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

Yalom credits Karen Horney, the famous psychoanalyst and author of Neurosis and Human Growth: The Struggle Towards Self-Realization, with the idea of removing obstacles from a patient’s life. Without obstacles, Homey argues, people will naturally develop and self-realize. Yalom found this idea particularly useful because he knew he could not change his patients’ entire outlooks or situations, but he could help them identify and overcome particular obstacles. For instance, when a widow was reluctant to try to love again, Yalom helped her identify and wrestle with each particular emotional obstacle until she felt more open to the idea.

Yalom names Homey as exemplifying an American movement within therapy, which he calls “neo-freudianism.” While these therapists do not share Freud’s focus on an individual’s built-in drives, they instead consider how people’s development is informed by a “vast influence of the interpersonal environment” (18).

diagnosing their clients. While diagnoses are essential in biologically-based disorders such as schizophrenia or bipolar disorder, they are often unhelpful for people who do not suffer from such severe and easily identified symptoms. Indeed, Yalom argues that diagnoses can limit a therapist’s insight into their patients by caricaturing them. It may also cause the patient to over identify with their diagnosis, accidentally perpetuating their symptoms and becoming a “self-fulfilling prophecy” (20). Yalom considers the Diagnostic and Statistical Manual of Mental Disorders (DSM) to be overly simplistic, comparing it to a restaurant menu. He believes that people’s complex identities and symptoms cannot be reduced to a single diagnosis.

Everyone experiences suffering and disappointment in life, and therapists themselves are no exception. While the traditional view of therapy casts patients as “the afflicted” and therapists as “the healers,” Yalom prefers to see everyone as “fellow travelers” (23-24). This view removes the hierarchy from the dynamic, while acknowledging that everyone is human and shares similar struggles.

Yalom summarizes Herman Hesse’s novel Magister Ludi, which is about two ancient healers, Joseph and Dion. Joseph, a young man, heals through his power to listen intently and make people feel better. Meanwhile, Dion heals by actively judging and advising people. Years pass and Joseph becomes severely depressed and considers suicide. He decides to venture to find Dion and ask for his help. He travels for days until he encounters a stranger and reveals his plight. After traveling together for some time, the stranger reveals that he is Dion. Dion asks Joseph to live with him, first as his servant, then as his student, and finally, as an equal colleague. Years later, Dion is on his deathbed and reveals that on the night they met, he had been searching for Joseph. Yalom considers how both the healers struggled with their own problems and sought help. He feels that if Dion had been more honest earlier, they both could have benefitted from the realization that they were both “simply human” (25).

Yalom believes that the therapist-patient relationship is very important. Therapy is useful to some people simply because their relationship with their therapist is one of the first deep and honest relationships they have experienced. Yalom always considers how the patient seems to be feeling toward him, and he asks them to share this openly. He asks his patients questions such as, “How are you and I doing today?” (27). He also asks them to consider how they think they will feel about the session in hindsight.

Yalom contends that one of the most memorable aspects of therapy for patients is the positive affirmations they get from their therapists. He believes that therapists should make a point of offering specific compliments to their patients about their behaviors and good qualities. This validation can be especially important to patients because their therapists may know them and their inner secrets better than anyone else.

Yalom argues that cultivating “accurate empathy” is essential to earning a patient’s trust and understanding their experiences. This means that the therapist has a detailed understanding of the patient’s perspective on their situation. Therapists can check their accuracy by rewording what they’ve heard from their patients and checking to see that they have understood them correctly.

Yalom marvels at how therapists and patients often experience the same session very differently. For instance, he asked one patient to write a reflection on each session, promising her that he would do the same. Later, when he read her notes, he was surprised to find that she did not mention his interpretations of her problems, but focused on his humor, compliments, and other “small personal acts” that were more meaningful to her (35).

This is why he asks that therapists empathize with their patients’ views, even if this is challenging and uncomfortable. Yalom recommends knowing as much as possible about a patient’s past in order to most accurately understand their perspective.

The author advises therapists to actively teach their patients how to extend empathy to others. He believes that many patients seek therapy because they have been unable to form meaningful relationships with others, and they may struggle to feel and show empathy. Therapists can teach empathy by asking their patients how their actions affect other people. If a patient hazards a guess about their therapist’s feelings, the therapist can respond by acknowledging or correcting their interpretation. For instance, if a patient feels that they must be boring or disappointing to the therapist, the therapist could clarify how they actually feel about them.

Yalom argues that therapists should be open to feeling emotionally invested in their patients, and therapists must acknowledge when they have been personally changed by their relationships with patients. He reveals that when he has been open with his patients about the effects they have had on him, they tend to become more comfortable and disclose more personal information to him, too. For instance, he once had a dream about a particular patient and he shared his interpretation of the dream with her, and she responded by sharing her interpretation, as well.

Yalom urges therapists to honestly acknowledge when they made a mistake in their sessions. He relays an anecdote about a difficult conversation he had with a patient who was offended by a remark that Yalom made. So, Yalom admitted that he had not expressed himself well, and he asked his patient to help him understand his “blind spots” that impeded his work. His humility and honesty helped him regain the patient’s trust and also better understand his own feelings about working with her.

