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 Key Thinkers in Practical Philosophy: Dr Irvin D. Yalom Stephen James Minton Dr Irvin D. Yalom, Emeritus Professor of Psychiatry at Stanford University School of Medicine since 1994, was born in Washington, DC in 1931, of Russian emigrant parents. Since receiving his MD in 1956, his career has been one of varied and considerable honours; as well as being an extremely successful psychiatrist, and individual and group psychotherapist, he has received the Commonwealth Club Gold Medal Award for Fiction (1993) for When Nietzsche Wept, one of the two novels he has published. His eleven books include these two novels (he is currently working on a third, this time about Schopenhauer), five text books on psychiatry/psychotherapy (including the excellent Existential Psychotherapy’(1980) and the near legendary (amongst group psychotherapists) The Theory and Practice of Group Psychotherapy (first published in 1970, and now in its fourth edition (1995)), three books of semi-autobiographical ‘tales of psychotherapy’ (including the best-selling Love’s Executioner (1990)), and an introduction to his own work, The Yalom Reader (1998). Additionally, he has authored over 60 articles, monographs and chapters. Yalom’s written output, therefore, is considerable in bulk, and sometimes not far short of astonishing in breadth. He has made numerous and significant medical, literary, psychological and (probably most interesting to readers of this journal) applied philosophical contributions. For convenience’s sake, I have chosen to group these contributions accordingly:  (i) the practice of psychiatry and psychotherapy;  (ii) the development of existential psychiatry and psychotherapy;  (iii) literary contributions and innovations. As the former and latter categories have rather less to do with the application of practical philosophy, I shall be brief here – however, to omit these areas entirely would be to misrepresent much of the general tone and scope of Yalom’s work. The practice of psychiatry and psychotherapy Yalom has made numerous contributions to the teaching and practice of both group and individual psychotherapy. Some of his writings concerning the above are more or less standard (but extraordinarily human, and well-written) textbooks, and two have enjoyed considerable commercial success on both sides of the Atlantic (Existential Psychotherapy (1980), and Theory and Practice of Group Psychotherapy’ (4th Edition, 1995)). Both are excellent texts; the in-depth and exhaustive coverage of the latter has ensured that it has become something of a ‘bible’ for all group psychotherapists. Yet I believe that Yalom is correct when he attributes at least ‘some of the success to storytelling – to a stream of brief human vignettes running through the text’ (Yalom, 2001). For it is in his books that address the practice of psychotherapy through the intensely reflective documentation of case studies – those that Yalom refers to as his ‘tales of psychotherapy’ (as may be found in Love’s Executioner (1989), Momma and the Meaning of Life (2000), and the early Every Day Gets A Little Closer (1974)) – his writing is at its most compelling. The legendary existential psychotherapist Rollo May (in his own right, an excellent writer) commented on Love’s Executioner that Yalom ‘writes like an angel   Practical Philosophy March 2001  http://www.practical-philosophy.org.uk 41 about the devils that besiege us all’. Yalom, like most existential therapists, does not rely upon symptom-based diagnosis; instead, he focuses upon the very real, human encounter between himself and his client, and the relationship that builds between them during the course of psychotherapy. Yalom is meticulously attentive to his own feelings, conscious and unconscious, towards the client, and encourages the client to be equally attentive to her or his own feelings towards him. He says that: ‘I have approached all of my patients with a sense of wonderment at the story that will unfold. I believe that a different therapy must be constructed for each patient because each has a unique story’. (Yalom, 2001) To me, the reason why Yalom’s work is so commercially successful (not to mention academically successful in communicating important truths about psychotherapy) is the sheer honesty and transparency with which Yalom documents this intensely personal, deeply thoughtful process. He is unafraid to admit to transient prejudices (for instance, his revulsion at obesity in the chapter, ‘Fat Lady’ in Love’s Executioner). We know that the acknowledgement of