Chapter 28: The World Handbook of Existential Therapy
Orah T. Krug, PhD
Introduction
I was a member of Irvin Yalom’s consultation group for twenty years until the spring of 2016. What an extraordinary experience my five colleagues and I had, meeting nearly each month in his San Francisco apartment. Upon arrival, when greetings concluded, I habitually settled into “my spot” on the couch, to the right of Irv’s chair, took in the glorious city view, and eagerly awaited the encounter to come. Ever the thoughtful host, Yalom never failed to have healthy snacks laid out on the cocktail table and sparkling soda on the counter. He started each meeting by asking who wanted time, noting our replies to ensure he honored the requests. Sometimes, he would begin by describing either a client’s dream or an intriguing here-and-now encounter. His willingness to be a member of our group as well as its leader was noted by all. Yalom did not talk about being a “fellow traveler,” he simply was one.
We presented informally, and typically, two or three people offered a case within the two-hour time frame. If it was my turn, I began by describing my client, the
therapeutic issues, maybe a relevant dream, and what I wanted from the consultation. I often “brought in” a client with whom I felt blocked, knowing I was caught in my context, but unclear as to the “how and why” of it. I hoped the group would illuminate an aspect of me, my client, and/or our relationship that I couldn’t see. The group did not disappoint. With their skill, experience, and artistry—my seasoned colleagues and Irv invariably provided new insights into my client’s personality, the nature of our relationship or an unrecognized self-protective pattern of mine.
During my tenure with Yalom, I filled several journals describing these stimulating case presentations. The source materials for this chapter, specifically, his teaching, his process interventions and his leadership style come from them. Yalom’s didactic teaching was extraordinary. Topics ranged from ways to illuminate unrecognized existential issues to interpersonal process work and dream work. But even more impactful was when he taught by example. That happened when Irv sensed our group had an unaddressed interpersonal issue. Then he never failed to intervene promptly, with skill and clarity; exemplifying one of his central therapeutic tenants: The safety and well-being of the relationship takes precedent over all else. The following vignettes illustrate this point.
Attention to Group Process
It happened early in my tenure. I thought I was comfortable in the consult group but my sketchy attendance in the first year seemed to indicate a healthy dose of ambivalence. Looking back, I understand that as intellectually stimulating and enjoyable as it was, I still was not fully committed to the group, nor entirely comfortable with Yalom’s approach. He did two things, almost in tandem that strengthened my commitment to the group and my respect for him. First, in private he directly raised the issue of my spotty attendance without any judgment or blame. He did not explore my evident resistance but simply asked if I was still finding the group valuable, given the fact that I missed a number of meetings. My answer was yes, and yet attending the meetings was difficult.
On one occasion, I searched for a parking space with no success. Finally, in desperation after half an hour, I called Yalom and told him my dilemma. He immediately offered to open his garage and let me use the guest parking. After my parking fiasco, Yalom offered our entire group the use of his garage on a regular basis. My trust in him grew, as did my commitment to the group, with his generous and immediate response to the parking problem.
It is interesting to reflect on this seemingly insignificant act in light of Yalom’s reference in Existential Psychotherapy (1980, p. 4) to the significance of the “throw-ins” of therapy. “Throw-ins” are “off the record” acts of generosity and caring that a therapist does not consider a part of the “treatment” but which have significantly positive impacts on the therapeutic relationship. Given my reaction to Yalom’s parking (as well as his many other) “throw-ins,” I would like to suggest that these qualities of “presence,” i.e., of caring and of extending oneself—so hard to define, much less teach—are also crucial for a successful consultative relationship. After these two events the question of whether I would stay or go became a moot point. I felt safer and more committed to the group, and the fact that I stopped missing meetings lends validity to this assertion.
Several years ago, another member began to miss meetings. Noting his absence at the beginning of a meeting, Yalom wondered if perhaps his feelings had been hurt by comments he and other group members had made about his work. We agreed that was possible, so we reached out to the absent member, letting him know we missed him. When he came back, Yalom immediately asked if his absence was connected to what had happened in one of the previous meetings. Our colleague (who I’ll call Jim) acknowledged feeling confused and hurt not only by the group’s feedback but also by Irv’s as well. Yalom’s group skills were evident. First, he intervened to repair his relationship with “Jim”, acknowledging his lapse of empathy, and then clarifying his intentions to “Jim.” Then he helped those members involved in the interaction repair their relationships with “Jim” in a similar manner. When we finished, we were pleased to have cleared the air and appreciated Yalom’s efforts as well as our own to acknowledge our interpersonal mistakes. Not surprisingly, after that, our absent colleague was consistently present.
