The Gift Of Therapy
The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients by Irvin D. Yalom, M.D.
Includes more than twenty additional pages of new therapy tips by the author.
Yalom writes with the narrative wit of O. Henry and the earthy humor of Isaac Bashevis Singer.
Dedication
To Marilyn, soul mate for over fifty years.
Contents
Dedication
Introduction
Acknowledgments
Chapter 1 - Remove the Obstacles to Growth
Chapter 2 - Avoid Diagnosis (Except for Insurance Companies)
Chapter 3 - Therapist and Patient as “Fellow Travelers”
Chapter 4 - Engage the Patient
Chapter 5 - Be Supportive
Chapter 6 - Empathy: Looking Out the Patient’s Window
Chapter 7 - Teach Empathy
Chapter 8 - Let the Patient Matter to You
Chapter 9 - Acknowledge Your Errors
Chapter 10 - Create a New Therapy for Each Patient
Chapter 11 - The Therapeutic Act, Not the Therapeutic Word
Chapter 12 - Engage in Personal Therapy
Chapter 13 - The Therapist Has Many Patients; The Patient, One Therapist
Chapter 14 - The Here-and-Now—Use It, Use It, Use It
Chapter 15 - Why Use the Here-and-Now?
Chapter 16 - Using the Here-and-Now—Grow Rabbit Ears
Chapter 17 - Search for Here-and-Now Equivalents
Chapter 18 - Working Through Issues in the Here-and-Now
Chapter 19 - The Here-and-Now Energizes Therapy
Chapter 20 - Use Your Own Feelings as Data
Chapter 21 - Frame Here-and-Now Comments Carefully
Chapter 22 - All Is Grist for the Here-and-Now Mill
Chapter 23 - Check into the Here-and-Now Each Hour
Chapter 24 - What Lies Have You Told Me?
Chapter 25 - Blank Screen? Forget It! Be Real
Chapter 26 - Three Kinds of Therapist Self-Disclosure
Chapter 27 - The Mechanism of Therapy—Be Transparent
Chapter 28 - Revealing Here-and-Now Feelings—Use Discretion
Chapter 29 - Revealing the Therapist’s Personal Life—Use Caution
Chapter 30 - Revealing Your Personal Life—Caveats
Chapter 31 - Therapist Transparency and Universality
Chapter 32 - Patients Will Resist Your Disclosure
Chapter 33 - Avoid the Crooked Cure
Chapter 34 - On Taking Patients Further Than You Have Gone
Chapter 35 - On Being Helped by Your Patient
Chapter 36 - Encourage Patient Self-Disclosure
Chapter 37 - Feedback in Psychotherapy
Chapter 38 - Provide Feedback Effectively and Gently
Chapter 39 - Increase Receptiveness to Feedback by Using “Parts,”
Chapter 40 - Feedback: Strike When the Iron Is Cold
Chapter 41 - Talk About Death
Chapter 42 - Death and Life Enhancement
Chapter 43 - How to Talk About Death
Chapter 44 - Talk About Life Meaning
Chapter 45 - Freedom
Chapter 46 - Helping Patients Assume Responsibility
Chapter 47 - Never (Almost Never) Make Decisions for the Patient
Chapter 48 - Decisions: A Via Regia into Existential Bedrock
Chapter 49 - Focus on Resistance to Decision
Chapter 50 - Facilitating Awareness by Advice Giving
Chapter 51 - Facilitating Decisions—Other Devices
Chapter 52 - Conduct Therapy as a Continuous Session
Chapter 53 - Take Notes of Each Session
Chapter 54 - Encourage Self-Monitoring
Chapter 55 - When Your Patient Weeps
Chapter 56 - Give Yourself Time Between Patients
Chapter 57 - Express Your Dilemmas Openly
Chapter 58 - Do Home Visits
Chapter 59 - Don’t Take Explanation Too Seriously
Chapter 60 - Therapy-Accelerating Devices
Chapter 61 - Therapy as a Dress Rehearsal for Life
Chapter 62 - Use the Initial Complaint as Leverage
Chapter 63 - Don’t Be Afraid of Touching Your Patient
Chapter 64 - Never Be Sexual with Patients
Chapter 65 - Look for Anniversary and Life-Stage Issues
Chapter 66 - Never Ignore “Therapy Anxiety,”
Chapter 67 - Doctor, Take Away My Anxiety
Chapter 68 - On Being Love’s Executioner
Chapter 69 - Taking a History
Chapter 70 - A History of the Patient’s Daily Schedule
Chapter 71 - How Is the Patient’s Life Peopled?
Chapter 72 - Interview the Significant Other
Chapter 73 - Explore Previous Therapy
Chapter 74 - Sharing the Shade of the Shadow
Chapter 75 - Freud Was Not Always Wrong
Chapter 76 - CBT Is Not What It’s Cracked Up to Be … Or, Don’t Be Afraid of the EVT Bogeyman
Chapter 77 - Dreams—Use Them, Use Them, Use Them
Chapter 78 - Full Interpretation of a Dream? Forget It!
Chapter 79 - Use Dreams Pragmatically: Pillage and Loot
Chapter 80 - Master Some Dream Navigational Skills
Chapter 81 - Learn About the Patient’s Life from Dreams
Chapter 82 - Pay Attention to the First Dream
Chapter 83 - Attend Carefully to Dreams About the Therapist
Chapter 84 - Beware the Occupational Hazards
Chapter 85 - Cherish the Occupational Privileges
Notes
P. S - Insights, Interviews & More …*
About the author
About the book
Read on
Other Works by Irvin D. Yalom, M.D.
Copyright
About the Publisher
Introduction
The author observes cobwebs in his patients' dreams and is reminded of his own aging.
One of our chief modes of death denial is a belief in personal specialness, a conviction that we are exempt from biological necessity and that life will not deal with us in the same harsh way it deals with everyone else.
