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

Yalom recommends acknowledging incidents when patients become particularly emotional or vulnerable and soliciting their feelings about what happened. It is most useful to do this in retrospect. For instance, if a patient breaks down in tears during one session, they could be asked to reflect on it in the following session. Other incidents can arise in therapy, including errors or misunderstandings, and these are also “grist for the mill” or potentially useful opportunities for discussion (82).

Yalom argues that therapists should check in with their patients about their relationship during each session, even if it seems positive and productive. He advises therapists to frame their initial sessions as “two-way interviews” and encourage the patient to ask them questions, too. This tactic has helped him develop a trusting relationship with his patients, and it also normalizes giving and receiving feedback.

Yalom says that asking the patient if they have lied to their therapist can reveal details that the patient decided to hide out of shame. He believes that discussing these lies or omissions helps to strengthen the therapist-patient relationship, and it also helps the therapist develop new insights and connections into their patient’s behavior.

Yalom discourages therapists from trying to be a “blank screen” for their patients to project their experiences upon. Instead, he believes that a therapist with a distinct, honest personality will not hinder their patients from revealing themselves. Yalom dismisses the outdated notion that therapy should be like an archaeological dig in which the therapist mines the patient’s past to uncover some particular original trauma. Instead, the therapist should try to engage in a more “authentic” human interaction with their patient, such as revealing some of their own true feelings and opinions to their patients. One method of doing this that Yalom used was sending his group therapy patients a summary of his own impressions of their session after it concluded. He believes that authenticity is always a boon to both therapist and patient.

Yalom believes that therapists should always be honest with their patients and says that there are many benefits to being open. He lists three types of self-disclosure: The first is “the mechanism of therapy,” the second is “here-and-now feelings,” and the third is “the therapist’s personal life” (94). He explains each of these in the following chapters.

Yalom examines the first of the three types of self-disclosure in this chapter, urging therapists to make the therapeutic process transparent and understandable for their patient. He claims that ambiguity and mystery only heighten patients’ anxiety. So, therapists should remember to inform their patients about the main purposes of psychotherapy and how patients can take actions to make progress possible. When therapists employ certain strategies, they should inform the patient about what they are doing and why. For instance, Yalom reveals to his patients that he will ask them about their mutual relationship in order to better understand the patients’ relationships and behavior generally.

Yalom recommends revealing therapists’ own feelings toward the patient in the present moment, but only if it is in the best interests of the patients. He also cautions that therapists must phrase this diplomatically. For instance, if a therapist feels that their patient is particularly distant or confrontational, they could comment on how they are experiencing the patient’s behavior. In one case, Yalom rarely received detailed follow-ups on a client’s revelations, and Yalom shared that he felt shut out and distanced from the client. His client then shared that he was scared to form a close bond with Yalom because he wanted him to remain an ideal, rather than a regular person.

Yalom chooses to reveal parts of his personal life to his patients because he strongly believes that avoiding certain topics, or remaining “opaque,” prevents him from having genuine exchanges with them. He acknowledges that this can be controversial and that therapists should be cautious about what exactly they reveal to patients. However, he maintains that being open with patients provides them with a positive model for self-disclosure. He believes that considering why patients ask the personal questions they do provides another opportunity for exploration.

Yalom cautions therapists to never reveal anything to their patients that they do not want to be public knowledge, since patients have no duty to keep their therapists’ revelations confidential. While therapists aren’t required to answer personal questions, Yalom believes that doing so builds trust between the therapist and patient. In his experience, patients generally do not pry too much.

Therapists can help normalize and destigmatize their patients’ experiences by relating to them and sharing similar stories from their own lives. For instance, when one of Yalom’s patients revealed that she felt guilty at being bored by her aging parents, he revealed that he felt the same way while visiting his elderly mother. He says that this “universality” is a “key therapeutic factor” for patients (108).

Some patients are uncomfortable with their therapists’ disclosure because they do not want to humanize them. Instead, they are comforted by the fantasy of an all-knowing, immortal therapist who is guaranteed to help and understand them. Yalom recommends that therapists gently confront these ideas by humanizing themselves and questioning why the patient may try to maintain this fantasy.

