24 August 2012

Existential Psychotherapy by Yalom - Review


Heavy in both senses of the term


I was delighted to receive this for Christmas last year. As most that know me are aware (and many that don't) I am in danger of placing Irvin Yalom on a pedestal, for his books are awesome (truly awesome, not "quite-good-but-I'll-say-awesome-to-make-it-sound-more-cool-and-vibrant-awesome").

Strangely, in an about-face of my usual reading preferences, I actually prefer Irvin's fiction to his non-fiction (this book is non-fiction, by the way). Generally speaking, I struggle with most fiction and can only really enjoy that which is edgy, inventive and written in terms of the world being various shades of grey (no, not that "shades of grey" - pah!) rather than black and white. So my favourite choices are Chuck Palahniuk, Will Self, Jean-Paul Sartre, H G Wells and some obscure sci-fi (look up the sub-genre "Dying Earth"). 

In the case of Yalom, his fiction hits the spot, and being that it is mainly about the psychotherapy profession holds automatic intrigue for me. The fact that Irvin is hugely super-intelligent and insightful, as well as humble and generous of spirit helps matters.

During my integrative training I firmly settled on preferring a person-centred approach for counselling. I did my placement hours at a person-centred organisation. The whole while I was aware that there was an undercurrent of existential approach to my practice and I explored this to a point whilst in training. Around a year ago I had a dream about some "experts" analysing my counselling work (this is the only dream I have ever had about my work, by the way). They told me that my approach was more existential than all the counsellors who were calling themselves existential.  This dream awoke me to the truth of my approach - more existential than I was caring to declare. I was reading Sartre's "Age of Reason" and holidaying in Paris at the time so maybe the existential vibes soaked into me irreversibly that night.

So, to the book.  Prior to reading this I warmed up with Skills in Existential Counselling and Psychotherapy by Emmy Van Deurzen and Martin Adams. It was decent enough, but quite basic and better suited to people in training (to whom I heartily recommend it). So I was eager enough to move onto the much weightier tome that is Yalom's offering.

I absolutely loved reading it. Every night, in bed,  I was happy to open the book and feel it's heavy mightiness aching my arms and pushing against my body (sounding a bit 50 Shades...). 

An enticing introduction explains a little about the history and current context of the realm of existential  therapy. Yalom states that :

"...it is my belief that the vast majority of experienced therapists, regardless of their adherence to some other ideological school, employ many of the existential insights I shall describe." Yalom acknowledges the reputation the approach has for being vague and indefinable and goes on to say that ..."the existential approach is a valuable, effective psychotherapeutic paradigm, as rational, as coherent, and as systematic as any other". 

Thereafter, the book is split into four parts - each part covering one of the "givens" of human existence. 

Part 1 - Death


Probably the most obvious one. I think most people have had the thought at some time in their life "Yikes, I'm going to die one day". This part explores reactions to this knowledge, starting off with childhood and then looks at differing coping mechanisms. The idea of there being The Ultimate Rescuer intrigued me. 

I was quite spooked when I read a paragraph on the relationship between sex and death. This part in particular, on the desire to merge with another and the paradoxical desire to retain autonomy:

"The task of satisfying both needs - for separateness and autonomy and for protection and merger - and of facing the fear inherent in each, is a lifelong dialectic that govern one's inner world. It is a task that begins in the first months of life, when the child, who first is symbiotically merged with the mother...must, in order to develop a sense of identity, of wholeness and separateness, disengage and differentiate from the mother..."

This was exciting for me to read as, before my appointment earlier this year with Yalom, I had mooted this very point as something I wanted to ask him about, before I was aware that he had written about it some 32 years earlier:

Connection – what is the source of our yearning for connection? Conception is the product of union; being born is the ultimate divide. Is love a construct to attempt to gain the approximation of the togetherness of gestation? And is death, therefore, sweet relief from the inevitable lifelong pain and yearning?