The author realizes that he is entering a designated later era of life.
Erik Erikson described this late-life stage as generativity, a post-narcissism era when attention turns from expansion of oneself toward care and concern for succeeding generations.
The author wants to pass on what he has learned. As soon as possible.
Guidance and inspiration to the next generation of psychotherapists is exceedingly problematic today, because our field is in such crisis.
An economically driven health-care system mandates a radical modification in psychological treatment, and psychotherapy is now obliged to be streamlined—that is, above all, inexpensive and, perforce, brief, superficial, and insubstantial.
The author worries about where the next generation of effective psychotherapists will be trained.
Psychiatry is on the verge of abandoning the field of psychotherapy.
The present generation of psychiatric clinicians, skilled in both dynamic psychotherapy and in pharmacological treatment, is an endangered species.
Clinical psychologists face the same market pressures, and most doctorate-granting schools of psychology are responding by teaching a therapy that is symptom-oriented, brief, and, hence, reimbursable.
An economically driven health-care system mandates a radical modification in psychological treatment, and psychotherapy is now obliged to be streamlined—that is, above all, inexpensive and, perforce, brief, superficial, and insubstantial.
Nonetheless, a cohort of therapists coming from a variety of educational disciplines will continue to pursue rigorous postgraduate training and find patients desiring extensive growth and change willing to make an open-ended commitment to therapy.
The book is written for these therapists and these patients.
The author advises students against sectarianism and suggests a therapeutic pluralism in which effective interventions are drawn from several different therapy approaches.
The author works from an interpersonal and existential frame of reference.
Group therapy and existential therapy are the author's two abiding interests.
When working in group therapy, the author works from an interpersonal frame of reference.
When operating from an existential frame of reference, the author makes a very different assumption: patients fall into despair as a result of a confrontation with harsh facts of the human condition—the “givens” of existence.
Existential psychotherapy is a dynamic therapeutic approach that focuses on concerns rooted in existence.
Definition of "dynamic approach"
Lay meaning: forcefulness or vitality.
Technical sense: rooted in Freud’s model of mental functioning, positing that forces in conflict within the individual generate the individual’s thought, emotion, and behavior; these conflicting forces exist at varying levels of awareness.
Existential psychotherapy is a dynamic therapy that assumes that unconscious forces influence conscious functioning.
Conflicting internal forces
Struggle with suppressed instinctual strivings.
Internalized significant adults.
Shards of forgotten traumatic memories.
Confrontation with the “givens” of existence: death, isolation, meaning in life, and freedom (ultimate concerns, according to theologian Paul Tillich).
The therapist should never try to force discussion of any content area: Therapy should not be theory-driven but relationship-driven.
Rainer Maria Rilke's Influence
Rainer Maria Rilke’s ghost hovered over the writing of this volume.
The author consciously attempted to raise himself to Rilke's standards of honesty, inclusiveness, and generosity of spirit.
The advice in this book is drawn from notes of forty-five years of clinical practice.
This volume is not meant to be a systematic manual; it is intended instead as a supplement to a comprehensive training program.
The eighty-five categories in this volume were selected randomly, guided by passion for the task rather than by any particular order or system.
The author wants to set the record straight about therapy procedures described in his fiction.
This volume is long on technique and short on theory.
The term patient (from the Latin fattens—one who suffers or endures) is used synonymously with client.
The therapist should intend to encourage throughout a therapeutic relationship based on engagement, openness, and egalitarianism.
The text will have an episodic, lurching quality because of the large number of suggestions and omission of much filler and transitions.
The first section (1–40) addresses the nature of the therapist-patient relationship, with particular emphasis on the here-and-now, the therapist’s use of the self, and therapist self-disclosure.
The next section (41–51) turns from process to content and suggests methods of exploring the ultimate concerns of death, meaning in life, and freedom (encompassing responsibility and decision).
The third section (52–76) addresses a variety of issues arising in the everyday conduct of therapy.
In the fourth section (77–83) the author address the use of dreams in therapy.
The final section (84–85) discusses the hazards and privileges of being a therapist.
This text is sprinkled with many of the author's favorite specific phrases and interventions, while also encouraging spontaneity and creativity.
The advice in this book derives from clinical practice with moderately high- to high-functioning patients.
Therapy goals: symptom removal, alleviation of pain, personal growth, and basic character change.
It is hoped that readers find their own creative way to adapt and apply what has been learned to their own particular work situation.
Acknowledgments
Acknowledgment of assistance from Marilyn, Murray Bilmes, Peter Rosenbaum, David Spiegel, Ruthellen Josselson, Saul Spiro, Neil Brast, Rick Van Rheenen, Martel Bryant, Ivan Gendzel, Randy Weingarten, Ines Roe, Evelyn Beck, Susan Goldberg, Tracy Larue Yalom, and Scott Haigley.
Chapter 1 - Remove the Obstacles to Growth
Karen Horney’s Neurosis and Human Growth was a pivotal book for the author.
Her concept that the human being has an inbuilt propensity toward self-realization greatly influenced the author, task was to remove obstacles blocking my patient’s path, as an acorn develops into an oak.
The patient would develop into a mature, fully realized adult automatically once you inspirit the patient with the desire to grow.
Example of young window
Love felt treasonous: betraying husband, diminishing past love, leading to self-destruction.
The widow met a man, she fell in love, she married again, without the author having to teach her anything.
About Karen Horney
A unique American "neo-Freudian" addition to psychodynamic theory reacted against Freud’s drive theory, emphasizing the interpersonal environment's influence on character structure.
Harry Stack Sullivan and Erich Fromm have also been deeply integrated into therapy language and practice.