Yalom concludes this chapter by warning therapists not to “cover-up” their mistakes but to fully admit them and embrace their lessons.

Yalom argues that therapy should be organic and spontaneous, and he criticizes the notion that readymade formulas and techniques can be applied to different individuals. He agrees with the famous psychologist Carl Jung that therapists should become attuned to their patients’ unique “inner world and language” and try to create therapeutic practices that are customized for them (46). He argues that therapists should remain attentive to their patients’ needs and spontaneously change their approach as needed, warning them against “prefabricated” approaches.

Yalom instructs therapists to engage their patients in what the patients find most helpful in therapy; soliciting their feedback can often yield surprising and useful information. Yalom often found that his patients appreciated unusual acts of trust or attention from him. For instance, he once gave money to a woman who was a compulsive shoplifter to help her think about why she was stealing, since she was not actually poor. When he called her during the holidays, she appreciated the gesture, and it kept her motivated to not shoplift. These acts were even more helpful for this patient than the therapy discussions themselves.

Yalom says that therapists can become better at their jobs by going to therapy themselves. The experience of being a patient helps therapists understand their own feelings and impulses, helping them develop their maturity and their ability to “accept feedback” and “discover their own blind spots” (53). Yalom reveals that he has attended individual and group therapy sessions throughout his life. These included a vast array of techniques and approaches, from Freudian psychoanalysis to behavioral therapy and bioenergetics. He urges therapists not to become too insular or “sectarian” and to keep an open mind about different forms of therapy and their uses. He believes that self-exploration and growth are life-long processes.

Yalom addresses the inherent “inequality” of the therapist-patient relationship: Patients have only one therapist, but therapists spread their time and energy amongst many patients. This sometimes bothers some patients, who feel insecure that they spend a lot of time thinking about their therapist and form a dependence on them, while the therapist has many other patients. Yalom explains that if patients are bothered by the sense that they are unimportant to the therapist, the therapist can comfort them by agreeing that the dynamic is part of the “inherent cruelty” of therapy. Yalom uses analogies—such as a teacher having many students or a nurse having several patients—to normalize the fact that every therapist has multiple patients.

Yalom urges therapists to make full use of the “immediate events of the therapeutic hour” in their sessions (59). He believes that these events hold great “therapeutic power” and are crucial to good therapy.

Yalom believes that a person’s social behaviors will become evident during therapy. This is highly consequential, as social behavior and the ability to form good relationships are among the most important features of a person’s life; they, in turn, inform their friend and family connections and their self-image. While gathering a history can be useful, using the information gleaned during therapy—or the “here-and-now”—is equally important, because a person’s social tendencies will ultimately come through in their relationship with the therapist. These events can be mined for further reflection and discussion.

Yalom coaches therapists to stay highly attuned to the events of the present moment, no matter how trivial they seem. The way patients respond to everyday matters and stimuli tells the therapist valuable information about them. For instance, Yalom used to offer sessions in his backyard cottage. Some patients would comment positively on the garden or surroundings, while others would focus on the negatives, such as confusing directions or a creaky door. Patients respond differently to the same stimuli because of their different inner worlds, and noticing these differences presents more opportunities for the therapist to help them reflect on their behavior.

Yalom believes it is more effective to address patients’ interactions with the therapist than to try to ruminate over stories involving other people. Since the therapist and patient can only guess at the third parties’ feelings, this is a limited approach. For instance, if a patient has an interaction with a family member that reveals their insecurity about being judged and rejected and then has a similar incident with the therapist about the same issue, the therapist should elaborate on the situation in which they were personally involved. This is more immediate and meaningful than dissecting stories involving others.

When a therapist recognizes a patient’s trait or behavior manifesting in the present moment, the therapist can bring it to the patient’s attention. For instance, Yalom noticed that one patient always apologized when opening his broken door, even though it was not her fault it was broken. When he raised this with her, she admitted that she often apologized unnecessarily, even though she knew that this habit was annoying other people in her life. Once she and Yalom mined this habit, they gained new insights into her hidden anger toward her family and others.

Yalom argues that therapy is invigorated when there is a focus on the therapist-patient relationship. He believes that this is because people learn about themselves when they hear others’ honest perspectives on their behavior. He relays how he observed different forms of group therapy and noticed that the more a group focused on the “here-and-now,” the more engaged its participants were. He attributes this to people’s inherent interest in giving and receiving feedback rather than passively listening to others according to a turn-taking checklist.

The author recommends considering therapists’ own feelings toward the patient as indicative of how other people may feel about them. This can help the therapist understand the patterns their patient is living out in their relationships. For instance, one of Yalom’s patients, Martin, was mean and critical toward Yalom, always focusing on the negative aspects of Yalom’s sessions. By considering how negatively he felt toward Martin, Yalom was able to realize that his experience was part of a long pattern that Martin also acted out with his girlfriends. By sharing his experience of Martin’s behavior, Yalom was able to help Martin recognize how others were experiencing his actions and understand how Martin was pushing others away due to his own insecurity.