such feelings, uncomfortable though it may be for him to confront, is made with the overriding and absolute concern for the client’s care uppermost in his mind – and that these feelings will be ‘worked through’, thus enriching the psychotherapeutic process. Yalom likens this ‘working through’ of strong unconscious and vaguely conscious powerful feelings about and towards the client (traditionally known as ‘counter-transference’; 1  the client’s unconscious feelings towards the therapist are termed ‘transference’) to working on one’s tennis backhand. Initially, the backhand can seem to be the weakest part of one’s game: with practice, though, the stroke can become a match-winner. His courage to share this process adds to the multi-layered approach that is taken to the teaching task of his texts: in other words, Yalom models good practice, as well as providing a set of salient empirical and epistemological points concerning psychotherapy. Whilst Yalom’s avowed therapeutic orientation is within the broad phenomenological-existential tradition, a key influence in Yalom’s work is his ability to communicate important general ideas about psychiatry, and the notoriously theoretically fragmented area of psychotherapy. One doesn’t have to agree with Yalom’s philosophical position to learn something from him: and we will do well to remember that there are precious few authors in the field about whom this can be said. However, having noted this point, we will now turn our attention to establishing what does constitute Yalom’s philosophical position, and how this informs his work. The development of existential psychiatry and psychotherapy Since the 1930s, many psychiatrists and psychologists have been interested in augmenting (initially) or replacing (increasingly so, nowadays) the insights of classical psychoanalysis with perspectives gained from a close study and application of phenomenological and existential philosophy. Early exponents and schools included the ‘phenomenological psychiatry’ of Eugene Minkowski, the ‘Daseinanalysis’ of Ludwig Binswanger and Medard Boss, and the ‘Logotherapy’ of Viktor Frankl. Since the 1950s  Notes 1  Words that are included in the glossary are underlined on their first appearance in the text.   Practical Philosophy March 2001  http://www.practical-philosophy.org.uk 42 especially, existential psychology, psychiatry and psychotherapy has been developed on both sides of the Atlantic: Rollo May did much to popularise this school of thought and practice in the United States, whilst in the United Kingdom, R.D. Laing and David Cooper developed an increasingly vitriolic critique of mental health treatment, suggesting and at least partially implementing alternatives from their phenomenological/existential perspectives. In Europe today, Hans Cohn, Ernesto Spinelli and Emmy van Deurzen are notable contemporary authors and practitioners within the field of existential psychotherapy. A common criticism of the existential approach within psychotherapy is that its central tenets remain unclear, drawn as its ideas are from an incredibly diverse set of thinkers. Indeed, there is little consensus amongst those who identify themselves as existential psychotherapists as to which philosophers the ‘school’ as a whole deems most influential (although somewhat predictably, a brief glance at much of the literature would uncover many references to Kierkegaard, Nietzsche, Heidegger, Sartre, Camus, Merleau-Ponty and Buber, and perhaps slightly fewer to Husserl, de Beauvoir and Tillich). In Existential Psychotherapy (1980), Yalom sought to write a text book for a course that did not exist; in effect, he systematised the influence that various phenomenological and existential philosophers2  and psychotherapists had on his practice of individual and group psychotherapy. He organised the text into four main sections, which had emerged from his analysis, synthesis and application of ideas. These four headings have become known as Yalom’s ‘ultimate concerns’ of human existence, significant by both the constant repetition of such themes in phenomenological/existential philosophy and literature, and their consistent influence in the psychotherapist’s/psychiatrist’s clients’ lives. They are:  (i) Death – each human life is finite, our own is no different; (ii) Freedom / Responsibility – these two are interchangeable; here, Yalom uses the Sartrean dictum, ‘man is condemned to freedom’ (Sartre, 1943). As humans, our absolute freedom is a given, and therefore so too is our absolute responsibility for the choices we make from this unpleasant and