Molière’s Bourgeois Gentilhomme
Monsieur Jourdain exclaimed with wonderment, “To think that all my life I’ve been speaking prose without knowing it.”
Chapter 2 - Avoid Diagnosis (Except for Insurance Companies)
Today emphasis is on diagnosis for managed-care administrators’ demand.
Therapy is a gradual unfolding process.
Diagnosis limits vision; it diminishes ability to relate to the other as a person, leading to selective inattention and self-fulfilling prophecies.
Low reliability of the DSM personality disorder category is cautioned about.
Diagnosis is easier in the first interview than in the tenth.
A colleague asks residents what DSM-IV diagnosis their therapist would use on someone as complicated as them.
Objectivity is vital and the text questions whether truly carving at the joints of nature is possible.
The DSM-IV Chinese restaurant menu format will one day appear ludicrous.
Chapter 3 - Therapist and Patient as “Fellow Travelers”
Andre Malraux described that “people are much more unhappy than one thinks … and there is no such thing as a grown-up person.”
Both therapists and patients are destined to experience inevitible darkness.
Arthur Schopenhauer on unhappiness in the life of every self-conscious individual
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.It is difficult to populate a “happy people” party because of life's adversities.
Yalom prefers to think of himself and patients as “fellow travelers,”
The idea of the fully analyzed therapist is a mythic nature.
No therapist and no person are immune to the inherent tragedies of existence.
Hermann Hesse’s Magister Ludi about Joseph and Dion (younger and older, rival yet codependent figures).
The two men received powerful help but in very different ways, Dion in particular receiving filial love.
Perhaps the real therapy occurred at the deathbed scene, when they moved into honesty that they were fellow travelers.
The twenty years of secrecy, helpful as they were, may have obstructed and prevented a more profound kind of help.
Rilke’s letters to a young poet: Have patience with everything unresolved and try to love the questions themselves and the questioners.
Chapter 4 - Engage the Patient
Conflicts in the realm of intimacy can be the reason for patients to seek help and the experience of an intimate relationship with the therapist can be therapeutic.
Some fear intimacy because of unacceptability, resulting in the act of self-revelation being the major vehicle for help.
Intimacy might be avoided because of fears of exploitation, colonization, or abandonment; in this case, a caring relationship that does not result in catastrophe can be a great experience.
Nothing takes precedence over the care and maintenance of my relationship to the patient.
Regular Check-Ins
How are you and I doing today?
How are you experiencing the space between us today?
Imagine a half hour from now—you’re on your drive home, looking back upon our session. How will you feel about you and me today? What will be the unspoken statements or unasked questions about our relationship today?
Chapter 5 - Be Supportive
The great value of obtaining intensive personal therapy is in turn giving positive support.
Positive support rather than insight is often what patients recall years later.
Regularly expressing your positive thoughts about patients along a wide range of attributes gives great power to the therapist.
Acceptance and support from one who knows you so intimately is enormously affirming.
If patients make an important and courageous therapeutic step, compliment them on it.
Don’t hesitate to express this also nonverbally, going over the hour by a few minutes.
Example: Novelist Michael and closing his secret PO box.
Of course you’re going to be revisited with longings. It’s inevitable—that’s part of your humanity.
An example: Robot, thank God, is what you are not.
We’ve talked often about your sensitivity and your creativity—these are your richest assets—that’s why your writing is so powerful and that’s why others are drawn to you.All therapists will discover their own way of supporting patients.
Ram Dass describing his leave-taking from a guru: I see no imperfections.
Support may include comments about appearance or wonder about the origins of the myth of his/her unattractiveness.
The ultimate questions: Am I appealing to men? To you? If you weren’t my therapist would you respond sexually to me?
If everything were different, we met in another world, I were single, I weren’t your therapist, then yes, I would find you very attractive and sure would make an effort to know you better.
This does not preclude other types of inquiry.
Chapter 6 - Empathy: Looking Out the Patient’s Window
A story: looking out the other’s window leads to a realization that there are two sides of the road, one may not be so beautiful as the other.
Try to see the world as your patient sees it even in death.
The woman who told me this story died a short time later of breast cancer, and I regret that I cannot tell her how useful her story has been over the years, to me, my students, and many patients.Carl Rogers identified "accurate empathy" as an essential therapist characteristic.
Therapy is enhanced if the therapist enters accurately into the patient’s world.
Patients profit enormously simply from the experience of being fully seen and fully understood.
It is important for us to appreciate how our patient experiences the past, present, and future.
I make a point of repeatedly checking out my assumptions.
Accurate empathy is most important in the domain of the immediate present, view of therapy hours (study by Irving Yalom).
Rashomon-Like Experience
The exchange of notes every few months provided a Rashomon-like experience.
Though we had shared the hour, we experienced and remembered it idiosyncratically.My elegant and brilliant interpretations? She never even heard them.
Instead, she valued the small personal acts I barely noticed: my complimenting her clothing or appearance or writing, my awkward apologies for arriving a couple of minutes late, my chuckling at her satire, my teasing her when we role-played.Terence’s statement from two thousand years ago—“I am human and let nothing human be alien to me”—and urged us to be open to that part of ourselves.
Knowledge of the patient’s past vastly enhances your ability to look out the patient’s window.
Chapter 7 - Teach Empathy
Accurate empathy is for patients and therapists, help patients experience empathy with you, and they will make extrapolations to others.
Include yourself when asking how a statement action might affect others.
Reality testing should be enacted if patients venture a guess about how I feel.
Encourage the patient to express errors that come about, show him your experience, make them realize that direct questions bring direct response.
Chapter 8 - Let the Patient Matter to You
It is sad to think of being together with others for so long and yet never to have let them matter enough to be influenced and changed by them.
It's urged that you let your patients matter to you, influence you, change you, and not conceal this from them.