I was so excited - no wonder I love reading his stuff - he articulates and puts forward the very contents of my meandering mind. How does he do that? (I know, I know, my position on the narcissism spectrum springs to mind). Actually, as a tangent, I recently looked up Yalom's Myers-Briggs type which is apparently the same as mine, my partner and some very close friends of mine. Maybe there's something in this MBTI. Alain de Botton, another of my declared heroes, is also the same type. However, so is Hitler...(keeping my feet firmly on the ground there; de-narcissifying perhaps).

So back to death. As with the entire book, references to fiction, philosophy and the words of other, eminent psychotherapists are woven throughout the text. I like this paragraph and Yalom's reference to Otto Rank: 

"The attempt to escape from death anxiety is at the core of the neurotic conflict.... The neurotic life style is generated by a fear of death, but insofar as it limits one's ability to live spontaneously and creatively, the defense against death is itself  a partial death. That is what Rank meant when he said that the neurotic refuses the loan of death to escape the debt of death by daily-partial self-destruction."

Heavy.

And yet, refreshing...

Yalom refers to the Stoics:

"Contemplate death if you would learn how to live"

and Santayana:

"The dark background which death supplies brings out the tender colours of life in all their purity."

Far from depressing and morbid (as death-talk is often accused of being) I find that exploring death in this way makes me feel more alive and more appreciative of my life force. I do appreciate that it's not everybody's cup of tea, however, and the differing strategies or constructs to deal with the harsh reality of death are covered at a satisfying depth.


Part 2 - Responsibility


This refers to the freedom we have to make choices about our life. When looked at fundamentally, this is actually more scary than it seems on the surface. Yalom kicks off with a quote from Sartre regarding responsibility - to be responsible is to be "the uncontested author of an event or thing". As it happens, one of my favourite quotes comes from Sartre "Freedom is what you do with what you've been given" - which I thinks honours the fact that there are some things that can't be changed, and acknowledges the fact that some things are our choice...(or are they...I drive myself round in circles with this one...) anyway, it pretty much works for me...

Yalom states that "For the patient who will not accept such responsibility, who persists in blaming others (who knows someone like that?) - either other individuals or other forces - for his or her dysphoria, no real therapy is possible."

I was interested to read a description of what can be so alluring to be a member of a cult-like organisation. Irvin describes the culture of est - Erhard Seminars Training which purports to be big on helping the members assume responsibility for their own lives. However, Yalom points out the high level of conformity required by members who were to volunteer their time. Yalom quotes a volunteer, a clinical psychologist who explains her tasks to arrange name tags in perfect parallel rows, pinning tablecloths in exactly the same, formal way (under supervision) with meticulous attention to detail. She describes being thanked by a superior for writing directions as leaving her "high for hours". There was also apparently only one way to clean the toilets and if a coffee cup was raised to clean underneath it, it had be placed back precisely where it was.

Yalom wryly observes: 

"Doing things the right way. Cleaning toilets the est way. Replacing coffee table objects precisely...doing humour at "humour time", "High for hours" after being complimented for mapping the most efficient route to the bathroom. These words reflect an obvious satisfaction in the losing of one's freedom, in the joy of surrendering  autonomy and donning the blinders of a beast of burden."

I am quite interested in cult mentality at the moment and am currently reading "Captive Hearts, Captive Minds - Freedom and Recovery from Cults and Abusive Relationships" (Madeleine Landau Tobias and Janja Lalich). Reading Yalom's chapter on responsibility helps me to understand why some people would rather hand their's over to a cult, a religion, an illness (labelling oneself an addict, for example) or even a prison warden.

I love this quote from Binswanger:

"The fact that our lives are determined by the forces of life is only one side of the truth; the other is that we determine these forces as our fate. Only the two sides together can take in the full problem of sanity and insanity."

