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

It is very common for people to experience distress or existential crises around particular dates, such as the anniversary of losing their spouse. People may even subconsciously react to significant anniversaries without being immediately aware of them. Yalom points to typically distressing life-stages, such as people outliving their parents’ age, milestone birthdays, or wedding or divorce anniversaries. Understanding the persistence of anniversary-related distress can help therapists predict their patients’ needs and feelings.

When patients feel anxious before, during, or after therapy with regard to their sessions, therapists should explore this with them. By understanding which aspects of therapy make the patient anxious, the therapist can address their concerns and ensure that they feel therapy is a safe space. Instead of assuming that anxiety will be persistent, therapists should help their patients search for the root of their anxiety so they can relieve it.

When patients ask for more validation, Yalom encourages them to brainstorm the exact words they hope to hear from him. This “self-soothing” exercise allows patients to give voice to their more dependent, immature selves, while also giving them a more authoritative role in the session. It also opens a new window for self-examination about why they find particular reassurances comforting.

Yalom is uncomfortable working with clients who are in love because such infatuation is inherently finite. However, rather than emphasizing the tenuous nature of their infatuation and becoming “love’s executioner,” Yalom chooses to sympathize with the patient and celebrate the positive feelings that come from being in love. Yalom helps “love-tormented patients” by focusing on the state of mind that comes from being in love (208), rather than dissecting the focus of their feelings. If the patient has sought therapy for help in navigating their infatuation, Yalom tries different activities to enhance their awareness. For instance, he asks them to record a tally sheet of positives and negatives of the relationship, or keep a log of how much time they spend thinking about their loved one. While all infatuations end eventually, this process can take months or even years, and seeing the loved one again is usually a major setback to this process. Yalom believes that infatuation can be subconsciously fueled by avoidance of painful thoughts, and he encourages his patients to consider what else they would think about if they were not gripped by obsession.

It is useful for therapists to get a sense of a patient’s personal history in their initial sessions. At first, this might follow a particular process, but over time, therapists usually do this intuitively, integrating these questions into the therapy itself.

In addition to discussing major life events, Yalom also asks his patients about the minutiae of their daily routines. This overview helps to shed light on valuable information and stimulate conversation, as patients’ habits and ongoing relationships are highly revealing.

Yalom borrows the clinical psychologist Ruthellen Josselson’s approach to visualizing relationships, in which the patient is the center of a solar system, and they locate the people in their life as planets around them, placing more important relationships closer to the center. Yalom always performs a “detailed inquiry” into a person’s relational life when they begin attending therapy.

It can be very useful for therapists to interview their patient’s significant other to better understand their relationship dynamics and how their partner interprets their behavior. It also allows the therapist to gain some insight into their partner and how their influence may be affecting the patient. These interviews should always be done with the patient present, so that no one feels left out and there are no secrets being kept. If couples therapy is required, the patient and their partner should seek a couples therapist who is equally invested in both of them.

Asking patients about previous experiences with other therapists can illuminate what they find helpful or unhelpful in their sessions. Many patients complain about former therapists being too impersonal or uninvolved. Yalom finds it useful to know what his patients found unproductive so he can be sure to not repeat that approach.

Yalom uses the metaphor of a shadow to refer to people’s darker instincts. He says it takes bravery to share negative thoughts and impulses, and effective therapists can establish the relatability and universality of many of these instincts. For instance, when Yalom was ashamed because he was looking forward to inheriting from his deceased parents, his therapist reassured him that everyone experiences such thoughts. Yalom reassured a patient who admitted that she sometimes fantasized about abandoning her children; he revealed to her that he, too, sometimes resented his kids for taking up his time and energy. These exchanges help patients stop feeling guilty for normal “shadow” thoughts or impulses.

While many therapists consider Freud’s work worthless, Yalom notes that without Freud, there would be no profession of therapy. Yalom laments that many critics of Freud dismiss all of his ideas as baseless and rely on commentaries of his work rather than reading his own words. While Freud may have been wrong about many things, he helped establish the basics of effective therapy by emphasizing self-expression and investigating fantasies, dreams, and the notions of resistance, transference and repressed trauma. Moreover, Freud was a talented writer whose clear prose is more accessible and appealing than many other psychologists.

