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The gift of therapy: An open letter to a new generation of therapists and their patients

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Twenty years ago when I read Irvin Yalom's Theory and Practice of Group Psychotherapy, I knew that I wanted to be a psychotherapist. These 20 years later, reading The Gift of Therapy, I am reminded that I made an excellent choice.

Irv Yalom's "open letter to a new generation of therapists and their patients" speaks to three essential aspects of myself: the psychotherapist, the human being, and the writer.

As a psychotherapist I am validated for thinking outside the traditional boxes and challenged to keep learning with every client I see. Yalom offers everything from specific suggested questions to ask clients to the wisdom of his experience such as "therapy should not be theory-driven, but relationship-driven," and "though the physicality of death destroys us, the idea of death can save us."

As a human being I am reminded that there is seldom --- if ever --- only one valid explanation for how we become who we are. And I am enlightened by Yalom's reminder of Paul Tilich's list of four "ultimate concerns" --- death, isolation, meaning, and freedom.

As a writer I am thoroughly entertained by how Yalom puts a sentence together. For instance, speaking of the importance of dream interpretation in therapy, he writes, "Pillage and loot the dream, take out of it whatever seems valuable, and don't fret about the discarded shell."

Most of all, as I close my now well-worn, underlined and dog-eared copy of Irv Yalom's new book, I am inspired by the man and the psychotherapist who has been, and remains, a hero of mine. (I suppose Irv would consider that literary transference.)

Bottomline: great book for therapists and non-therapists alike.

The Gift of Therapy
by Irvin Yalom, M.D.
Reviewed by Suzanne M. Retzinger, Ph.D.

Waiting for my brother to complete his three-hour dialysis, I browsed the bookshelf provided for the waiting. I came across Love's Executioner and read it for the first time. I had read Yalom's Theory and Practice of Group Psychotherapy text in grad school - like all requirements. Now he grabbed me by the shoulders and forced me to listen - inspired, I had to read more and found The Gift of Therapy (2003, Perennial edition; 263 pages $12.95).

Yalom is the first, of many that I've read on the therapeutic relationship, who doesn't "talk" about the therapeutic relationship - but "shows" it - a path for the bold to venture, a real connection between therapist and patient. My interest in his work lies in his openness about his own feelings and how he uses them therapeutically. Nothing, he says, "takes precedence over care and maintenance of my relationship to the patient,... and how we regard each other." Most patients come to therapy starving for intimacy, their conflicts being precisely in this area - and it is the therapeutic relationship, itself, that creates change.

For this reason, the "blank screen" model is far from what Yalom sees as effective patient therapist relationship; he sees therapist opaqueness as counterproductive. Because of the alienated nature of many clients' lives, the here and now space between therapist and patient is what matters. It's about the space that we create with our clients and how we use that space - "the betweenness". Yalom spells out 3 levels of therapist transparency that can be productive or not, asking of each, "is this disclosure in the best interest of the client?".

Standardization, he believes, renders therapy less effective, threatening therapist spontaneity. Therapy is a journey - and in Yalom's view the therapist and client are "fellow travelers". Whatever relationship there is, we build together with our clients. Be "prepared to go wherever the patient goes" - The long brown path before me leading wherever I choose (Walt Whitman - Song of the Open Road).

The relationship is key - I know - I've heard this from the beginning: in school, supervision, exam study courses, yatta, yatta, yatta. But at the same time I hear "don't get too close", or "reveal anything about yourself", "god forbid you touch a client" - a double message - the unspoken message: hold your nose, close your eyes, use a 10-foot pole. In my first career - research - I learned to jump in with all I have - open my eyes, my ears and each and every sense, throw away that pole. Yalom breathes life into therapy by attending to the inbetweens, the emotions that arise in this space and discussion of this process with the patient.

Western culture is awash in alienation; therapy is a process that can renew intimacy for those who choose this path. It is a "dress rehearsal for life", says Yalom. Affect and analysis are altering sequences, microcosms of our patients' lives that must be examined for lasting change to occur. Feelings, thoughts, words along with their analysis are not taboo; they are the stuff of intimacy. We must not confuse intimacy with sex, Yalom says. Sex is always inappropriate with clients, intimacy is not.

Yalom expresses his concern with the direction the mental health field has taken. With the growing alienation in our world, people are becoming less important. Even in our profession we see fewer sessions provided by HMO's, medication in place of human contact, focus on technique, fear of intimacy because of lawsuits. In this age of pharmaceuticals, HMOs, and lawsuits, is the relationship being lost? This book (as well as his others) is a wakeup call, a reminder for us all - the experienced as well and the novice - that we are in the business of healing relationships and not to loose them in the shuffle.

