The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients

Yalom’s approach is to discuss the patient’s perspective on death openly and frankly, uncovering how they have thought of it throughout their lives and exploring the losses they have experienced thus far. If therapists are calm and open about death, this signals to the patient that they are allowed to bring up the subject.

Yalom claims that sexual obsessions are often simply fears about death manifesting in a different way, because sex is “the absolute vital antithesis of death” (138). Therapists should help their patients explore their fantasies and understand their deeper meaning or impetus.

Many people seek therapy due to a crisis of meaning in their lives. Yalom believes that there is no intrinsic meaning in life, and people must create it for themselves. Many people find altruistic endeavors to be the most meaningful, while others prize creative pursuits or self-actualization. Yalom argues that therapists should approach life meaning in a less direct way than other existential matters, exploring different self-transcendent meanings in their patients’ lives. He disagrees with the notion that therapists should provide specific meanings or moral instructions to patients. By helping their patients remove obstacles to their engagement with the idea of meaning, therapists can help them consider what is truly meaningful to them.

While political freedom has wholly positive associations, therapists focus on a somewhat different notion of freedom: the individual’s freedom to construct their own identity, make their own choices, and assert their will. This type of freedom is inherently a source of anxiety, as people worry about how their actions, or lack thereof, inform their lives and selves. While many approaches to therapy do not specifically discuss “freedom,” they do focus on responsibilities and decisions, which fall under the same umbrella as freedom.

Yalom considers “responsibility assumption” a crucial first step in the process of therapy (149). Therapists should encourage their patients to consider how they are responsible for creating the situations and relationships they find themselves in. Therapists can acknowledge how other people have played a role, or how systemic issues may influence their patients’ lives, but they should always examine their patients’ behavior, as well. Yalom recommends telling patients that therapists want to examine the part that is the patients’ responsibility, no matter how small, because that is where therapy can be the most useful. People respond very differently to this aspect of therapy: Some are very willing to accept responsibility while others find it incredibly difficult. Assuming responsibility can trigger regrets, which the therapist should redirect into new attention on the present moment, where the patient can foster real change.

Yalom advises therapists to avoid trying to make decisions for their patients. He cites an instance in which his patient’s dilemma of choosing between two women seemed very clear, as one woman seemed to be more suitable for him than the other. Yalom tacitly encouraged him to break up with his long-term girlfriend and date his new love interest. Months later, when the relationship soured and his patient was nostalgic for his old relationship, Yalom realized that he should have been more objective. He claims that all therapists work with “unreliable data” as they hear stories that are filtered through the biased lens of their patients’ perspectives; this is why they should be wary of trying to make decisions for them. He offers one caveat to his rule, which is that he always strongly advises people who have been physically abused to never return to situations or relationships with their abuser.

Yalom goes on to say that there are several reasons why therapists should not make decisions for patients. Firstly, if patients feel pressured to take a certain course of action, then they may stop attending therapy altogether. Secondly, the choices people make and how they make them are highly revealing of their inner world. If patients avoid making decisions, or deny their choices, that requires therapeutic investigation. Yalom recommends helping patients see which choices they’ve made and asking “‘Are you satisfied with that?’ (Satisfied both with the nature of the decision and with their mode of making the decision)” (154).

Making decisions is difficult because they are inherently limiting; saying yes to a certain relationship or career means saying no to others. Many people find making decisions difficult because it means confronting the fact that their potential, and their life itself, is finite. For this reason, the avoidant behavior about making decisions should be thoroughly examined by therapists and patients.

Yalom believes that it is helpful to sometimes give advice to patients in order to help them break out of entrenched habits. For instance, he suggested to his patient Mike that he contact his father directly rather than communicating through his mother. This helped Mike change his family dynamic and better understand his own role in the family dysfunction. A therapist’s advice should not be the end of the discussion, but rather, “a means to encourage exploration” (161).

Yalom employs several methods when helping his patients foster the clarity and strength needed to make decisions. One method is to remind the patient that their past cannot be changed, and they must make decisions based on how they would like to change their present. Another device Yalom uses is to role-play with stuck patients to help them discover what it is that they truly want. A third method is to describe their situation to them in the third person so they can gain some objectivity about it.

Yalom believes that it is highly effective to tape sessions and listen to the exchanges before attending the next session. This keeps the discussion fresh and makes it easier to continue exploring repeated themes. He notes that all therapy is cyclical, as it requires paying attention to different topics and revisiting them repeatedly over time.

