Letting the Patient Matter: Some Thoughts on Irvin Yalom's View of the Therapeutic Relationship

• Opening the Secret Door
• When a Patient Spells Trouble
• Therapist Blunders and Breakthroughs
• A Doctor Making House Calls?
• Patient as Fellow Traveler
• References

In his recent book The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients, psychiatrist and writer Irvin Yalom recalls a poignant encounter with one of his cancer patients. The woman is embarrassed by her hair loss after chemotherapy, and during one of her therapy sessions, she reveals that she would like a sign from Yalom that her baldness does not repulse him. Yalom, who has always admired this patient for the intelligence that illuminates her features, tells her he's not repulsed at all. In fact, he asks if he can act on his impulse to run his fingers through the lovely gray strands of hair remaining on her head. The result is a warm, intimate moment that is cathartic for both.

Such moments, related in his latest book, The Gift of Therapy, serve as vivid arguments for breaking down the walls that separate patient and therapist. Directed to a new generation of therapists and their patients, Yalom is a keen advocate for unmasking the therapist. One of the main reasons that patients fall into despair is that they are unable to sustain gratifying relationships. According to Yalom, therapy is their opportunity to establish a healthy give-and-take with an empathetic counselor; one who is not afraid to show his or her own vulnerabilities.

Opening the Secret Door

A professor emeritus of psychiatry at Stanford University and the author of several widely read books and novels on psychotherapy—including the best-selling therapeutic memoir Love's Executioner and various classic textbooks on group psychotherapy and existential psychotherapy—Yalom's insight into this world throws open the secret door to therapy, both for counselors and the patients who visit them.

What we see behind Yalom's door is a far cry from the stereotype of a therapist. From comic strips to Hollywood features, the analyst is often portrayed seated behind a desk or a notebook, literally out of reach and out of sight of the person being analyzed. As patients, we perceive that person sitting across from us as a powerful and impenetrable figure, yet we're expected to reveal ourselves up to their scrutiny. Within the charged atmosphere of the 50-minute therapeutic hour, our psyches are exposed, while the therapist maintains an enigmatic mask.

This may be the traditional model of psychoanalysis, but Yalom challenges it as ineffective and ultimately unhealthy. Real treatment, he says, requires an intimacy between therapist and patient that is born from a solid bond of trust. After all, a patient regularly entrusts a therapist with intimate revelations, so the therapist must be able to respond with true spontaneous empathy rather than stock therapeutic phrases. Nor does empathy evolve in a vacuum. "Friendship between therapist and patient is a necessary condition in the process of therapy," says Yalom, and he encourages the therapist to "let the patient know that he or she matters to you."

When a Patient Spells Trouble

Sometimes letting the patient matter can be a challenge. In his book Love's Executioner, Yalom describes an incident with an Argentine patient who is in the last stages of incurable lymphoma. Because "Carlos" was isolated and depressed, Yalom sent him to a therapy group led by a female colleague, thinking that Carlos might form some personal connections to help him through the challenges of his last months of life. Instead, Carlos' obsession with the female patients alienated everyone in the group. After several of the women brought up their painful experiences with rape, Carlos voyeuristically interrogated them about intimate details and then declared the assaults "no big deal." Furious, the therapist asked Carlos to leave the group.

Although repelled by Carlos' behavior, Yalom persuaded the group leader to let him work with him to see whether he might be able to change his attitude. Carlos defended his prurient interrogations to Yalom, leering that, "All men are turned on by rape," and "If rape were legal, I'd do it . . . once in a while." Sitting in silence for a few minutes, Yalom wondered whether Carlos was as depraved as he sounded, or whether his crudeness was partly bluster. "I was interested in, grateful for, his last few words: the 'once in a while,'" he recalls. "Those words, added almost as an afterthought, seemed to suggest some scrap of self-consciousness or shame." Knowing that his patient was close to his teenage children, Yalom decided to turn the tables on him.