unrequested ‘vantage’ point; (iii) Isolation – although humans’ being is essentially one of relating-to, we are in fact ultimately alone; (iv) Meaninglessness – in the absence of a pre-ordained system of faith or ultimate meaning, we are compelled to consistently create and recreate our own life’s meaning, and uphold it in the face of the objective uncertainty of our world and modern day life. Around these section headings, the text of Existential Psychotherapy includes philosophical reflection and analysis, individual and group case material, and empirical data where possible. (For example, outcome studies of out-patient psychotherapeutic groups for persons with terminal cancer appear in Yalom’s section on ‘Death’, as well as the more reflective, case material-driven chapter on children’s conception of death). Problems with this otherwise excellent text occur when people are tempted to see Yalom’s list of existential givens as prescriptive; rather than serving as a personal and pragmatic synthesis, the four take on the characteristic of deterministic bogeymen – the four ‘ultimate concerns’ becoming the ‘four horsemen’, perhaps! It would be naïve to  2  Taking Yalom’s work as a whole, and in terms of numbers of citations, references, quotes, and dominant themes in his analysis of psychotherapeutic problems, the dominant philosophical influences seem to me to be Nietzsche, Sartre and Kierkegaard.   Practical Philosophy March 2001  http://www.practical-philosophy.org.uk 43 argue that a philosophical system or school is inherently ‘above’ schematisation; indeed, when we apply philosophy, particularly in fields that have long courted the empirical method (such as psychiatry and psychotherapy)3 , a certain amount of ‘listing’ is perhaps inevitable. Serious problems arise, though, when we simplify beyond the point that is necessary, as we may run the risk of misrepresenting ideas in our attempt to apply them. There is a danger of this when Yalom gives an overly brief introduction to his ideas in Love’s Executioner (1989): here, the four ‘ultimate concerns’ are posited (in diagrammatic form) as driving ego concerns, as an alternative to the Freudian notion of unconscious, libidinous impulses providing this same impetus. In this way, the issues of death, responsibility, freedom, isolation and meaningless are cast solely as deterministic, intrapersonal ghosts, and the very substance of existential psychotherapy – dialectic, encounter, the I-Thou relationship (elsewhere emphasised by every existential psychotherapist, and ironically enough, perhaps Yalom most of all)4  – remains understated. Of course, a balanced reading of Yalom’s texts quickly redresses this, but I have known of many psychotherapists who have neglected to pursue their understanding of existential psychotherapy beyond this introductory chapter. Yet there is no philosophy that makes greater demands on the reader for personal involvement with the text than existentialism5 ; and no relationship, perhaps, under greater and more minute scrutiny than the psychotherapeutic one. The very substance of the thought to be applied and the medium to which it should be applied seems to invite, if not demand, that the practitioner finds her or his own synthesis of ideas. Ideologically and sometimes philosophically, the concerns and tenets of phenomenological/existential psychotherapy and anti-psychiatry have often overlapped; in other words, many authors and practitioners of an existential orientation have been sharply critical of conventional psychiatry and psychotherapy – for example, Dr Thomas S. Szasz in the United States, and Drs R.D. Laing and David Cooper in the United Kingdom. However, Yalom advocates and epitomises the attempt to rehumanise these disciplines, whilst remaining within their professional boundaries. Yalom has not, of course, always found this easy:  3  ‘Das Bestehen der experimentellen Methode läßt uns glauben, wir hätten das Mittel, die Probleme, die uns beunruhigen, loszuwerden; obgleich Problem und Methode windschief aneinander vorbei laufen’ (Wittgenstein, 1953). (‘The existence of the experimental method makes us think we have the means of solving the problems which trouble us, though problem and method pass each other by’). 4  Yalom said that his personal dictum in psychotherapy is, ‘The relationship heals, the relationship heals, the relationship heals.’ (Yalom, 1989). 