Existential Psychotherapy

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Existential Psychotherapy Books by the Same Author Theory and Practice of Group Psychotherapy Every Day Gets a Little Closer: A Twice-Told Therapy (with Ginny Elkin) Encounter Groups: First Facts (with Morton A. Lieberman and Matthew B. Miles) EXISTENTIAL PSYCHOTHERAPY Irvin D Yalom .. BasicBooks A Division ofHarperCollinsPublishers Library of Congress Cataloging in Publication Data Yalom, Irvin D 1931-Existential psychotherapy. Includes bibliographical references and index. 1. Existential psychotherapy. I. Title. RC489.E93Y34 616.89 80-50553 ISBN: Q-465-Q2147-6 Copyright @ 1980 by Yalom Family Trust Printed in the United States of America Designed by Vincent Torre 25 24 To Marilyn, for every reason. CONTENTS ACKNOWLEDGMENTS CHAPTER 1 I Introduction Existential Therapy: A Dynamic Psychotherapy 6 The Existential Orientation: Strange But Oddly Familiar 11 The Field of Existential Psychotherapy 14 Existential Therapy and the Academic Community 21 PART I I Death CHAPTER 2 I Life, Death, and Anxiety Life-Death Interdependence 30 Death and Anxiety 41 The Inattention to Death in Psychotherapy Theory and Practice 54 Freud: Anxiety without Death 59 CHAPTER 3 I The Concept of Death in Children Pervasiveness of Death Concern in Children 76 Concept of Death: Developmental Stages 78 Death Anxiety and the Development of Psychopathology 103 The Death Education of Children 107 CHAPTER 4 I Death and Psychopathology Death Anxiety: A Paradigm of Psychopathology 112 Specialness 117 The Ultimate Rescuer 129 Toward an Integrated View of Psychopathology 141 Schizophrenia and the Fear of Death 147 xi 3 29 75 110 An Existential Paradigm of Psychopathology: Research Evidence 152 vii Contents CHAPTER 5 I Death and Psychotherapy Death as a Boundary Situation 159 Death as a Primary Source of Anxiety 187 Problems of Psychotherapy 204 Life Satisfaction and Death Anxiety: A Therapeutic Foothold 207 Death Desensitization 211 PART II I Freedom CHAPTER 6 I Responsibility Responsibility as an Existential Concern 218 Responsibility Avoidance: Clinical Manifestations 223 Responsibility Assumption and Psychotherapy 231 Responsibility Awareness American-Style-Or, How to Take Charge of Your Own Life, Pull Your Own Strings, Take Care of Number One, and Get "It" 253 Responsibility and Psychotherapy: Research Evidence 261 Limits of Responsibility 268 Responsibility and Existential Guilt 276 CHAPTER 7 I Willing Responsibility, Willing, and Action 286 Toward a Clinical Understanding of Will: Rank, Farber, May 293 The Will and Clinical Practice 301 Wish 303 Decision-Choice 314 The Past versus the Future in 346 PART III I Isolation CHAPTER 8 I Existential Isolation What Is Existential Isolation? 355 Isolation and Relationship 362 Existential Isolation and Interpersonal Psychopathology 373 viii 159 218 286 353 Contents CHAPTER 9 I Existential Isolation and Psychotherapy 392 A Guide to Understanding Interpersonal Relationships 392 Confronting the Patient with Isolation 397 Isolation and the Patient-Therapist Encounter 401 PART IV I Meaninglessness CHAPTER 10 I Meaninglessness The Problem of Meaning 422 Meanings of Life 423 Loss of Meaning: Clinical Implications 447 Clinical Research 455 419 CHAPTER 11 I Meaninglessness and Psychotherapy 461 Why Do We Need Meaning? 462 Psychotherapeutic Strategies 470 EPILOGUE NOTES INDEX ix 485 487 513 ACKNOWLEDGMENTS MANY have helped me in my work, and I am unable to thank them all: this book was several years in the writing, and my debts stretch back beyond,my memory. Rollo May and Dagfinn Follesdal were exceptionally important teachers and guides. Many colleagues read and criticized all or parts of the manuscript: Jerome Frank, Julius Heuscher, Kent Bach, David Spiegel, Alex Comfort, James Bugental, Marguerite Lederberg, Michael Bratman, Mitchell Hall, Alberta Siegel, Alvin Ro-senfeld, Herbert Leiderman, Michael Norden, and numerous Stan-ford psychiatric residents. To all, my gratitude. I am indebted to Gardner Lindzey and the Center for Advanced Study in the Behavioral Sciences for providing me with an ideal setting for scholarship during my fellowship year of 1977-78. I am deeply grateful to Stanford University, which throughout my career has g e ~ erously provided me with the equipment of academic life: intellectual freedom, material support, and professional colleagues of the highest order. I am grateful, too, to Thomas Gonda, Chairman of the Depart-ment of Psychiatry, for considerately shielding me from administrative chores. And to Marjorie Crosby, for her sponsorship and encourage-ment. Phoebe Hoss provided magnificent editorial assistance. This is a