Don’t be afraid of showing your feelings either that it doesn’t interfere that you would show your darker side.That it does not jibe with my inner experience, and the error is always in the same direction: You read me as caring for you much less than I do.
Do you ever think about me?
Therapist disclosure begets patient disclosure.
Sharing the dream and connecting it to his discussion in our previous session, the patient conflated her father and the text, but it could also be the expression of her regrets to the therapist as well.
Chapter 9 - Acknowledge Your Errors
Winnicott observation: difference between good mothers and bad mothers, is not commission of errors but what they do with them.
Acknowledge errors, because an act of authenticity gains patients’ trust and leads to better outcomes in later relationships with other partners.
Own up, admit it: it sets a good example and it shows the patients how much they matter to you.
You can often ask help from the patient to understand the issues (Sandor Ferenczi's concept).
Chapter 10 - Create a New Therapy for Each Patient
Contemporary psychotherapy research has a paradox: research requires standardization so replication is possible, yet the act of standardization itself renders therapy less real and less effective.
Pair the problem with the fact that so much psychotherapy research uses inexperienced therapists or student therapists.
Experienced therapists urge patients to begin each session with their point of urgency.
At its very core, the flow of therapy should be spontaneous.
The therapist and patient must build a relationship, build trust and safety.
Try to avoid technique that is prefabricated and do best if you allow your choices to flow spontaneously from the demands of the immediate clinical situation.
Technique has a different meaning for the novice than for the expert.Offer comfort, but most of all there has to be a means to ensure to be supported.
Impulsively offering to change time is good, but the patient must feel secure and protected, it allows you to go into the projection of a self-hatred onto you.
Chapter 11 - The Therapeutic Act, Not the Therapeutic Word
Learn from patients and inquire of them into views of what is helpful about the therapy process.
Patients views of helpful events in therapy are relational, involving some act of the therapist, concrete examples, consistency, and presence.
Ex: the Christmas shopping season where someone steals often.
In this compulsive act, is the therapist the reason that they would not go into the shop? Is it due to feeling ungrateful is not to be part of the experience?, what helps the patient get past the feeling of being poor.Action permits control, interventions permit her to cut short, and rationalization permits her to deal with the compulsion.
Attending one of the recitals is helpful because he will realize that people exist to create change, and not a series of issues they must overcome. He agreed to accede to her request as a sign of loving respect or showing someone loving respect.
Chapter 12 - Engage in Personal Therapy
Personal psychotherapy is, by far, the most important part of therapy training.
The therapist’s most valuable instrument is the therapist's self: we must demonstrate our willingness to enter into a deep intimacy with our patient while showing personal modeling.
The personal is more valuable than formal training.Learning should occur with a mentor, rather than a formal, rigid, structure which emphasizes technical ability over creativity.
Young therapists must therefore:
work through their own issues, accept feedback, discover blind spots, appreciate their impact, and ultimately obtain the inner strength to cope with occupational hazards.
The author’s odyssey of therapy
a 750-hour Freudian psychoanalysis during residency
a year with British “middle school” analyst Rycroft
two years with Gestalt therapist Baumgartner
three years with an interpersonally and existentially oriented analyst, and numerous shorter stints, as well as group therapy.
It is important to avoid sectarianism and appreciate varying approaches.
A discomfort in one’s own life is an educational opportunity to explore what various approaches have to offer.
A different set of issues can arrive at different junctures of the life cycle, making repeated therapy is essential.
The student members’ competitiveness and their complex relationships outside the group offer insight and education.
A strong sense of cohesiveness can make a group never be forgotten, so that experience is also provided in the future for patients.
Chapter 13 - The Therapist Has Many Patients; The Patient, One Therapist
My patients lament the inequality of the psychotherapy situation and may ask, Do you ever think about me?
Though the inequality may be irritating, it is at the same time important and necessary: we want the therapy hour to be one of the most important events in the patient’s life.
Reality testing—the patient thinks more about the therapist than vice versa because of the arrangement that therapist has many patients.
Often, the teacher analogy is helpful: the teacher has many students, who think more about her than she about them.
I know it feels unfair and unequal for you to be thinking of me more than I of you, for you to be carrying on long conversations with me between sessions, knowing that I do not similarly speak in fantasy to you.
But that’s simply the nature of the process. I had exactly the same experience during my own time in therapy, when I sat in the patient’s chair and yearned to have my therapist think more about me.
Chapter 14 - The Here-and-Now—Use It, Use It, Use It
The here-and-now is the major source of therapeutic power, the pay dirt of therapy, the therapist’s best friend.
The here-and-now refers to the immediate events of the therapeutic hour, to what is happening here (in this office, in this relationship, in the in-betweenness—the space between me and you) and now, in this immediate hour.
It is basically an ahistoric approach and de-emphasizes (but does not negate the importance of) the patient’s historical past or events of his or her outside life.
Chapter 15 - Why Use the Here-and-Now?
The rationale for using the here-and-now rests upon two basic assumptions: (1) the importance of interpersonal relationships and (2) the idea of therapy as a social microcosm.
Interpersonal relationships have enormous influence.Individuals seeking therapy have relational problems: problems in forming and maintaining enduring and gratifying interpersonal relationships.
Psychotherapy based on the interpersonal model is directed toward removing the obstacles to satisfying relationships.
Therapy as a social microcosm means that eventually the interpersonal problems of the patient will manifest themselves in the here-and-now of the therapy relationship, whether they are demanding, fearful, arrogant, self-effacing, seductive, controlling, or judgmental.
Little need of extensive history-taking. The rationale for using the here-and-now is that human problems are largely relational and that an individual’s interpersonal problems will ultimately be manifested in the here-and-now of the therapy encounter.
Chapter 16 - Using the Here-and-Now—Grow Rabbit Ears
Identify the here-and-now equivalents of your patient’s interpersonal problems and to focus on this aspect.
