Monday, January 29, 2024

Yalom's Gift

I recently binge-watched all of Group, a show inspired by a novel by Irvin Yalom, The Schopenhauer Cure. So I revisited Yalom's non-fiction to see how closely the series aligns to his actual practices.

The Gift of Therapy is a fascinating read from 2017 in which Yalom dives openly into his existential psychotherapy practice, explaining the four givens that affect how we think, feel and act that need to be explored at depth: death, isolation, meaning of life, and freedom (xvii). In the introduction, he jumps right into death denial revealed through a belief in personal specialness (xiii). Our current culture of selfies is likely rife with this! An existential perspective is best for clients who despair from "a confrontation with harsh facts of the human condition" (xvi). We didn't see much of this type of discussion in the show. In fact, the therapist didn't talk much at all beyond reminding the group to be honest and forthcoming.

On Group Therapy 

Yalom clarifies the distinction between group therapy and individual therapy in that group is more useful when "patients fall into despair because of their inability to develop and sustain gratifying interpersonal relationships." He offers two instructive points: a just-right structure to alleviate anxiety yet not miss potential revelations if turn-taking is too regulated, and the importance of individual summaries at the end of session recognizing that each person has a different experience of what happened. Yalom also writes and shares his own summaries of each session to group members to maintain continuity from one session to the next.

He runs on the premise that "people want to interact with others, are excited by giving and receiving direct feedback, yearn to learn how they are perceived by others, want to slough off their facades and become intimate" (64).   

That's about it when it comes to group from this book, but elsewhere he wrote about these therapeutic factors to attend to:

1. Instillation of Hope: members develop optimism of their own growth
2. Impart Information: education/advice provided by therapists and members 
3. Universality: recognize we're not along, that others have similar issues
4. Altruism/Recapitulation: help one another, value others and feel valued
5. Socializing Skills: improve skills together by helping express ideas appropriately
6. Imitative Behaviour: mirror behaviours presented by therapist and members
7. Interpersonal Learning: get insights about abilities to connect with others
8. Group Cohesiveness: gain feelings of trust, belonging, safety, and togetherness
9. Corrective Recapitulation: re-enact family dynamics with group in corrective manner
10. Catharsis: externalize verbally personal past and present feelings
11. Existential factors: accept life, death, pain, purpose, and responsibility

For people to change, they need to undergo these factors, typically a few presented in each group session, often sequentially. 

At this point it's clear that Yalom's group therapy work might have prompted the show, but didn't significantly influence the script, which mainly followed romantic and sexual connections between participants. All the rest of this book is about individual therapy using a writing style that allows for what feels like eavesdropping from the reader, with a lot of philosophy in the mix:

"We therapists are part of a tradition reaching back not only to our immediate psychotherapy ancestors, beginning with Freud and Jung and all their ancestors--Nietzsche, Schopenhauer, Kierkegaard--but also to Jesus, the Buddha, Plato, Socrates, Galen, Hippocrates, and all the other great religious leaders, philosophers, and physicians who have, since the beginning of time, ministered to human despair " (259).

He believes internal conflicts exist at different levels of awareness, leading to suppressed instincts. There's some Freud mixed in, but he also criticizes some Freudian notions along the way. Here's what the rest of it says and then some. I can never read a book without reading the origin stories contained within.

Therapist-Patient Relationship

Yalom says we can get closer to self-realization only by removing blockers to reveal our suffering. A diagnosis can get in the way by becoming a self-fulfilling prophecy or by limiting our vision and creating a treatment formula that all but ignores the patient. I've found myself frustrated by the "bakers" in the field who, after finding out one pertinent detail, it feels like they look up the right page number and follow a recipe. They're a bit better than the "cheerleader" therapists who just tell you how amazing you, though, but not by much. Sometimes feeling worse after a session means it's working.

He quotes Schopenhauer:

"We are like lambs in the field, disporting themselves under the eyes of the butcher, who picks out one first and then another for his prey. So it is that in our good days we are all unconscious of the evil that Fate may have presently in store for us--sickness, poverty, mutilation, loss of sight or reason." (7)

It's from "On the Sufferings of the World," written in 1891, in which Schopenhauer concludes that we should each refer to one another as "my fellow sufferer" and suggests evil is a backdrop that we largely ignore until it's upon us. We need to zoom out to remember the big picture. 

