother and your father, you would have been the next great rabbi of Amsterdam.”

“I must go. I have a meeting I must attend.”

“You’re going to the Sabbath service at the synagogue? Yes? We too. I am taking Franco, for he must return to his faith. Can we walk with you?”

“No, I go to another kind of meeting.”

“What other kind?” says Jacob, but then immediately reverses himself. “Sorry. It’s not my affair. Can we meet tomorrow? Would you be willing to help us on the Sabbath? It is permitted, since it is a mitzvah. We need you. My cousin is in danger.”

“Strange.” Spinoza shakes his head. “Never have I heard such a request. I’m sorry, but you are mistaken. I can offer nothing.”

Franco, who had been staring at the ground as Jacob spoke, now lifts his eyes and utters his first words: “I ask for little, for only a few words with you. Do you refuse a fellow Jew? It is your duty to a traveler. I had to flee Portugal just as your father and your family had to flee, to escape the Inquisition.”

“But what can I—”

“My father was burned at the stake just a year ago. His crime? They found pages of the Torah buried in the soil behind our home. My father’s brother, Jacob’s father, was murdered soon after. I have a question. Consider this world where a son smells the odor of his father’s burning flesh. Where is the God that created this kind of world? Why does He permit such things? Do you blame me for asking that?” Franco looks deeply into Spinoza’s eyes for several moments and then continues. “Surely a man named ‘blessed’—Bento in Portuguese and Baruch in Hebrew—will not refuse to speak to me?”

Spinoza nods solemnly. “I will speak to you, Franco. Tomorrow midday?”

“At the synagogue?” Franco asks.

“No, here. Meet me here at the shop. It will be open.”

“The shop? Open?” Jacob interjects. “But the Sabbath?”

“My younger brother, Gabriel, represents the Spinoza family at the synagogue.”

“But the holy Torah,” Jacob insists, ignoring Franco’s tugging at his sleeve, “states God’s wish that we not work on the Sabbath, that we must spend that holy day offering prayers to Him and performing mitzvahs.”

Spinoza turns and speaks gently, as a teacher to a young student, “Tell me, Jacob, do you believe that God is all powerful?”

Jacob nods.

“That God is perfect? Complete unto Himself.”

Again Jacob agrees.

“Then surely you would agree that, by definition, a perfect and complete being has no needs, no insufficiencies, no wants, no wishes. Is that not so?”

Jacob thinks, hesitates, and then nods warily. Spinoza notes the beginnings of a smile on Franco’s lips.

“Then,” Spinoza continues, “I submit that God has no wishes about how, or even if, we glorify Him. Allow me, then, Jacob, to love God in my own fashion.”

Franco’s eyes widen. He turns toward Jacob as though to say, “You see, you see? This is the man I seek.”

Irvin Yalom on Existential Psychotherapy and Death Anxiety

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.