Yalom confesses that he has mixed feelings about psychoanalytic institutions, which are sometimes very rigid and formal, but also foster stimulating discussions on psychoanalytic issues.

EVT stands for Empirically Validated Therapy, meaning that the therapy has been proven effective by a scientific study. Yalom asserts that only Cognitive Behavior Therapy, or CBT, has been scientifically validated, and thus psychology programs are quickly changing their curriculum to incorporate CBT at the expense of other methods.

Yalom strongly feels that the trend that favors CBT is misguided. Firstly, just because a therapeutic approach has not been the subject of a scientific study does not mean it has been invalidated. Many approaches lack the simplicity of CBT and are therefore harder to study. He feels that CBT is overly simplistic and is geared toward making therapy brief, cheap, and therefore accessible to the masses. This method attempts to address one symptom, rather than holistically evaluating the whole person. Yalom claims that therapists who rely on manuals and fixed methods are less effective than those who engage in unscripted, naturalistic conversations with patients.

Yalom considers dreams to be visual representations of a patient’s deeper concerns, and he therefore believes that they are useful for exploration. Many therapists are confused about how to pursue dream analysis, which is a controversial subject within the profession.

Yalom says it is impossible to fully analyze a dream with complete accuracy. New therapists should focus on using the dream to further facilitate their discussions with patients.

Yalom provides several examples of how he and his patients have used dreams as jumping-off points for new discussions into their sessions’ existing themes. He explains how dreams are largely symbolic and often contain clues to the patients’ fears, whether conscious or subconscious. Rather than trying to understand every aspect of dreams, Yalom focuses on understanding the major themes and imagery, and he helps his patients make connections between their dreams and their opinions and feelings.

Therapists should encourage their patients to record their dreams so they can better remember and reflect on them. Discussing dreams in the present tense helps therapists and patients accurately convey the dream and discuss its emotional content. It is useful for therapists to know what happened in the preceding day that might have influenced the dream. Some therapists believe that every aspect of a dream represents some part of the dreamer themselves, and patients can imagine the dream from the perspective of different people or objects.

Many dreams contain fascinating clues about a patient’s real-life memories. Exploring these can be useful for understanding the patient and their histories and for uncovering connections between their past and present. Yalom asks his patients to explain their own theories and associations about the events and symbolism of their dreams.

According to Yalom, the first dream that patients experience after entering therapy can be particularly profound. Many people, including Yalom, experience anxious dreams in which they are violated or exposed in some way. Discussing this dream can help reassure patients about their upcoming experience in therapy and give the therapist some insight into their patients’ anxiety.

Yalom explains that it is common for patients to dream about their therapist, and these dreams can be very revealing about patients’ attitudes toward their therapy and the therapist-patient dynamic. He points to many examples of his patients’ dreams that revealed their attachment to him, resentment of him, or other strong feelings. Exploring these helped his patients understand their past experiences and how they manifested in their relationship with Yalom.

Being a therapist is a demanding profession, and therapists often experience frustration or anxiety. Ironically, many therapists are socially isolated, expending their social energy on their clients and finding little time to establish deep friendships with others or extend their professional network. Some therapists hide their profession due to people either devaluing or over-idealizing their profession and abilities. Normal life events like having children, marital issues, illness, and loss can all take a toll on therapists and their ability to do their job. Yalom warns against overworking, noting that burnout is a real hazard to therapists. Particularly stressful experiences include patient suicides and malpractice lawsuits. To cope with these and other strains, Yalom recommends attending a support group for therapists.

Yalom encourages therapists to appreciate their role as “cradlers of secrets” (260). Therapists take great joy in seeing their patients improve and progress. Since therapists are always focused on gaining clarity and making informed decisions, they also have the chance to reflect honestly about their own lives and live intentionally.

Yalom feels that being a therapist has made him more aware of his own weaknesses and more compassionate toward others. He loves the intellectual stimulation of his work and the exploratory journeys he and his patients go on together. Yalom reminds therapists that, through their work, they are continuing an ancient tradition of emotional healing and therefore belong to an “honorable guild of healers” (260).