Since that first day at the dialysis center where I found Love's Executioner, I've read much of what Yalom has written. It's not only the brilliance of what he writes that draws me in, but the way he writes that touches me. His books are "serious, down to earth, and pulse with levity and life".

Yalom's book The Gift of Therapy is a gift to therapists past, present, and future. Like Yalom, we need to `show' and not `tell' our clients the road to connectedness. My hope is that this, and other works like this, will not be lost in a world so desperately in need of human connection.

Psychiatry residency is challenging in a different way than other medical specialties. Medical school prepares you for the medical aspects of psychiatry, specifically the neuroscience and pharmacology. But for therapy, medical schools barely touch on it. Things that help are being in therapy yourself, or having at least been in therapy, as well as seeking out really good supervision. Good books help too. But picking up those first couple patients is scary and the PGY-2 year is too exhausting to spend hours and hours reading up on the art of therapy. Yalom's "The Gift of Therapy" was given to me by one of my chief residents during my PGY-2 year and was very helpful. I've since had time to read more of Yalom's works and have enjoyed many of his therapeutic tales as well as his group therapy primer, but for where I was at that time, "The Gift of Therapy" was just what the doctor ordered. The key is extremely short chapters. It's a book that can be by the bedside (or stuffed in a white coat pocket if that's your style) and read just a couple of pages at a time. Some chapters focus on nuts-and-bolts everyday issues but what is particularly helpful are the chapters that give the flavor of the process. Many of the chapters help to reinforce the `it's all grist for the mill' notion, that there are few true mistakes, that almost anything you do in therapy creates opportunities and provides data on how the patient reacts and relates. This is an important concept and also, for me, alleviated some of the anxiety of being a new therapist. It's much better to approach outpatients with enthusiasm as opposed to angst, and no doubt patients can feel that difference as well. I also very much appreciate Yalom's attitude about not adhearing to a particular model or modality of therapy, but the recognition that different situations call for different approaches, that flexibility is the greatest tool for the therapist.

Nothing turns me off more than hearing analysts knock cognitive behavioral therapy or vice versa, just to pick an obvious example. Before my medicine days, I studied Anthropology, and it was this very same kind left me bored and disenchanted. The majority of people's energy went into "deconstructing" other people's ideas rather than contributing something positive and helpful. Yalom emphasizes that certain discrete symptoms are best treated with CBT type approaches, some questions call for an existential approach, sometimes analytic techniques are best, and so on. Especially in training, the focus should be on acquiring as many tools as possible, staying flexible, and maintaining an open mind. He also models the importance of continually refocusing on the here-and-now and counter-transference. These may be rudiments, but early on in training it can't be overemphasized. Especially coming from a western medical model, these fundamental concepts tend not to come naturally. So this book is exactly what you need as a PGY-2: good, light reading that is also helpful, instructive, and helps generate some confidence and enthusiasm towards outpatient work.

Dr. Yalom is a good writer and offers a unique perspective here on his decades of work in psychotherapy. It's definitely thought-provoking reading, and very easy to follow.

But it left me with questions for the author (and some serious reservations)--never a good feeling at the end of a book.

On the one hand, I appreciate that his training was to remain distant from patients where, as he described it, even helping an elderly woman put on a coat would be frowned on. I appreciate that, through experience with real-life patients, he realized the importance of establishing warmth, an interpersonal connection, a -human- relationship with patients rather than a distant "psychiatrist-as-remote-God-like" figure.

However, reading many of the chapters here, I couldn't help but think some of the therapy methods he describes could be too intimate and too seductive with his patients. I kept feeling that it would be very easy to act like this and wind up crossing the line--or being misunderstood--in a therapy setting. Sexual attraction (and, as he says, even unconsummated love that is mutually felt) is a recurrent theme in so many stories he shares from his practice.

There seemed to me to be much too much emphasis on talking about the therapist-patient relationship each week. Dr. Yalom writes, over and over, that he realizes he is far more important to his patients, personally, than they are to him. And yet he also seemed to intentionally intensify their feelings for him in the course of therapy, giving example after example of how he pushed them to share dreams about him, fantasies about him, etc. Where there was conflict between what he felt and what they felt, the solution was often to focus on how they were thinking and feeling erotically and/or emotionally about him. When a patient describes how she bonded with her husband when they jointly laughed at something she quoted Yalom saying, he resents the shared jokes about him with her husband, and reminds her that the three of them are in a relationship "triangle".