And another Stoic quote - this time Epictetus:

"I must die. I must be imprisoned. I must suffer exile. But must I die groaning? Must I whine as well? Can anyone hinder me from going into exile with a smile? The master threatens to chain me: what say you? Chain me? My leg you will chain - yes, but not my will - no, not even Zeus can conquer that."

Although I do think of water boarding and electric shock torture and wonder if those are capable of  removing a man's will...? Another discussion...

And so onto...

Part 3 - Isolation


In a shorter section, Existential Isolation is explained. This is not lack of friends, or feeling "lonely" in the usual sense, which is interpersonal isolation. Nor is it intrapersonal isolation which Yalom describes as "whenever one stifle's one's own feelings or desires, accepts "oughts" or "should" as one's own wishes, distrusts one's own judgement, or buries one's potential". (*gulp*, been there, I can feel my existential guilt coming on...).

Existential isolation refers the gritty realisation that there will always be a gulf between us and another being, and, moreover, between us and the rest of the whole world (universe - EVERYTHING!).

Yalom writes a lot about relationship here and there is an analysis of Buber's contribution to the philosophy of relationship. Including this haunting dream which Buber writes about in his book "Between Man and Man":

whilst "in a vast cave, or mud building, or on the fringes of a gigantic forest.... I cry out....Each time it is the same cry, inarticulate but in strict rhythm, rising and falling, swelling to a fullness, which my throat could not endure were I awake, long and slow quite slow and very long, a cry that is a song. When it ends my heart stops beating. But then, somewhere, far away, another cry mourns towards me, another which is the same, the same cry uttered or sung by another voice"

Yalom moves on to Maslow who describes two types of love; one motivated by deficiency (selfish love) and the other by growth (unselfish love). Then comes Fromm's answer to the fundamental concern of existential isolation "The full answer lies in the achievement of interpersonal union, of fusion with another person, in love."

Ah! How romantic. 

I could go a bit 50's shades here and describe Fromm's "symbiotic union" which consist of "an active (sadism) and a passive (masochism) form... a state of fusion where neither party is whole or free" but let's not. Let's look at "Mature love...a union under the condition of preserving one's integrity, one's individuality...In love the paradox occurs that two beings become one and remain two".

Which reminds me of how much I value Yalom's drawing upon centuries of philosophical and psychotherapeutic endeavour and presenting it, along with his own wisdom, throughout all of this work.

And so on to the final part...

Part 4 Meaninglessness


I struggle a little with the title as it implies (to me) that there is actually no meaning, although I do tend to see existence that way, personally. However, I appreciate that some people do believe that life has meaning for everybody. I'm not one of them. I believe that we create meaning for ourselves in order to make life easier. Enough of me.

Yalom starts off with a rather sombre suicide note (and yes, all the given of human existence overlap, at times considerably, and Yalom has done a good job of keeping them separate and honouring the overlaps):

"Imagine a happy group of morons who are engaged in work. They are carrying bricks in an open field. As soon as they have stacked all the bricks at one end of the field, they proceed to transport them to the opposite end. This continues without stop and everyday of every year they are busy doing the same thing. One day one of the morons stops long enough to ask himself what he is doing. He wonders what purpose there is in carrying the bricks. And from that instant on he is not quite as content with his occupation as he had been before.
I am the moron who wonders why he is carrying the bricks."

So the final part looks at how we struggle with and attempt to come to terms with the fact that existence does not come with meaning automatically provided. Yalom looks at Viktor Frankl's contributions which I very much value. I do struggle a little with an element of Frankl's philosophy - that EVERYBODY has choices (am working my way through Frankl's The Doctor and the Soul). I don't believe that everybody has choice. I do believe that those that come for counselling have the capacity to choose, and in the context of a blogpost written from the perspective of a counsellor, I think it is important to say that. I do enjoy reading Viktor Frankl and highly recommend "Man's Search for Meaning" to just about anybody. Yalom explores Frankl's "Logotherapy" which is not very well heard of but I think is a relatively philosophically sound approach to psychotherapy, from what I've read. Logotherapy is a therapy based on man finding meaning in life.

