The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients

“Instead, I prefer to think of my patients and myself as fellow travelers, a term that abolishes distinctions between ‘them’ (the afflicted) and ‘us’ (the healers). […] We are all in this together and there is no therapist and no person immune to the inherent tragedies of existence.”

Yalom develops the theme of Openness and Equality in the Therapist-Patient Relationship as he explains his egalitarian approach to relating to his patients. While some psychoanalytical models emphasize the differences between therapists and their clients, Yalom believes that therapists should remember their shared humanity. In doing so, they can better relate to their patients and avoid condescending to them. This quotation also adds to Yalom’s point that therapists can and should experience personal growth through their interactions with their clients.

“It is extraordinarily difficult to know really what the other feels; far too often we project our own feelings onto the other.”

Yalom encourages therapists to carefully evaluate their own interpretations of their patients’ feelings and to avoid making quick assumptions about their patients’ experiences. This idea builds on the theme of Therapists’ Personal Development and Self-Awareness, as he argues that therapists should have a good understanding of their own biases and feelings to avoid conflating their own experiences with that of their patients.

“If you make a mistake, admit it. Any attempt at cover-up will ultimately backfire. At some level the patient will sense you are acting in bad faith, and therapy will suffer. Furthermore, an open admission of error is good model-setting for patients and another sign that they matter to you.”

Yalom argues that humility and authenticity help therapists create positive relationships with their patients. This quotation ties in with the theme of Therapists’ Personal Development and Self-Awareness, as he emphasizes that therapists are human, too, and should openly acknowledge the flaws and biases that crop up in their work.

“To my mind, personal psychotherapy is, by far, the most important part of psychotherapy training. Question: What is the psychotherapist’s most valuable instrument? Answer (and no one misses this one): the therapist’s own self.”

Yalom urges therapists to consider pursuing ongoing therapy as patients in order to learn more about themselves and their strengths and weaknesses. This bolsters his theme of Therapists’ Personal Development and Self-Awareness, as he paints introspection and personal therapy as a prerequisite to becoming a competent therapist.

“So vital for effective therapy is the here-and-now that I shall discuss it more extensively than any other topic in this text. 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 deemphasizes (but does not negate the importance of) the patient’s historical past or events of his or her outside life.”

Yalom believes that therapist-patient interactions during therapy hold valuable clues about a patient’s behavior and worldview, and he urges therapists to stay attuned to their clients’ reactions in the present moment of therapy. This passage establishes Yalom’s theme of Harnessing the Power of the Present During Therapy, arguing that the “here-and-now” is an essential part of therapy that is more important than mining a client’s past experiences.

“The here-and-now offers a far better way to work. The general strategy is to find a here-and-now equivalent of the dysfunctional interaction. Once this is done, the work becomes much more accurate and immediate.”

By coaching therapists to use their clients’ immediate, present behavior as an opening to discuss chronic issues, Yalom develops his theme of Harnessing the Power of the Present During Therapy. This passage helps to explain why Yalom finds this technique so effective, motivating therapists to try it in their own sessions.

“If you develop a deep knowledge of yourself, eliminate the majority of your blind spots, and have a good base of patient experience, you will begin to know how much of the boredom or confusion is yours and how much is evoked by the patient.”

Yalom develops the theme of Therapists’ Personal Development and Self-Awareness as he coaches therapists to build their own self-understanding. He explains that without self-awareness, therapists may blame their patients for making them feel bored or confused rather than understanding their own role in creating this disconnected dynamic.

“Everything—especially episodes containing heightened emotion—is grist for the mill. Many unexpected events or reactions occur in therapy. […] Though I feel uncomfortable going through some of these experiences, I also feel confident that, if I address them properly, I can turn them into something useful in the therapeutic work.”

Yalom develops the theme of Harnessing the Power of the Present During Therapy as he asks therapists to consider uncomfortable events that occur during therapy as opportunities to gain better clarity and understanding of their patients. This positive approach will help therapists make full use of difficult moments for the benefit of their patients, rather than trying to ignore them just because it might be simpler to do so.

“Responsibility assumption is an essential first step in the therapeutic process. Once individuals recognize their role in creating their own life predicament, they also realize that they, and only they, have the power to change that situation.”

Yalom emphasizes how accepting responsibility is a key part of the process of self-actualization. He reminds therapists that they can’t help their patients simply by empathizing with them. Rather, they must help their patients discover and use their own agency.

“Decision is another boundary experience. It not only confronts us with the degree to which we create ourselves, but also to the limits of possibilities.”

Yalom discusses the crucial element of decision making as a means of achieving self-actualization. He argues that people’s process of making, or avoiding, decisions reveals their relationship to their existential concerns, particularly their fear of death. Patients who are more anxious about their mortality have a harder time making decisions, which are inherently limiting, since this reminds them of the ultimate limitation of death.

“If therapists are to be the historians of the therapy process and to attend to the continuity of the sessions, then it follows that they must keep some chronicle of events.”

Yalom advises therapists to take detailed notes on their therapy sessions as soon as they conclude and to revisit these notes prior to the next session with the same patient in order to make therapy feel seamless and continuous. This pragmatic advice helps therapists to remember to jog their memory and keep their patients’ stories and concerns fresh in their minds.

“Because weeping often signifies the entry into deeper chambers of emotion, the therapist’s task is not to be polite and help the patient stop weeping. Quite the contrary—you may wish to encourage your patients to plunge even deeper.”