Develop here-and-now rabbit ears.Focus on the process, not the patient’s historical past or events of his or her outside life.
Therapy is like a living Rorschach test—patients project onto it perceptions, attitudes, and meanings from their own unconscious.Certain baseline expectations because all my patients encounter the same person. For example: the stimulus of the garden, or the landmark Fresca (that's considered upscale but not to the preference of all patients). Thus do we come to see the inner world, which can take to the heights or descend to the depths. Responses to surroundings, like the door latch, or Kleenex box, are important.
Patient's responses to your books constitute a rich source of material.
Aside from external factors, there are also: standard reference points, as well as: that most elegant and complex instrument of all—the Stradivarius of psychotherapy practice—the therapist’s own self.
Chapter 17 - Search for Here-and-Now Equivalents
Explore the situation at great depth and try to help the patient understand his/her role in the transaction, explore options for alternative behaviors, investigate unconscious motivation, guess at the motivations of the other person, and search for patterns.
But all too often it is based on inaccurate data supplemented by the patient.
Best strategy is to find such here-and-now equivalent of the dysfunctional interaction.
Example: Keith and permanent grudges.
A long-range task, to which we would return in the future, was to explore Keith’s inability to relinquish control. A more immediate task was to offer some immediate comfort and assist Keith to reestablish equilibrium.
Find: Keith’s apprehension and I was the subject in a personal relation of needing someone he treasured.
Work focused on greater immediacy and accuracy of one's awareness and sensitivity of another's feelings.
In the final analysis I feel certain that this here-and-now therapeutic work was far more powerful than a “then-and-there” investigation of the crisis with his son and that he would remember our encounter long after he forgot any intellectual analysis of the episode with his son.
Example: Alice and crudity.
Relationship between the patient's life in the present, and what she has come to experience are often key elements to finding solutions.
I was aware that I, too, wanted out and had pleasurable fantasies in which she announced she had decided to terminate. Even though she brashly negotiated a considerably lower therapy fee, she continued to tell me how unfair it was that I should charge her so much.
Exploration proves so useful and to which months later some very astonished elderly gentlemen received her phone calls of apology.
Example: Mildred and the lack of presence.
Similarities how she related to the text, and to what she had come to be there, in a relationship to their husband.
But how shut out I fell by her, then Mildred began to appreciate, to not exist to their husband, or the reverse.I never look my husband in the eyes when we have sex.”
Example: Albert and swallowed rage.
A here-and-now relationship, where the patient conveys to the analyst that things must go with direction, so they should not come to experience the feeling ripped off and giving him so little.
Expresss how you can know more as a patient than another, then you are going to make it with outcome where his analogy of his feelings is what we want it to be.
Chapter 18 - Working Through Issues in the Here-and-Now
Recognize patients problems here-and-now, identify the solutions to proceed.
Often focus on the same problems and help generate greater insight.Identify the relationship, and have the patient understand, or identify the here an now. Fastidious.
And not only the door, but also my cluttered desk, heaped high with untidy stacks of books.
Recognize patients problems here-and-now, identify the solutions to proceed.
Often focus on the same problems and help generate greater insight.
Identify the relationship, and have the patient understand, or identify the here an now. Fastidious.
And not only the door, but also my cluttered desk, heaped high with untidy stacks of books.
Chapter 19 - The Here-and-Now Energizes Therapy
When the here-and-now work is effective, therapist and patient alike feel enlivened by it.
Energy is generated by the potency of encounters.
It is often helpful to explain that you wish to offer a here-and-now experience, for the patient may benefit in two ways:
receiving help with the immediate problems between you and your other person
learning how to relate to others, and, in the future, to attend to the here-and-now relationship
patients often find this idea of learning how to attend to the here-and-now appealing and thus, in turn, are more open to discussing the relationship between the therapist and the patient
Chapter 20 - Use Your Own Feelings as Data
Therapist feelings toward the patient provide extremely useful information and can be used as valuable data about the patient’s impact on others.
The first rule is to experience the feeling; allow it to enter into full awareness.
Chapter 21 - Frame Here-and-Now Comments Carefully
One’s goal is to facilitate the most open communication possible.
First step, to increase feedback behavior, to make patients safer when they offer negative feedback. Use preparatory information and present this gradually.
Encourage patients to be less fearful of being honest with each other—especially about negative feelings. They have to be able to state things directly, to avoid the issues that led them to be patients.
Chapter 22 - All Is Grist for the Here-and-Now Mill
Here-and-now material is always available.
Consider comments re: the lateness of their arrival or how they are dressed
Chapter 23 - Check into the Here-and-Now Each Hour
Check-in with each patient along the lines of the half-hour drive recap.
How are we doing?
How have we been doing?
What will you be dwelling on when you leave?
What tensions or unspoken questions remain between us?
Chapter 24 - What Lies Have You Told Me?
In therapy, as in life, people are likely to lie or to suppress material which would leave a bad impression.
Deception is one of the central issues in an intimate relationship.
One way, a gentle exploration into the patient’s fears and reasons of untruth
Do you often cover up things that might make you look bad?
Can you remember ever trying to mislead me?
Is it always easy to be honest with me?
Is there something you felt like telling me but decided not to?
Chapter 25 - Blank Screen? Forget It! Be Real
Idea of analyst attitude of neutrality, passivity, anonymity, and near-invisibility must be abandoned.
The therapist must be real and must relate to the patient as one human being to another.
Chapter 26 - Three Kinds of Therapist Self-Disclosure
Three kinds of therapist self-disclosure:
mechanism of therapy—transparency
disclosure re: here-and-now feelings toward the patient
disclosure of the therapist’s personal life and experiences
Chapter 27 - The Mechanism of Therapy—Be Transparent
Transparency and disclosure that it is often advantageous for the therapist to share with the patient one’s thinking about what is happening in the therapy hour.