At least in this retelling, its unclear that this intense emotional intimacy with patients is genuinely best for the patient.

I'm not saying there's any sexual misconduct. In fact, Yalom clearly says that a therapist should never, ever become sexually involved with a patient as it is "a serious betrayal and does great harm to both". He is unequivocal about this and says it is better to even see a prostitute than violate the patient's trust. Nevertheless, putting an outright physical relationship aside, I do feel his methods/remarks as he describes them here, often seem very "seductive" in the broader sense, especially as so many women seek treatment with him for their relationship issues (including loneliness, marital and sexual problems, and low self-esteem).

Its possible that being on first-name basis with a therapist who routinely discloses himself and his personal feelings about you--and who says and shows that he cares about you personally--may be therapeudic. But as recounted in this book it sometimes seems ...a potentially inappropriate pattern with female patients. (I'm also interested that his bi-monthly "leaderless" support group that has met for years consists of 11 psychologists/psychiatrists--ALL of whom are men. Ironic, given his intimate and seductive approach to female patients in therapy, how that "missing" female psychiatrist regularly might be just the right person to offer HIM feedback).

Yalom does quote a renowned psychotherapist who bluntly questions his methods, saying, "Doesn't the intense personal intimacy you have with patients interfere with their ability to terminate treatment?" A great question, and one that, imo, he should have worrying about a great deal more than he shows here.

Anyway, I liked the idea that an emotionally engaged therapist can help a patient more than a distant one. He tells a good story, the short chapters are a bit brave style-wise and serve the reader well. I liked how he revisited Freud in a positive way, reminding us of the historical context of his insights and achievement.

I recommend this book, but with a discussion group. Otherwise, it leaves too many questions about the advisability of intentionally building relationships of intense intimacy and dependency with patients. Alone, it left me with too many unresolved questions and criticisms. As the focal point of group/class discussion, however, it would be perfect.

Long after Dr. Yalom has departed for that great therapist's office in the sky, this book will still be known as a must read for the novice and veteran counselor because of the common-sense and compassionate advice it offers. This is Dr. Yalom's Opus Magnum.

I first came across Dr. Yalom's works when I took a required course in group therapy, and his text on the subject was the reference for the course. It did not take me long to gain a sense of awe at his wisdom, the likes of which can only be compared to something usually reserved for a demi-god. Nevertheless, Dr. Yalom is a wise man who has "been there," and his writings reflect the wisdom of his years.

The Gift of Therapy will renew your sense of passion for the mental health field. Dr. Yalom has a way of giving his readers insight into the therapy process, which affords the practioner or therapist-to-be a vantage point that will make him or her appreciative of all of the good we can do in the service of humankind.

There were times when reading this book, when I had to set it down and ruminate on what I had just read; Dr. Yalom has a way of expressing the profound, without pedantry, and the sublime, without silliness. After reading this book I am literally in awe of this "giant" and I am proud that we are both serving humanity in the same field.

This is the latest book by Irvin Yalom, whose books I've been following over the years. From the very first page of the introduction, Yalom's writing is gripping & right to the point. He mentions turning 70 years old, which has made him feel a need to "pass on" his knowledge & some of his experience to younger generations of therapists & patients. This is what he tries to do in this substantial book, a book of tips, long on technique & short on theory (as Yalom himself says).

Each "tip" that Yalom gives comes from years of experience & in most cases, makes perfect sense. Something that should be noted is that his book is not written, I think, for the non-psychologically trained reader. It's aimed towards psychotherapists, & tries to steer them in the direction of good choices & good therapeutic work with clients / patients. Most tips may seem like common sense to most psychologists / psychotherapists, but if you think a little bit more about them, most of them are not used as often as they should be. Also, apart from the more obvious tips, Yalom offers a whole range of extremely innovative (& maybe some times controversial) pieces of advice. These chapters alone are, in my opinion, well worth the price of the book, since they make you sit down & think.

All in all, a great reference book for psychotherapists which comes alive through wonderful, clear writing, & lots of lively clinical examples.

I've bought this book for some of my clinical trainees and grad students. I personally learned a lot from the book, and found it entertaining. Many have reviewed it previously, so here are a few things that I have to add:

1) Consider ordering Yalom's DVD "The Gift of Therapy." It is a one hour interview with Yalom that supplements the material in the book. If you are fascinated by Yalom, or if you'd rather watch the video... then obtain it online from Yalom's professional website.