long book, and every word of every draft from first scribblings to fin-ished manuscript was typed by my secretary, Bea Mitchell, whose pa-tience, exuberance, and diligence rarely flagged over the many years we worked together. My wife, Marilyn, provided not only endless sus-tenance but, as with all my previous books, invaluable substantive and editorial counsel. Grateful acknowledgment is made for permission to quote from the following sources: The Standard Edition of the Complete Psychological Works of Sigmund Freud, translated and edited by James Strachey. By permission of Sigmund Freud Copyrights Ltd., The Hogarth Press Ltd., and The Institute of Psycho-Analysis; also of Allen lc Unwin Ltd. and Basic Books, Inc. EST" 60 Hours That Transform Your Life, by Adelaide Bry. Copyright C 1976 by Adelaide Bry. Reprinted by permission of Harper lc Row Publishers, Inc. xi Acknowledgments Maria Nagy, "The Child's Theories Concerning Death," Journal of Genetic Psychology (1948) 73:3-27. Reprinted by permission of the author and The Journal Press. "Everyman," in M. Abrams, et al., eds., The Norton Anthology of English Literature, vol. I, pp. 281-303. Copyright @ 1962. Reprinted by permission of W. W. Norton, Inc. E. Fromm, D. Suzuki, and R. DeMartino, Zen Buddhism and Psychoanalysis. Copyright @ 1960. Reprinted by permission of Harper &c Row Publishers, Inc. "Forgive, 0 Lord," from The Poetry of Robert Frost, edited by Edward Connery Lathem. Copyright @ 1962 by Robert Frost. Copyright @ 1967 by Holt, Rinehart and Win-ston. Reprinted by permission of Holt, Rinehart and Winston, Publishers. Four lines from "Desert Places," from The Poetry of Robert Frost, edited by Edward Con-nery Lathem. Copyright@ 1936 by Robert Frost. Copyright@ 1964 by Lesley Frost Ballantine. Copyright @ 1969 by Holt, Rinehart and Winston. Reprinted by permis-sion of Holt, Rinehart and Winston, Publishers. Purpose in Life Test (PIL) by James C. Crumbaugh and Leonard T. Maholick. Reprinted with permission of James C. Crumbaugh. Published by Psychometric Affiliates, P. 0. Box 3167, Munster, Indiana 46321. V. Frankl, "Fragments from the Logotherapeutic Treatment in Four Cases," in A. Burton, ed., Modern Psychotherapeutic Practice (Palo Alto, Calif.: Science Behavior Book, Inc., 1965). by permission of Arthur Burton. xii Existential Psychotherapy CHAPTER 1 Introduction 0 NCE, several years ago, some friends and I enrolled in a cooking class taught by an Armenian matriarch and her aged servant. Since they spoke no English and we no Armenian, communication was not easy. She taught by demonstration; we watched (and diligently tried to quantify her recipes) as she prepared an array of marvelous eggplant and lamb dishes. But our recipes were imperfect; and, try as hard as we could, we could not duplicate her dishes. "What was it," I wondered, "that gave her cooking that special touch?" The answer eluded me un-til one day, when I was keeping a particularly keen watch on the kitch-en proceedings, I saw our teacher, with great dignity and deliberation, prepare a dish. She handed it to her servant who wordlessly carried it into the kitchen to the oven and, without breaking stride, threw in handful after handful of assorted spices and condiments. I am con-vinced that those surreptitious "throw-ins" made all the difference. That cooking class often comes to mind when I think about psycho-therapy, especially when I think about the critical ingredients of suc-cessful therapy. Formal texts, journal articles, and lectures portray ther-apy as precise and systematic, with carefully delineated stages, strategic technical interventions, the methodical development and resolution of transference, analysis of object relations, and a careful, rational pro-gram of insight-offering interpretations. Yet I believe deeply that, when no one is looking, the therapist throws in the "real thing." 3 1 I Introduction But what are these "throw-ins," these elusive, "off the record" ex-tras? They exist outside of formal theory, they are not written about, they are not explicitly taught. Therapists are often unaware of them; yet every therapist knows that he or she cannot explain why many pa-tients improve. The critical ingredients are hard to describe, even hard-er to define. Indeed, is it possible to define and teach such qualities as compassion, "presence," caring, extending oneself, touching the pa-tient at a profound level, or-that most elusive one of all-wisdom? One of the first recorded cases of modern psychotherapy is highly il-lustrative of how therapists selectively inattend to these extras.1 (Later descriptions of therapy are less useful in this regard because psychiatry became so doctrinaire abou