One has to take whatever risk is required to be authentic.
Example: Feeling sleepy and sharing it openly with the patient.
Chapter 28 - Revealing Here-and-Now Feelings—Use Discretion
Disclose feelings about patient with immense care; only when it serves patient’s interest—never to satisfy own needs.
Ask:
What exactly do I want to accomplish by telling patient this? (e.g., increase intimacy, diminish guilt, alter patient’s behavior?)
What are patient’s needs? Can patient hear it? Is patient strong enough to use information constructively?
Chapter 29 - Revealing the Therapist’s Personal Life—Use Caution
Revealing facts of therapist’s personal life must be done sparingly & judiciously.
Key issue: authenticity—patients quickly sense that therapist is putting on an act.
There is no way to teach authenticity—must be cultivated throughout therapist’s life.
Use: universality—realization that others have similar feelings/experiences.
Chapter 30 - Revealing Your Personal Life—Caveats
Never unload problems—counterproductive & role-reversing.
Brief—no more than a few sentences.
Disclose only if it will clearly benefit the patient.
Chapter 31 - Therapist Transparency and Universality
When the therapist becomes transparent, there may occur the expression on his/her face and in the gestures the emotional state.
The patient's reaction, should be used as something that can be considered for what they have come there to solve.
Chapter 32 - Patients Will Resist Your Disclosure
Patients enter therapy with deeply ingrained expectations—generally a wish for an omniscient and potent authority figure—and so, as powerful as the disconfirmation can be, not all patients are ready for it. Some will resist and attempt to maintain you in the established role. Some will reject your honesty; some will profess to want it but, in reality, reject it; some will distort it and attempt to fit it into the conventional therapeutic role.
Chapter 33 - Avoid the Crooked Cure
The “crooked cure”—inducing patients to like you in order to change.
Resist the temptation of being liked, approved, or admired.
Chapter 34 - On Taking Patients Further Than You Have Gone
No therapist can work with every patient; some patients require greater experience, courage, or endurance than any one therapist possesses.
Each therapist must know his/her limitations & refer patients when necessary.
Chapter 35 - On Being Helped by Your Patient
Don’t protect yourself from your patient; let the patient matter; be open to change.
Chapter 36 - Encourage Patient Self-Disclosure
One might pose a question: What secrets are you keeping from me?
Chapter 37 - Feedback in Psychotherapy
Effective psychotherapy is closely linked to the patient’s capacity to use feedback effectively.
Effective feedback:
must be clear and comprehensible
must be offered at an opportune moment
must be offered with adequate tact and empathy
Chapter 38 - Provide Feedback Effectively and Gently
The person can learn by receiving feedback when they act in a way that may not be appropriate, and often this allows them to change.
They do not have to change, however the ability to do so is of paramount importance, and as a therapeutic, your goal is to help the client become the person they want to be as defined by them and their values.
Chapter 39 - Increase Receptiveness to Feedback by Using “Parts,”
Suggest “parts” terminology to patients to consider self as composed of multiple parts.
Chapter 40 - Feedback: Strike When the Iron Is Cold
Strike when their iron is cold to let them consider information rather than make immediate decisions.
Chapter 41 - Talk About Death
Death is the 800-pound gorilla in the consulting room. It is always present. It knocks on the door of every session—sometimes subtly, sometimes not.
Death anxiety is ubiquitous, protean, and easily disguised.
Ignoring death is ignoring a powerful, omnipresent force that crucially shapes character structure and behavior.
The contemplation of death—even of one’s own death—is, paradoxically, a life-enhancing experience.
Chapter 42 - Death and Life Enhancement
My clinical experience has taught me that the best way to prepare for death is to live life to the fullest, to live meaningfully. To be engaged, to be, not just do.
Viktor Frankl argued, only suffering individuals are capable of reaching great spiritual depths.
Chapter 43 - How to Talk About Death
Begin gently and indirectly, then slowly and tentatively approach the subject.
Consider: are you afraid of dying? or often think about death? are you satisfied with the way you’re living? if you knew you had a terminal illness, how would you live differently?
Chapter 44 - Talk About Life Meaning
Patients, particularly those who have passed through middle age, often express grave concerns about meaning in life.
There is no means for prescribing or bestowing meaning. Meaning must be discovered by each person.
Therapy can help patients encounter existential awareness, the realization that they are in charge of their own lives.
Chapter 45 - Freedom
The “existential givens” or ultimate concerns: death, isolation, meaninglessness, and freedom.
Freedom, the ground from which we may create our own world (in essence, be responsible for our own world, destiny, suffering).
Chapter 46 - Helping Patients Assume Responsibility
The patient must understand that, regardless of the source of their problems, only they can do something about it.
I endeavor to teach my patients that although we cannot choose the cards we are dealt, we can choose how we play the hand.
Chapter 47 - Never (Almost Never) Make Decisions for the Patient
The therapist avoids imposing his/her judgment because decision making is crucial for the development of autonomy and identity.
Chapter 48 - Decisions: A Via Regia into Existential Bedrock
Decisions, freedom, and responsibility are inextricably linked. A focus on decision opens directly into ultimate existential concerns. Decision is the royal road to existential awareness.
Chapter 49 - Focus on Resistance to Decision
My approach to patients who face difficult decisions is seldom content-oriented. I never offer advice about the external situation. What interests me is their decision-making process: How do they avoid making a choice? What feelings and fantasies does the thought of deciding arouse in them? Are they aware of their responsibility in constructing their world?
Chapter 50 - Facilitating Awareness by Advice Giving
Advice giving has a powerful effect of rapidly shifting power balance in therapy. Advice-giving almost always stems from the advice-giver’s needs, not the patients’.