This passage advances Yalom’s theme of Harnessing the Power of the Present During Therapy by coaching therapists to respond with curiosity to their patients’ emotional expression. By exploring how and why their patients are expressing themselves in certain ways, therapists can use the present moment to explore memories from the past and ongoing concerns.

“Home visits are significant events, and I do not intend to convey that beginning therapists undertake such a step lightly. Boundaries first need to be established and respected, but when the situation requires it, we must be willing to be flexible, creative, and individualized in the therapy we offer.”

Yalom believes that home visits can be highly beneficial for patients and that therapists should perform them more often. This idea adds to his theme of Openness and Equality in the Therapist-Patient Relationship, as he urges therapists to reconsider their existing boundaries with patients and become open to the idea of seeing their homes and daily life.

“The beauty of it is that it keeps patient and therapist tightly connected while the real agent of change—the therapeutic relationship—is germinating.”

Developing his theme of Openness and Equality in the Therapist-Patient Relationship, Yalom praises the “hunt,” or intellectual pursuit of clues from the patient’s life, which the therapist and patient undertake together. He disagrees with Freud that this process has a certain destination, such as uncovering a specific original trauma. Instead, he feels that the process of analyzing memories and ongoing events is inherently bonding for the therapist and their patient.

“In the late stages of therapy, I am energetic in ensuring transfer of learning. If I deem it necessary, I begin to coach actively, to press the patient to experiment with new behaviors in work, social, and family settings.”

Yalom acknowledges that some patients may participate in every aspect of therapy but still struggle to apply their learning in their lives. He confronts this passivity by encouraging his patients to change their behavior and apply the skills they have learned in therapy. He emphasizes how patients can claim their agency and make different choices to reach toward self-actualization.

“Artificial boundaries—patient and therapist, the sick and the well, the dying and the living—evaporated as we all felt joined to the others by a common humanity. I make a point to touch each patient each hour—a handshake, a clasp of the shoulder, usually at the end of the hour as I accompany the patient to the door.”

Yalom explains how, with consent and boundaries, he incorporates supportive physical gestures into his relationships with patients. By acknowledging that physical touch can break down formality and build a closer connection between therapist and patient, Yalom challenges therapists to consider being physically affectionate with patients. With this, he builds on the theme of Openness and Equality in the Therapist-Patient Relationship.

“Although anxiety may sometimes issue from the content of the therapy discussion, far more commonly it stems from the process—from feelings about the patient-therapist relationship.”

Yalom argues that much of patients’ anxiety around attending therapy has to do with their relationship with the therapist. By encouraging therapists to discuss this form of anxiety with their patients and acknowledge the patients’ vulnerability, Yalom develops the theme of Openness and Equality in the Therapist-Patient Relationship.

“I make sure everything is discussed, including eating and sleeping habits, dreaming, recreation, periods of discomfort and of joy, precise tasks at work, the use of alcohol and drugs, even reading, film, and TV preferences. If this inquiry is sufficiently detailed, therapists can learn a great deal, uncovering information that is often missed in other history-taking systems.”

Yalom coaches therapists to thoroughly analyze their patients’ lives, even discussing seemingly trivial aspects of daily life. This opens therapists to the idea that they can form a more holistic view of their patients by understanding their day-to-day routines.

“Since I prefer to have no secret, outside knowledge of my patients, I always interview the significant other in the presence of my patient. Elicit the partner’s feedback and suggestions for ideas of the changes the patient might make rather than conduct a personal interview of the partner. You will get a sufficiently complex picture of the partner just from the way he/she gives you feedback.”

This idea pushes therapists to consider novel ways of how they could gain a clearer understanding of their patient and help them progress. It ties in with the theme of Openness and Equality in the Therapist-Patient Relationship, as he recommends always being open and transparent with patients and their partners to maintain a trusting working relationship.

“There Freud posits the fundamentals of our field: the value of insight and deep self-exploration and expression; the existence of resistance, transference, repressed trauma; the use of dreams and fantasies, role playing, free association; the need to address characterological problems as well as symptoms; and the absolute necessity of a trusting therapeutic relationship.”

Yalom defends Freud from critics who negate all of Freud’s work. By emphasizing Freud’s positive contributions, many of which are foundational to the profession of psychotherapy, Yalom challenges therapists to read Freud’s work and consider his ideas for themselves. This passage encourages therapists to keep an open mind about different approaches to therapy, including Freudian perspectives.

“Highly experienced therapists have always relied on dreams. Freud considered them ‘the royal road to the unconscious.’”

Yalom advances his idea that patients’ subconscious ideas and anxieties can be uncovered by dream analysis. By revealing how and why he works with patients on understanding their dreams, Yalom normalizes dream work and encourages therapists to regularly discuss their patients’ dreams.

“I particularly inquire about repetitive dreams, nightmares, or other powerful dreams. Dreams occurring in the previous nights or last few nights usually yield more productive associations than older ones…I find that asking the patient to repeat the dream in the present tense often brings it to life and plunges the patient back into the dream.”

Yalom explains his approach to dream analysis, helping therapists envision how he weaves this into his work with patients. Yalom’s continued focus on dreams reveals how important he believes them to be to the therapeutic process.

“Of all the dreams offered by patients, I believe there are none more valuable to the therapy enterprise than dreams involving the therapist (or some symbolic stand-in for the therapist).”

Yalom continues to build on the idea of using dream analysis to better understand his patients’ subconscious ideas and anxieties. He believes that patients’ dreams about their therapist reveal their attitudes toward therapy, which often revolve around their deepest insecurities or unresolved traumas. This is why he believes that these dreams are particularly useful for therapists to explore.