2) If you've read Yalom's therapy novels, then you'll appreciate this book. It clarifies themes that show up in Yalom's novels. I especially loved "Lying on the Couch." If you liked the "open letter," then you'll enjoy "Lying on the Couch." Poignant, deep, hilarious.

3) One line that has stuck with me from the book has to do with empirically validated therapies. "UNvalidated does not mean INvalidated," or something like that... Frankly, I'm a big, big, big fan of empirically validated approaches. I see plenty of value in short-term behavioral and cognitive approaches. But the hubris surrounding "empirically-validated" behavioral and cognitive approaches is annoying, especially in this era of managed care fascism/stupidity. There is so much to mental health, psychotherapy, and life that cannot be validated using empircal methods. We need scientific validation of our interventions if possible, but we also need to acknowledge the profound limitations of science. This seems remarkably obvious to me but so many people on either side of the battle don't get it. If you are "anti-science," or, conversely, if you are "anti-things-that-can't-be-validated-empirically," then you are narrow minded. I know I sound arrogant here... but I'm right. ;-)

4) Consider keeping this book by your bedside, and read a chapter each night. Chapters are very brief and can be completed within a few minutes, before you go off to sleep.

5) If you are a supervisor or instructor, consider using this book in your therapy courses. I don't believe that a book like this one will replace an intro text on psychotherapy (e.g., Weiner's classic text). However, it is an easy read and students will enjoy it. When I buy this book for my students, it is often with the expectation that we will discuss its contents at various times.

This book gives the most honest, real, ethical and human answers to some of the most common questions young therapists ask (and seasoned ones, too, I have been told!) With a beautiful framework and combination of Gestalt and Person-Centered therapy styles, Yalom clearly and concisely addresses issues like: When your client weeps, occupational hazards, answering questions your client asks, taking patients further than you have gone, acknowledging your errors, discussing death with clients, taking notes in session, and giving yourself time between appointments, etc., etc.

The short chapters make it a realistic read for the very busy college student or therapist - to read in entirety or to read selectively on issues that are important for them.

I felt so much relief reading this book - specific answers and assurances about day-to-day occurances in the field (counseling, psychotherapy or clinical social work). I love all the examples he gives, and the range of ethical and appropriate solutions to the issues . . . his lack of personal bias.

This book is well worth the time and money - at least three times over!

This is an excellent book, containing 85 tips for a successful therapy experience. I am well versed in theory and technique, and still I found many helpful morsels in this book.

For example, his words on Tip #2, Avoid Diagnosis, are a refreshing attack on the Insurance-Driven emphasis to Diagnose and Treat One Thing Only. His Tip#8, Let the Patient Matter to You, is a helpful balance to the Institutional bias towards chilly Best Practices. His Tip #10, Create a New Therapy for Each Patient, is beautiful but not for beginners!

The book reflects Yalom's conviction that "the effective therapist should never try to force discussion of any content area: Therapy should not be theory-driven but relationship-driven." (p. xviii) This idea gives focus to his book. It is written from Yalom's point of view of the interpersonal frame - that the most important work and growth comes from exploring the relationship between the therapist and client within the therapy room. This book would have been better titled: Using the Therapy Relationship in Psythotherapy.

This is not to be confused with Interpersonal Therapy, a short-term evidence-based technique for treating depression (Yalom rightly is critical of giving too much respect to these `evidence based' methods, see his Tip # 76). Technically, he is offering his insight on how best to work in Carl Rogers' Client Centered Therapy with an emphasis on working with the transference.

If you are thinking of therapy for yourself, you might look at the definitions of different therapy approaches on the Psychology Today website. (Tab: Therapy Center, then Tab: Orientation)

If you are a therapist, you will find that Yalom's emphasis on working in the transference expands into coverage of therapist self-disclosure and talking to clients about the mechanisms of therapy, giving feedback, treatment of the subject of death (Yalom is also an existentialist), touching clients (he does), interviewing the client's significant other, use of dreams in therapy, and more. His emphasis on the here-and-now of transference will be familiar to therapists who have studied his book on groups.

Do not hesitate to contact me if you have questions about this book.

I read this book at the 3-year point of my therapy for anxiety and depression. It was very helpful to me to read this book as it gives us patients the therapist's perspective. It has been immediately useful as I have been able to freely address a barrier between myself and my therapist which I had only been aware of as a vague discomfort.

It has also helped me understand what is going on in therapy. It also helps me to be less fearful. I had a clinical psychologist for a stepdad who was pretty mean to me, and Dr Yalom's book (similarly to books by Scott Peck, MD) have been very helpful to me. These doctors remind me that their main mission is to help patients.