There is a fascinating exploration of the clinical manifestations of meaninglessness with headings such as "Existential Vacuum and Existential Neurosis" and  Crusadism, Nihilism, and Vegetativeness". I do enjoy looking at the concept of nihilism in particular (click on the word if you're unsure as to it's meaning, and want to potentially stumble down a rabbithole).

In summary


This is a marvellous book, not for everybody but certainly for any therapists and for the layman who wants to explore his or her own existential givens.


It took Yalom 10 years to write it, and I am so glad he perservered. Thank you for providing this gift to the world. I want my children to read it, I want my loved ones to read it.

Amanda Williamson is a professional, private counsellor working in Exeter, Devon















7 comments:

Kate Wilson said...

I really like the sound of this book... I think I count as an existential layman!

John Marsden said...

Enjoyed reading your reflections on a great book.

John Marsden said...

Enjoyed reading your reflections on a great book.

Philip Ohl said...

Thanks for posting, just purchased the book!

Amanda Williamson said...

The following two nights after writing this I had dreams about my clinical supervisor (having stated above I have only dreamt once about my work!).

Matthew Bishop said...

Thanks Amanda, it sounds like you're working your way through quite a few books. I've got this book of Yalom's sitting there to be read at some point. I've read most of his other stuff and have enjoyed it.

That said, I don't consider Yalom to be an existential therapist. Not in the strict sense at least. So I find it strange that he is seen as 'the' existential therapist (he's the only one that many therapists can name). I view him rather as a psychodynamic and humanistic therapist who focuses on existential themes. The themes are especially the ones you've laid out. But it is interesting to look at his manner of working with clients, as seen in the case studies/stories, and this is where we can see him working according to those other traditions. I will be brief and so simplistic, so to take an example:

The way he conceives of our response to the givens of existence in terms of defense mechanisms is psychodynamic.

His interventions, such as when he engages in "love making" (emotional intimacy) with a client as he goes through her handbag (was that in Love's Executioner?) and describes this as the finest therapy he ever gave, is humanistic (his theorising about therapy of which this provides an example is also consistently humanistic).

So I consider Yalom an interesting integrative therapist who works more psychodynamically and humanistically than existentially, though his integration is of all three. It is an intriguing example of an integration, and I should clarify that am very grateful for the presence of his work.

This also means that he works psychologically rather than philosophically. An existential approach is phenomenological, and so for example the interpretation of defense mechanisms is not high on its list as it is for Yalom. A properly philosophical approach does not place relating at the centre of the therapeutic work either, at least not in the humanistic way that Yalom does - it is more concerned with being-with the other as a way of drawing out and helping them to gain understanding, than in prescribing values regarding intimacy in the way that humanistic therapy and Yalom do.

This is why I'm so attracted to the books coming out of 'the British school' such as Emmy's work. I think it's much better from a strict existential perspective. Which is a breath of fresh air because, let's face it, psychologists and the psychological perspective (such as is expressed in psycho-dynamics) constitutes the dominant paradigm and tends to mute or distort other voices - I think this is why Yalom is treated as 'the' existential therapist in common therapist opinion, while the genuinely existential therapists are so much less heard of. It is for this reason I have to disagree with your assessment of van Deurzen and Adam's book - despite being very accessible, I think that the background conceptual work is far more aware and tight and properly existential by comparison with the confusion that we must ascribe to Yalom when we claim that his project is existential.

I do also think that he tends to romanticise death a little. But that's a matter for another conversation....

Amanda Williamson said...

Matthew. I am very appreciative of your well written and comprehensive response. Maybe Yalom is seen as 'the existential therapist' because the way he writes about it is so accessible and enticing.
Are there any other good books you personally recommend on the subject?
Best wishes
Amanda

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