Yalom describes the “crooked cure” as a kind of sudden improvement based on the patient’s incredible faith in the therapist, whom they have idealized. He describes how one of his patients was immediately buoyed by Yalom’s attention and interpretations. While Yalom enjoyed the idea that he was responsible for this sudden change, he knew that his patient was overly reliant on a fantasy ideal of him, and he discussed this matter with her. The “crooked cure” ultimately makes patients regress because they are overly dependent on the therapist’s attention and approval. While some patients crave a confident authority figure, Yalom encourages therapists to humanize themselves and relate to the patient as equals.

There are two main views about therapists working with patients who have similar issues to themselves. One view maintains that therapists with unresolved problems will not be able to effectively therapize patients past their own point of development. Another view, which Yalom supports, contends that therapists can focus on removing obstacles from their patients’ lives, and their patients will naturally mature and develop through this process. Yalom shares that, in spite of his own limitations, many of his patients have achieved great change and that he has been inspired by their progress.

Yalom reveals that it is common for therapists to receive some help from their patients because of the nature of their intimate exchanges. He agrees with Jung that the “wounded healer” can be especially effective because of their ability to relate to their patients, and he says that they may also experience some healing by working with others. Yalom admits that he has sometimes been troubled or worried about his own personal life during his sessions, and he then felt happier or relieved at the end. He attributes this to the satisfaction of helping others, or the power of a positive connection with a patient. While patients are not meant to treat their therapists, sometimes they provide some comfort or support, such as when Yalom’s mother passed away. Doing this can boost the patient’s self-esteem, making them realize that they matter to the therapist.

Self-disclosure is an inherent part of the therapeutic process, and therapists should always focus on helping their patients become comfortable enough to make personal revelations. There are two types of disclosure: vertical disclosure, in which a patient reveals something personal, and the therapist asks exploratory questions about it; and horizontal disclosure, in which the therapist and patient talk about how it felt to disclose the information. In group therapy, participants tend to value their fellow members’ self-disclosure, and they sometimes punish people for not being open or for delayed disclosures. Yalom instructs therapists to always intervene when this occurs and to value all patient disclosure, no matter how delayed.

Joe Luft and Harry Ingram created the Johari Window, which is a tool for understanding group therapy disclosure and feedback. The Johari Window consists of four quadrants: the public self, the blind self, the secret self, and the unconscious self. Group therapy aims to maximize the public self by encouraging self-disclosure, while shrinking the blind self through helpful feedback. Group members are encouraged to provide feedback to one another about how they are perceiving each other’s thoughts and behaviors. Similarly, in individual therapy, the therapist is the sole provider of feedback, with the ultimate aim of shrinking the blind, secret, and unconscious selves of their patients.

Yalom shares his strategy for providing feedback in a gentle, acceptable way. He first reveals his strategy to the patient, explaining that he will share his personal impressions with them, and he then asks for their consent in receiving this feedback. Next, he shares his feedback with them, connecting it with the patient’s broader issues. For example, one of his clients was an authoritative businessman who always took detailed notes during his therapy sessions. Yalom revealed that this made him feel “scrutinized” and “cautious,” and he wondered if his patient considered how his demeanor affected others in his life. Rather than making claims about the patients’ intentions, Yalom focuses on his own feelings in reaction to them, reducing their defensiveness.

Yalom says that therapists should make their feedback as specific as possible, offering affirmations about particular behaviors rather than general validation. Speaking in “parts” can help the therapist acknowledge negatives without overgeneralizing. This can help to gently frame critical feedback, as well as introducing patients to more nuanced ways of understanding situations. For instance, when dealing with a suicidal patient, Yalom acknowledged that some part of them wanted to heal and live, and that’s why they showed up to therapy; so, he implored to talk to that “part” of the patient.

Yalom turns the popular expression—strike when the iron is hot—on its head by advising therapists to offer feedback on a patient’s behavior at a later time. This helps the patient reflect honestly about their behavior without being put on the spot. In a related strategy, Yalom shares his concept of “age states” with his patients, usually noting if he finds that they are acting in an age-appropriate way. This empowers the patient to consider when they feel they are acting in a younger or older age-state.

Yalom believes that much of people’s thoughts, fears, and behaviors are subconsciously motivated by their anxiety about death and mortality. This is why he says that therapists must raise these topics in therapy. While they can be serious and anxiety-provoking topics, Yalom argues that therapy should explore the meaning of life, of which death is an inevitable part.