Yalom's technique is to abolish any division between therapist and patients and to just attend to every nuance of the patient. As long as therapists don't do anything harmful, clients mainly remember if their therapist was supportive and attentive. Go where the patient goes; transcend learned techniques and trust spontaneous moves, and if the client hates the therapist, all the better for finding fertile ground. It's in the dyad - as well as in groups - that conflicts arise that are common to their personal lives. Finding patterns in these conflicts can lead to a more in-depth awareness of the self, which can be driven by the therapist's discussion of their own feelings being with the client, something I've never encountered in therapy. For Yalom, it's always about using the here-and-now experiences to flush out blind spots, and the therapist is part of that: "the interpersonal problems of the patient will manifest themselves in the here-and-now of the therapy relationship . . . everyday events of each therapy hour are rich with data" (48-9). Current conflicts or ways of relating can be tied to any history of it or any payoff. "We learn best about ourselves and our behavior through personal participation in interactions combined with observation and analysis of that interaction" (63).

Yalom argues that the therapist doesn't have to be in a state of exceptional well-being. He quotes Nietzsche (and wrote a great fictionalized bio of him): "Some cannot loosen their own chains yet can nonetheless redeem their friends" (104) (from "The Friend" in Thus Spake Zarathustra). We can help one another even when we can't help ourselves. Some of the most pivotal healers were tormented people, and Jung wrote about "the increased efficacy of the wounded healer" (107). 

But Yalom goes so far to suggest that if the therapist doesn't change, then the client doesn't either, which makes the task of therapy that much more onerous. The relationship is a two-way street although the responsibility is unidirectional. Yalom strongly advocates for therapists to be authentically themselves instead of a Rogerian blank canvas. "I urge you to let your patients matter to you, to let them enter your mind, influence you, change you--and not to conceal this from them. . . . Therapist disclosure begets patient disclosure" (26-29). It's the most authentic experience I've heard suggested. He takes a bit from Sándor Ferenczi's Clinical Diaries, which "pushed therapist self-disclosure to the limit by engaging in 'mutual analysis'" (81). Disclosing thoughts and feelings about the patient are valuable; "the most valuable source of data is your own feelings" (87) provided sharing is always in the best interest of the patient.

I also recently binge-watched The Curse, which points a finger at the incredibly performative nature of daily life and the self-serving manner in which we make a display of helping one another in ways that don't help at all (see Thomas Flight for more on that). Calling for authenticity in the age of clicks and likes is a difficult but necessary giant step towards getting back to the essential character of the self. 

Methods of Exploring Concerns

Yalom considers two of Heidegger's modes of existence: utility and existence. The everyday distracted mode wondering about how things are and the ontological mode that is filled with wonder that things are (127). We need awakening experiences to jolt us from our everydayness to pay attention to being. This can come with confrontations with one's own death through the death of a pet or death or illness of a loved out, or remembrance of someone's passing or through other "boundary experiences" that jolt us out of the daily grind like a quarter-life or mid-life crisis. He does the reverse of Freud, who thought most of our imaginings were really about sex. Yalom thinks most of our preoccupation with sex is really masquerading concerns about death, and he advocates probing about what makes death terrifying for each patient (129).

Jung said a full third of his patients came for meaning-of-life issues, having lost passion for things. Today, we might look into dopamine depletion issues, but Yalom encourages writing their own epitaph instead (134). Schopenhauer saw meaning as the main issue to explore: "Every human life is tossed backward and forward between pain and boredom" (135) (from World as Will and Ideas / Representation, p. 401, in which boredom is translated as ennui). Many people are terrified of boredom, and Yalom takes that as a sign of a lack of purpose, which he tackles by plunging into many possible meanings for the client one at a time: "The question of meaning in life is, as the Buddha taught, not edifying. One must immerse oneself into the river of life and let the question drift away" (136).

A part of meaning-making is around freedom and its derivatives: responsibility, willing, wishing, and deciding (138). Then he gets at Sartre's notion of 'radical freedom.' The more we take responsibility for our decisions in life, all our decisions, the more we can begin to feel free: 

"We must encourage our patients to assume responsibility--that is, to apprehend how they themselves contribute to their distress. . . . Even if 99% of the bad things that happen to you is someone else's fault, I want to look at the other 1%--the part that is your responsibility. . . . If they find themselves in an exploited role time and again, then surely the role must contain some lure for them" (139-140). 

Typically, we have much more responsibility for--and therefore control over--our lives than we're willing to acknowledge because that would mean it's all our doing. But if we fail to accept it, then we give away our agency and any chance at change. 