Chapter 51 - Facilitating Decisions—Other Devices
Encourage self-monitoring, have patient imagine worst-case scenario, employ role-playing.
Chapter 52 - Conduct Therapy as a Continuous Session
Therapy is far more effective when both patient and therapist regard it as a continuous process that extends far beyond the consulting room. This means encouraging patients to think about their therapy and the insights they gain even outside of scheduled sessions. Therapists can facilitate this by suggesting exercises or reflections that patients can engage in between appointments, reinforcing the idea that therapy is an ongoing journey rather than an isolated event.
Chapter 53 - Take Notes of Each Session
Record information—facts and subjective reactions—so you can be maximally prepared for the next meeting. Detailed notes help the therapist track progress, identify patterns, and recall important details shared by the patient. These notes should include not only factual information but also the therapist's own reactions and observations, providing a comprehensive record of the therapeutic process.
Chapter 54 - Encourage Self-Monitoring
One way of extending the therapy beyond the session is encouraging our patients to take notes about themselves between sessions. Self-monitoring can involve journaling, tracking moods, or noting specific behaviors or thoughts that arise. This practice helps patients become more aware of their own patterns and triggers, empowering them to take an active role in their therapeutic journey.
Chapter 55 - When Your Patient Weeps
When your patient weeps, do nothing. Stay present. Don’t reach out, fidget, or offer a tissue.
One runs the risk of diminishing them—of stopping the flow. If you do something, you rupture the connection. Allowing the patient to experience their emotions fully without interruption can be a powerful therapeutic intervention. It communicates acceptance and allows the patient to process their feelings authentically.
Chapter 56 - Give Yourself Time Between Patients
Always allow time for personal reflection after each session. This time allows the therapist to process the session, reflect on their own reactions, and prepare themselves mentally and emotionally for the next patient. This practice helps prevent burnout and ensures that each patient receives the therapist's full attention and care.
Chapter 57 - Express Your Dilemmas Openly
Share your own therapy dilemmas with the patient. When appropriate, sharing relevant dilemmas the therapist faces can foster a sense of collaboration and normalize the challenges inherent in the therapeutic process. This self-disclosure must be used judiciously and only when it serves the patient's therapeutic goals.
Chapter 58 - Do Home Visits
Home visits offer therapists invaluable information about patients. Visiting a patient's home environment can provide unique insights into their daily life, relationships, and challenges. This information can be invaluable in tailoring the therapeutic approach to the patient's specific needs and circumstances.
Chapter 59 - Don’t Take Explanation Too Seriously
Don’t take explanation too seriously; there are some things we cannot know. Acknowledging the limits of understanding can be liberating for both the therapist and the patient. It encourages acceptance of uncertainty and fosters a focus on the present moment rather than dwelling on elusive explanations.
Chapter 60 - Therapy-Accelerating Devices
Consider the following therapy-accelerating devices:
homework assignments
written summaries of each session
asking patients to formulate their own diagnosis
exchanges of audiotapes (or videotapes) between therapist and patients
asking patients to write a letter to significant individuals (living or dead) in their life
These devices enhance the therapeutic process by encouraging active participation, self-reflection, and exploration of emotions and experiences.
Chapter 61 - Therapy as a Dress Rehearsal for Life
Use enactments in therapy to provide patients opportunities to rehearse new behavior. Ex: woman negotiating with boss rehearsed her speech with therapist. Therapy can serve as a safe space for patients to practice new skills and behaviors before applying them in real-world situations. Role-playing, simulations, and other enactments can help patients build confidence and develop effective coping strategies.
Chapter 62 - Use the Initial Complaint as Leverage
The initial complaint serves as a potent lever for therapeutic change. By focusing on the patient's initial concerns, the therapist can gain valuable insights into their underlying issues and motivations. This approach helps to establish a clear focus for therapy and facilitates progress toward the patient's goals.
Chapter 63 - Don’t Be Afraid of Touching Your Patient
Touching can further the therapeutic work. When used appropriately and with sensitivity, touch can be a powerful tool for building trust, conveying empathy, and facilitating emotional connection. However, therapists must be mindful of boundaries and cultural considerations when using touch in therapy.
Chapter 64 - Never Be Sexual with Patients
A therapist never engages in sexual activity with a patient. Maintaining clear boundaries and avoiding any form of sexual contact with patients is essential for ethical and effective therapy. Such behavior is always harmful and exploitative.
Chapter 65 - Look for Anniversary and Life-Stage Issues
Always be alert to the possible impact of anniversary reactions. Significant life events, such as anniversaries or birthdays, can trigger intense emotions and unresolved issues. Being aware of these potential triggers allows the therapist to provide support and guidance as patients navigate these challenging times.
Chapter 66 - Never Ignore “Therapy Anxiety,”
Always attend to the level of anxiety experienced by patients prior to each therapy session. Addressing therapy anxiety can help to create a more comfortable and productive therapeutic environment. Therapists can use relaxation techniques, mindfulness exercises, or open communication to alleviate anxiety and encourage patients to engage fully in the process.
Chapter 67 - Doctor, Take Away My Anxiety
Understand both the advantages and disadvantages of the patient’s symptom(s). Exploring the function of anxiety or other symptoms can provide valuable insights into the patient's coping mechanisms and unmet needs. This understanding can help the therapist develop more effective interventions and support the patient in finding healthier ways to manage their emotions.
Chapter 68 - On Being Love’s Executioner
A discussion on “love’s executioner” in therapy. This concept refers to the difficult but necessary role that therapists sometimes play in helping patients confront painful realities and make difficult choices in their relationships. It requires empathy, honesty, and a commitment to the patient's well-being, even when it means delivering uncomfortable truths.