"All right, Carlos, let's consider this ideal society you're imagining and advocating. Think now, for a few minutes, about your daughter. How would it be for her living in this community—being available for legal rape?" At that point, Carlos' macho mask begins to crumble. He winces visibly and stammers that he wouldn't like that for her. What he wants, he says, is for his daughter to have a loving relationship with a man, and to have a loving family. Again, Yalom presses him to confront his own words: "But how can that happen if her father is advocating a world of rape? If you want her to live in a loving world, it's up to you to construct that world—and you have to start with your own behavior." The discussion was so difficult for Carlos that he became faint, but shortly thereafter he was able to change his cynical approach to other people. Following this breakthrough, he was able to rejoin the group that had rejected him and, in the months before his death, to enjoy a number of close, supportive friendships with the women and men there.

Therapist Blunders and Breakthroughs

As in any other intimate relationship, Yalom feels that it is important for both parties to admit when they have made an error or blunder. He notes that when he has owned up to his own limitations and lack of understanding, it has often led to an important breakthrough in therapy.

Such was the case when Yalom found himself extremely uncomfortable while counseling a chatty, obese woman suffering from depression—another story he relates in Love's Executioner. He takes us through his challenging journey to understand his resistance to treating "Betty," beginning with his family and its line of "fat, controlling women," to his need for a scapegoat in his high school years in racially segregated Washington D.C., in which he was regularly attacked for being white and Jewish. (Yalom recalls that he, in turn, could look down on the "fat kids": "I supposed I needed someone to hate, too," he reflects. "Maybe that was where I learned it.") In the process of therapy, Yalom persuades Betty, who deflects most of his questions with a joke, to stop trying to "entertain" him and to talk about her life with the seriousness it deserved. When she does, he eventually conquers his discomfort and comes to feel an enormous respect and liking for his patient. And, after some months of treatment, Betty is able to overcome her depression and achieve a more comfortable weight for herself.

A Doctor Making House Calls?

Yalom's personal involvement during therapy doesn't stop with sharing his own biases. By occasionally visiting patients at home, Yalom says he has learned important information that he's been able to put to good use in therapy. For example, one severely depressed patient was for months unable to move beyond the initial phases of grieving over his wife's death. When Yalom made a house call, he found that the patient had so saturated his environment with material reminders of his wife—to the point of keeping the ratty sofa where his wife had died on prominent display in the living room—that his own personality had all but disappeared.

Together, patient and therapist worked out a series of changes in the house that would help free the patient from some of the invisible chains that bound him.

Patient as Fellow Traveler

Because building trust and intimacy takes time, Yalom is critical of the current trend towards short stints of behavioral therapy. While they may work in some instances, he allows, there is no substitute for ongoing, weekly sessions in which a caring doctor and a troubled patient engage in a "dress rehearsal for life." Although the "life" in question is usually the patient's, Yalom feels that if change does not occur in the therapist as well, the therapist is not working effectively.

Forty-five years of clinical practice have led Yalom to note that the patient and therapist are "fellow travelers" in therapy—they're both human beings dealing with essential problems of existence and must work cooperatively to solve them. The therapist must be able to "look out the other's window." Learning to actively empathize with a patient's experience is the most important gift a therapist can give a patient, Yalom says.

Certainly the world of analysis and therapy have changed dramatically from the days of glorifying the neutral, distant and emotionally removed therapist with a pipe in hand. In particular, Yalom's works pose a far-reaching question: Is it time for psychoanalysts and psychotherapists to reveal more of themselves to their patients? And, in addition to challenging their patients to grow, should they remember to treat them with empathy and simple human kindness beyond that of the detached professional caring? In The Gift of Therapy, Yalom makes the brave assertion that the therapist is responsible for bringing his or her own humanity to the forefront of the therapy. After all, this may be the most valuable gift that the therapist can offer the client.

References

Yalom, I. D. (2002). The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients. NY: Harper Collins.

Yalom, I. D. (1989). Love's Executioner and Other Tales of Psychotherapy: For Anyone Who's Ever Been on Either Side of the Couch. NY: Harper Perennial.

This article is adapted from an article originally published on the Consumer Health Interactive website (www.yourhealthconnection.com) (2002).


Copyright © 2003 Psychotherapy.net. All rights reserved.