An absolute pleasure to read, I still maintain that Irvin Yalom is the best writer I’ve ever read with his elegant use of language that appears simple and natural at first glance but allows for exploring deep and complex ideas. This book made me reflect on the the human desire of closeness and intimacy, and makes me want to be more honest and open in the future, after hearing how so many people’s suffering is a result of a lack of connection. From hearing Irvin’s own thoughts and how they were expressed when working with patients, I also reflected on how a therapist has to have a deep understanding of of their own mind and unconscious beliefs and biases in order to prevent them from interfering with therapy.
“This need for connection to ease the existential concerns has certainly been true for me, brought into sharp focus after my wife of sixty-five years, Marilyn, died in 2019. COVID appeared just months later, and I spent much of the following three years, the time frame of this book, in heavy isolation. Add to that the fact that I had entered serious old man territory. Nearly all of my friends and colleagues had passed away, or seemed to be doing so as quickly as possible. Living to a ripe old age, while maybe better than the alternative, has its drawbacks.”
“To be an effective therapist you must both understand the experience of therapy from the patient’s perspective and get to know yourself extremely well. This last piece is critical to working in the here and now, because you need great awareness of your own perceptions and biases. During the session, a good therapist is reading the interaction and making careful notes of the emotional responses they are having to the patient. If, for instance, I find myself getting frustrated at a patient’s evasiveness, as I had with Sophia of the first dates, I need to recognize that I’m having this frustration immediately, rather than sinking into the emotion without awareness, as one usually does. My frustration indicates something critical about the interaction we’re having, in this case that Sophia’s refusal to open up was off-putting to me and, by extension, likely to others she encountered. If the therapist has blind spots about themselves, then those emotional responses will not be reliable indicators of how others would generally respond, and the idea of therapy as social microcosm falls apart.”
“We all have unconscious biases and neuroses that might make our perceptions less reliable, and more fraught with potential countertransference. Knowing oneself as deeply as possible is essential, and exploring one’s faults, strengths, and dark corners as a therapy patient is the best way I know of honing one’s perceptions in service of providing one’s patients the most effective therapy.”
“Then a very odd thing happened. As I continued looking at Elsa’s face, I experienced a strong rush of warmth toward her. I did not recognize her, nor did I feel a flood of memories return from our session. But I felt intense positive emotion, a keen desire to be helpful, and a powerful sense of protectiveness. Though I could recall almost no explicit details of my previous meetings with Elsa, the implicit warm feelings that I had toward her were obviously very much alive and well preserved somewhere in my mind.
Of course I often have positive feelings toward my patients, and meeting with them generally brings me pleasure. But this potent wave of emotion was quite different, almost as if my emotional system were compensating for my lack of conscious awareness. It was surprising, and briefly disorienting in a pleasant way. How odd, to feel so strongly toward someone with no recollection as to why!”
“I am reminded of the important fact that therapists have many patients, while patients have only one therapist. This is an inherent inequality, which can sometimes be used to the benefit of the therapy—that is we want to be important in the patient’s mind, so that our words and the experiences we share in therapy can have a powerful transformative impact. On the other hand, imagine the potential damage for someone who, placing great importance on the approval of their therapist, finds themselves completely forgotten.”
“In Maya’s case, I resorted to a very direct confrontation, whereas generally it is far more effective to lead patients toward making these discoveries for themselves. As therapists we lay out possibilities and ask thought-provoking questions that often cause patients to consider how they are living, whether their actions align with their values, and whether their beliefs are serving them well, understanding all along that deep change has to come from within.
There is a difficult irony here because patients usually come to therapy in significant distress. What they want in that state, by and large, is a solution to the suffering they are experiencing, whether the problem appears to be external or internal. And this solution, they often imagine, is advice about what to do. But again, real change needs to come from the patient reconsidering their own tendencies and making a shift rather than being told what to do in a given situation. Almost always there is a lot less utility in my telling someone what to do rather than helping them overcome whatever internal obstacles they have so they can reach their own conclusions that better align with their deeper values.”
“ I have long believed that therapists are most effective when we offer ourselves to our patients as fellow travelers, human beings who must also suffer the slings and arrows and other indignities of being alive.”
“One type of self-disclosure is absolutely central to my here-and-now work: being deeply honest as to how I feel about a patient in the immediate present. I don’t blurt out my feelings indiscriminately, of course, but rather use these as my main source of data and carefully consider how I can best employ this information to the patient’s benefit. For example, if a patient appears to be withholding something, I ask about that; if they are being combative, or flirtatious, or childish, I let them know in the most useful way I can that this is what I am receiving from them.”
“Most often this existential fear is buried in the subconscious and manifests in many other ways, often reluctance to engage fully in life—for if one never really lives, one has no real life to lose!—or, conversely, efforts to thumb one’s nose at mortality through death-defying feats like skydiving or constantly seeking the excitement of sexual union.”
“Most important is this: as Marilyn’s illness progressed, we agreed over and over that we had few regrets about how we had lived our lives. In fact, even now, I can almost hear her saying, ‘The death of an eighty-seven-year-old woman, who lived her life fully, who had four wonderful children and a loving husband always by her side, is not a tragedy.”
“She didn’t know what anxiety was, and she grew up calm, graceful, and self-assured. I, on the other hand, have been plagued by anxiety throughout my life, a constant, dreadful companion that I’ve never been able to fully shake. ”
“Sharing of oneself—one’s vulnerability, one’s compassion, one’s humanity—and encouraging the patient to do the same may not be the only way to achieve this, but it certainly is what works best for me.”
“Oh Sonja! It struck me that she had no close relationships, and perhaps had never had any in her entire life. Even the most self-sufficient people need close relationships. I knew what I had to do. I had to help her understand what it is to share deeply with another person, to know what is possible, so she might become able to create it elsewhere in her life. Therapy often serves as a valuable dress rehearsal for life, with the therapist serving as a rehearsal mate. With this goal in mind, I wanted Sonja to experience intimacy.”
“Among the things therapists can impact, by far the most important is the therapeutic alliance, the relationship between the therapist and patient. This accounts for 30 to 50 percent of therapy’s success or failure. Beyond these two, the particular type of therapy and the particular therapist’s skill split up the scant remaining 10 to 20 percent.”
“His work has been being in caring, intimate relationship with patients, and together using that closeness to examine the big issues of what it means to be human. He has written eloquently about his approach in many books, but the specific mechanisms are less important than the goals. Ultimately his is a therapy of human connection, of letting others matter to us deeply, of seeking meaning and sharing ourselves in the richest and most useful ways possible. Let us take this legacy and strive to encounter one another truly—therapists, patients, fellow humans—in all of our rich, flawed complexity.”