At the end of each session, all therapists should record the major topics they discussed with their patients and their feelings about them. It is also useful to record if nothing much occurred in the session, since this could be a sign of stagnation. Yalom always reviews his notes before each session so a patient’s previous session is fresh in his mind.

Patients should actively participate in their therapy by monitoring themselves in different situations. For instance, they can consider their feelings and reactions when trying an activity that puts them out of their comfort zone, or when visiting their family.

Therapists should build on emotional moments by inquiring about their patients’ feelings and encouraging them to put their feelings into words. Yalom always asks his patients “the content and meaning” of their crying (170), and he also asks them to reflect on how it felt to cry openly in front of him.

Yalom recommends that therapists take breaks between patients. He acknowledges that this is unpopular advice, as this reduces a therapist’s income. However, he feels that therapists must have enough time to take notes on their sessions and review their patient files before beginning. Without this preparation, Yalom doubts that therapists can provide the same quality attention to each patient.

Yalom is transparent with his patients when he experiences dilemmas, explaining to them that he has competing ideas about how to best work with them. For example, if Yalom wants to be more frank with a patient but worries about hurting their feelings, he may reveal that to them. When Yalom learned that one of his patients had made fun of him to soothe her husband’s insecurities, Yalom felt conflicted about revealing his hurt feelings to her. However, in doing so, they were able to better explore how his patient often struggled in three-person relationships and often hurt one person to feel closer to the other.

Yalom urges therapists to try to incorporate some home visits into their therapy sessions. He has always gained valuable new insights into the lives and struggles of his patients by observing how they live. A patient’s hobbies, decor, cleanliness, or furnishings can reveal much about their emotional lives; it sometimes helps to fully explain issues they are having in their relationships. Yalom acknowledges that home visits require good boundaries and mutual trust, but he advises therapists to consider them if they seem appropriate and helpful.

Therapists tend to value their own intellectual investigation into their patients’ lives and their own interpretations of patients’ problems. Meanwhile, patients do not necessarily value this as highly; many of them fondly remember other aspects of therapy, such as the attention and validation they receive. Yalom questions Freud’s perspective that therapists are like archaeologists uncovering original traumas or puzzlers finding all the pieces to a puzzle to solve it completely. While therapists might crave the closure of finding some “absolute truth,” this is an unrealistic and ultimately unhelpful notion. Therapists help patients by taking them on the hunt, rather than finding a specific answer at the end of it. This process of uncovering events and feelings together also helps create a bond between the therapist and patient.

Yalom discusses several devices that can help foster new discussions or breakthroughs in group therapy. These include practicing a trust fall, anonymously exchanging secrets and discussing them, or analyzing past group therapy tapes. These techniques are most effective if the therapist encourages the group to consider how they feel about being trusting or open to others during the exercises.

Yalom also recommends an activity in which people write down key parts of their identities on eight slips of paper and then arrange them in order of priority. By considering each one, people become more aware of their “core self” and how they have constructed their identity. In individual therapy, viewing old photographs, role-playing, or doing a home visit can be useful.

Successful therapy requires that therapist and patient form a kind of friendship in order for patients to feel safe and to experiment with self-disclosure. The therapist-patient relationship can be a positive model for other friendships in the patient’s life. Patients should not see therapy as a “substitute” for life, but rather as a “dress rehearsal”: They must actively apply their lessons and new behaviors into the rest of their lives rather than simply self-disclose in therapy and continue on as usual outside of therapy.

When faced with difficult patient behavior, Yalom recommends reminding the patient of their initial reason for seeking therapeutic help. For instance, one therapist was alarmed by her patient’s demanding and immature behavior toward her. However, she was able to make these unfortunate incidents useful by connecting her patient’s rudeness to his initial complaint, which was that he always failed to develop healthy and lasting relationships with women. By pointing out this connection, the therapist was able to help her patient understand how his behavior was profoundly alienating to other people.

Yalom advises therapists to incorporate kind physical gestures into their sessions, when appropriate. If patients are comfortable ending their sessions with hugs or clasped hands, Yalom is happy to agree. In some sessions, an affectionate touch can be reassuring or validating. For instance, one of Yalom’s group therapy sessions ended with participants holding hands. In another case, one of Yalom’s patients had cancer and was moved when, with her permission, Yalom gently touched her remaining hair. While touching patients in any way used to be very discouraged, Yalom believes that, with consent and mutuality, these gestures can show compassion and humanity.