He calls decision-making a "royal road into a rich existential domain" (146) that "ignites freedom-anxiety" so patients fight to avoid them; however, all decision ignored are also decisions made. In the words of Geddy Lee, "If you choose not to decide, you still have made a choice." Then Yalom asks, "Are you satisfied with this decision you made?" Decisions are hard because they "demand renunciation" or the closing of doors to paths that will no longer be available to us. Our overriding fear of death is connected to our fear of decisions, as explained by both Heidegger and Sartre: "The impossibility of further possibility. The path to decision may be hard because it leads into the territory of both finiteness and groundlessness--domains soaked in anxiety" (149). Furthermore, Yalom says, "there is a correlation between the degree of death anxiety and the degree one has fulfilled oneself. The more unlived life the individual senses, the greater the dread of death." Patients need to become who they are, which Nietzsche says in a letter to Lou Salomé, quoting Pindar who added this important bit: by learning who they are. 

There's an appreciation of the absurd throughout as well. In one case a patient was sure he couldn't move forward because of the way his mom treated him as a child, so Yalom had him repeat, "I'm not going to change, Mother, till you treat me differently when I was eight" over and over until the absurdity of the stuckness became clear (155). We all have to "relinquish the goal of having a better past" (155). Sometimes this stuckness comes from a fear of disappointment. People don't know their own desires or needs because acknowledging them provokes awareness of how far they are from being met. Scary! But the alternative is allowing them to get further and further from fruition. Alternatively, people become stuck in a desire that is so far-fetched that they can rely on never attaining it, and Yalom reads them a line of Camus: "The hardest thing for a man to give up is that which he really doesn't want, after all" (156) (from The Fall). If that doesn't work, to help patients see themselves more objectively, he asks if they wouldn't mind helping him with another patient, then describes that patient as having their exact same problem. Even when patients catch on, it still helps. 

Everyday Conduct of Therapy 

Yalom generally waits for the patient to start the session or else just recaps the prior session to help them find their "point of urgency" (159). He encourages patients to stay in the space of emotional expression (weeping, anger, love) in order to alternate between affect expression and reflection/analysis of the experience. "We cling tenaciously to the belief that explanation, some explanation, is possible" (175). Feeling like we're understanding ourselves matters more than actually getting to the bottom of things. He quotes Nietzsche again: "Truth is an illusion without which a certain species could not survive" (175) from The Will to Power 4:493, translated there as an error instead of an illusion. And again "There is no truth, there is only interpretation" (3:481). Yalom explains that the accuracy of the content the patient reveals doesn't matter; it's about the "hunt" - the process of solving the riddle of a life that enacts "the real agent of change--the therapeutic relationship" (176). There's "relief through making sense of previously inexplicable feelings . . . benefit in feeling that one understands . . . a sense of greater mastery if one can name the problem" (PS, 10).

Psychotherapy is a safe place to practice relating, but it should never be a substitute for life. It's necessarily different from real life. It's in these sessions that people can bring out their shady side, which is important and daunting. Freud's pupil, D.W. Winnicott, wrote about 18 ways mothers hate their children (p. 355) to get mothers to acknowledge the full range of feelings they have for their children in order to keep their relationship based in reality. Our current society rallies against any negative view of children, making some parents absolutely paralyzed with a quest for perfection in all their choices and then find themselves flummoxed when things don't go as planned. Yalom explains that Freud and other early psychoanalysis's view was that the therapist's insights into the patient was most important in a top-down approach, and they were "clueless about the importance of the human encounter in the therapeutic process" (220). Listening to someone express their darkest thoughts in a safe, supported, confidential manner can help them be cleansed by sunlight, clearing the way through the miasma of crap we might have accumulated over a lifetime. 

I'm so intrigued by this process, but I'm not sure how many therapists out there have the courage and authenticity to be able to pull if off! 

Yalomy Questions for Patients:

*What are the imaginary conversations you have with me after session?
*How are you and I doing today?
*If you weren't so sensitive, could you be such a good artist?
*What's the origin of the myth of your unattractiveness?
*Is there a history of this? Is there a payoff for you? 
*You're into a long tale, and I'm beginning to feel lost. Can you help?
*Is this a familiar place for you? Would you be willing to look at your part in getting here?
*How could you live now so you'll be able to look back in five years without regret?
*What blocks you from acting on the decision you already seem to have made?
*List ten answers to Who am I? Meditate on removing each identity starting from the most peripheral.
*What would be the perfect thing for me to say to you?
*What would you be thinking about it you weren't obsessed with this?
*What frightens you most about death?

Cross-posted at 3 Quarks Daily

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