5  I am aware that Ray Monk believes this to be true of Wittgenstein’s Philosophical Investigations, to the point that unless the reader is or has been troubled by the same philosophical problems as Wittgenstein, she or he would find that the book ‘will quickly become boring… [as Wittgenstein] is presenting a technique for the unravelling of confusions… Unless these are your confusions, the book will be of very little interest’ (Monk, 1991, p. 366). However, existential classics such as Heidegger’s Being and Time and Sartre’s Being and Nothingness seem to me to be just as explicit in their absolute demand on the reader’s most active and personal involvement in the ideas discussed in each text.   Practical Philosophy March 2001  http://www.practical-philosophy.org.uk 44 ‘As the years pass, this attitude moves me farther and farther from the centre of professional psychiatry, which is now so fiercely driven by economic forces in precisely opposite directions – namely accurate de-individualising (symptom-based) diagnosis and uniform, protocol-driven brief therapy for all.’ (Yalom, 2001) Yet Yalom remains honoured equally as a psychiatrist, psychotherapist, researcher and author – in all cases, one may assumes, at least partly for the energetic combination of academic excellence, communicative skill and deep sensitivity that he brings to each of these facets of his work. Literary contributions and innovations As we have already seen, a contributory factor to Yalom’s success as both author and teacher (and one suspects, as practitioner) is the man’s ability to communicate complex ideas (in themselves, and in application) clearly to both the specialist and nonspecialist audience. In 1992, Yalom satisfied his long held belief – ‘that writing a novel is the very finest thing a person can do’ (Yalom, 2001) – and confirmed for us what many had long suspected: that his literary skills in themselves are indeed something special. His first novel, When Nietzsche Wept – which centres on a fictional psychotherapeutic encounter between Nietzsche and Dr Josef Breuer (a Viennese neurologist, a pioneer in the field of psychoanalysis, and a historical contemporary of Nietzsche) – won the 1993 Commonwealth Club Gold Medal Award for Fiction. Since then, in the enjoyable On the Couch (1997) and the fictional elements of Yalom’s latest offering, Momma and the Meaning of Life (2000), Yalom has continued to evidence a considerable facility with fiction, and a real talent for both suspense writing and the provision of insightful narrative. Small wonder, given his background skills, that Yalom considers such works to be ‘pedagogical works – books of teaching stories and a new genre – the teaching novel’ (Yalom, 2001). As therapists and non-therapists alike have very much enjoyed Yalom’s novels, it is safe to say that this aspect of his work has succeeded on all levels. However, despite his genuine ability to write to such a broad audience, there are those from orientations outside of the existential tradition who find his theoretical work to be too phenomenological, or too far outside of the conventional bounds of psychiatry6 . Within the existential tradition, there are those who consider his case study work in particular to be too populist and pragmatic, and not phenomenological enough! These are well-worn arguments, and perhaps worthy of inclusion, but I have been satisfied simply to provide an overall introduction to Yalom’s contributions, in terms of applied philosophy and otherwise. A closing thought: Wittgenstein once said of Russell’s work that it should be divided in two:  6  This to me would read as an absolute recommendation, indeed a positive accolade – but I have heard it expressed and intended as a criticism.   Practical Philosophy March 2001  http://www.practical-philosophy.org.uk 45 ‘Russell’s books should be bound in two colours… those dealing with mathematical logic in red – and all students of philosophy should read them; those dealing with ethics and politics in blue – and no-one should be allowed to read them.’ (In Monk, 1991, p.471) With the readership of this journal in mind, Yalom’s work should perhaps be similarly divided in two: the work on psychotherapy, which will be helpful for philosophical counsellors to read, and the novels, which I believe will be enjoyable for everyone to read. References Cohn, H. (2000) Heidegger’s way to psychotherapy, Journal for the Society of Existential Analysis, 11:2, pp.2-10. Heidegger, M. (1927/1962) Being and Time (transl. J. Macquarrie and E.S. Robinson). London: Harper & Row. Monk, R. (1991) Ludwig Wittgenstein: The Duty of Genius. London: Vintage. Reber, A.S. (1995) The Penguin Dictionary of Psychology (new edition). Harmondsworth:  

 
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