Chapter 69 - Taking a History
Taking a history—the therapist’s initial effort to get to know the patient, his/her world, and the reasons s/he has come to therapy—is an important and significant part of therapy. Gathering a thorough history helps the therapist understand the patient's background, experiences, and presenting concerns. This information is essential for developing an effective treatment plan and building a strong therapeutic relationship.
Chapter 70 - A History of the Patient’s Daily Schedule
A history of the patient’s daily schedule can lead to important data gathering. Examining the patient's daily routine can reveal patterns, stressors, and opportunities for change. This information can be used to identify areas where the patient may benefit from lifestyle adjustments or coping strategies.
Chapter 71 - How Is the Patient’s Life Peopled?
Ask the patient about the important people in his/her life. Understanding the patient's relationships and social support system is crucial for effective therapy. Exploring the quality of these relationships and any conflicts or challenges that may arise can provide valuable insights into the patient's interpersonal dynamics.
Chapter 72 - Interview the Significant Other
Interviewing significant others in the patient’s life can be helpful in understanding the patient. With the patient's consent, interviewing family members or partners can offer additional perspectives and insights into the patient's behavior, relationships, and challenges. This information can be particularly helpful in addressing interpersonal issues and developing collaborative treatment strategies.
Chapter 73 - Explore Previous Therapy
Investigating the patient’s previous therapy can reveal important information (patient’s expectations re: therapy, their attitude toward therapists, etc.). Exploring the patient's experiences in previous therapy can help the therapist understand their expectations, preferences, and any potential barriers to progress. This information can be used to tailor the current therapy to the patient's specific needs and goals.
Chapter 74 - Sharing the Shade of the Shadow
Integrate what is rejected and alien back into ego (Carl Jung believed). This concept involves helping patients to acknowledge and integrate aspects of themselves that they have previously disowned or rejected. By embracing these "shadow" qualities, patients can achieve greater wholeness and self-acceptance.
Chapter 75 - Freud Was Not Always Wrong
The author’s reflection on some of Freud’s contributions to psychotherapy. Despite criticisms of some of Freud's theories, he made significant contributions to the field of psychotherapy, including the importance of the unconscious, the role of early childhood experiences, and the value of interpretation.
Chapter 76 - CBT Is Not What It’s Cracked Up to Be … Or, Don’t Be Afraid of the EVT Bogeyman
A presentation of the strengths and limitations of Cognitive Behavioral Therapy. While CBT can be effective for certain conditions, it may not be appropriate for all patients or all issues. It's important to consider the patient's individual needs and preferences when choosing a therapeutic approach and not be overly influenced by the emphasis on Evidence Based Treatments.
Chapter 77 - Dreams—Use Them, Use Them, Use Them
Dreams offer a rich source of material for therapy. They can provide insights into the patient's unconscious thoughts, feelings, and conflicts. Therapists should encourage patients to share their dreams and explore their potential meanings. Exploring dreams can uncover hidden emotions, unresolved issues, and symbolic representations of the patient's inner world. Therapists can use various techniques to help patients interpret their dreams, such as free association, dream journaling, and examining recurring symbols or themes.
Chapter 78 - Full Interpretation of a Dream? Forget It!
A full, exhaustive interpretation of a dream is often unnecessary and impractical. Instead, therapists should focus on identifying the most relevant and meaningful elements of the dream for the patient's current concerns. Overanalyzing every detail of a dream can be time-consuming and may not always yield useful insights. Prioritizing the most salient aspects of the dream allows for a more focused and productive exploration.
Chapter 79 - Use Dreams Pragmatically: Pillage and Loot
Therapists should approach dreams pragmatically, extracting useful information and insights without getting bogged down in complex symbolism or theoretical interpretations. "Pillage and loot" refers to selectively taking what is valuable from the dream. This approach emphasizes the practical application of dream analysis to address the patient's immediate concerns. It encourages therapists to be flexible and creative in their interpretation, focusing on what resonates most with the patient.
Chapter 80 - Master Some Dream Navigational Skills
Therapists should develop skills in dream interpretation, such as recognizing common symbols, identifying recurring themes, and understanding the patient's personal associations with dream elements. Proficiency in dream analysis enhances the therapist's ability to guide patients in exploring their unconscious processes. Understanding dream language and symbolism can help unlock deeper layers of meaning and facilitate therapeutic breakthroughs.
Chapter 81 - Learn About the Patient’s Life from Dreams
Dreams can provide valuable information about the patient's past experiences, current relationships, and future aspirations. Therapists should pay attention to the people, places, and events that appear in the patient's dreams. Examining the narrative structure and emotional content of dreams can reveal patterns and conflicts that may be influencing the patient's waking life.
Chapter 82 - Pay Attention to the First Dream
The first dream shared in therapy can be particularly significant, as it may reveal the patient's initial expectations, fears, and hopes for the therapeutic process. This dream can serve as a baseline for understanding the patient's unconscious motivations and concerns. Attending to the details and emotions expressed in the first dream can help establish a strong foundation for therapeutic exploration.
Chapter 83 - Attend Carefully to Dreams About the Therapist
Dreams about the therapist can offer valuable insights into the therapeutic relationship and the patient's feelings toward the therapist. These dreams should be explored with sensitivity and openness. Analyzing these dreams can provide opportunities to address transference issues, clarify boundaries, and deepen the therapeutic bond.
Chapter 84 - Beware the Occupational Hazards
Therapists face several occupational hazards, including burnout, compassion fatigue, and vicarious traumatization. It's important for therapists to engage in self-care and seek support to mitigate these risks. Recognizing and addressing these hazards is essential for maintaining well-being and providing effective therapy.
Chapter 85 - Cherish the Occupational Privileges
Therapy offers unique occupational privileges, such as the opportunity to witness personal growth, make a positive impact on others' lives, and engage in meaningful work. Appreciating these privileges can foster a sense of fulfillment and purpose in the therapeutic profession.