Yalom’s sensitivity to group process was further demonstrated when he allowed the group’s needs to shape his approach, an event that happened early in the group’s life. One of us (who I’ll call Bob), who had trained with James Bugental asked Irv to engage in a role-play exercise whereby Irv would be the therapist and “Bob” would role-play one of his clients, similar to how those of us in the group, had role-played our clients with Bugental. At first he declined, saying he was not convinced of its value, believing it to be somewhat artificial. However, we persisted and thereafter, as my journal attests, he agreed, allowing us to experience his masterful approach to working with interpersonal process. By reversing his position on the value of role-play, Yalom embodied yet another one of his core therapeutic principles, i.e., the therapist must shape the therapy to the needs of the client—in this case, the consultant to the needs of the consultees.
On one occasion another member and I came to a consult group just having had a difficult conversation about a work-related project. Without consulting me, he brought it up in our group with the intention to work on it there. I had to decide if I trusted the group enough to open up with them. It came as a bit of a surprise to recognize how willing I was to work on it there. Yalom’s immediate support and availability helped me feel safe and confident in my decision. It was a good decision, because in working through the conflict, I had to confront a tendency to take on too many projects and the unintended consequences that, at times follow. Yalom and the group helped me see this, using their own experiences with me. It was not easy to hear but quite valuable in helping me face this behavior and explore its underlying dynamics. Yalom not only validated my feelings, but also suggested that I reflect on aspects of my behavior that were not serving me. He did this with the utmost respect and care. As a result of his feedback and the group’s feedback I felt more open and intimate with the group. I had risked working through a thorny conflict with a group member without being blamed or shamed. Instead I felt supported and accepted by the group when Irv and others shared their experiences of me.
To summarize, Yalom’s attention to our group and interpersonal processes cultivated a sense of safety and intimacy within our group. The narrative testifies to the ways in which he embodied his core principles of group and interpersonal process work, for example being both a collegial leader and fellow traveler. The narrative only hints at the numerous ways he quickly attended to problems within the group resulting from interpersonal issues, most memorably, the respectful and effective ways by which he repaired breeches that arose between group members, himself included.
An Interpersonal Focus: Cultivating Presence in the Relationship
After my first consultation group I wrote in my journal, “I feel off balance, my theoretical footing feels shaken. I hear what Yalom is saying, but I do not get it.” I was confused because Yalom’s here-and-now focus was quite different from that of my other mentor, James Bugental with whom I had trained for many years. Bugental almost exclusively focused on his clients’ subjective here-and-now experiences. Bugental’s goal was to germinate his clients’ sense of “I-ness,” i.e., personal agency to increase self-awareness and to mobilize the will (Bugental, 1976, p. 5). In contrast to Bugental, Yalom also has an interpersonal focus, which aims is to link an experience of “I-ness” with “you-ness.” Why does Yalom value an interpersonal focus? Believing that “human problems are largely relational,” (Yalom, 2002, p. 48) he surmised that an interpersonal focus in a safe and caring therapeutic relationship could help clients immediately experience how their relational patterns affect the therapist and vice versa, thereby helping them develop more intimate and satisfying relationships beyond the therapy room.
“The here-and-now is the major source of therapeutic power, the pay dirt of therapy, the therapist’s (and hence the patient’s) best friend,” says Yalom (2002, p. 46). The immediacy of working the here-and-now is what makes it the therapist’s best friend. He urged us to bring the “then and there” into the “here-and-now.” For example, if a client says, “I have difficulty trusting my friend because” Yalom suggested we refocus our client’s attention to the immediate relationship by asking, “Do you sometimes have difficulty trusting me?” His intention is to move the individual from “talking about his life and relationships” outside the therapy room to “experience being in his life with another” in the therapy room.
Time and again Yalom would challenge us to find “here and now” equivalents, to give interpersonal feedback, to cultivate the transference, and to teach clients to express their feelings about us. Yalom implicitly and explicitly reminded us that our task was to cultivate a safe and intimate therapeutic relationship with our clients. According to Yalom (2002) “therapeutic intimacy” is only possible if two factors are in place: (a) the underlying ground of safety that presupposes everything else, and (b) the therapist’s willingness to tolerate and deeply engage the client in this deep intimacy that characterizes his here-and-now method. And as the preceding section illustrates he taught this by example, as he willingly engaged in our group and interpersonal processes.
According to Yalom, (2002) it is not the content of the explanations that heal, even though explanations bond the client and therapist together in a joint enterprise. It is only when the client consistently experiences the safety, acceptance, understanding, and connection with the therapist that healing occurs. As a result, the client feels increased intimacy and acceptance with self and with others, thus resolving the central problem of estrangement. My personal experience with Yalom validates this assumption. His willingness to engage with me most definitely led to greater self-acceptance, and to a stronger connection with him and with the group.
For the field of psychology this is a truly radical notion—even though research consistently points to the primacy of the therapeutic relationship as the crucial ingredient for effecting change. In my opinion, one of Yalom’s most significant contributions to the field is his meticulous examination of how a therapist can use the here-and-now method to cultivate such an intimate, interpersonal relationship.
Working interpersonally was challenging for me to learn. I felt out of my comfort zone, somewhat like flying on a trapeze without a net. But as I became more comfortable with this more personal way of working, I saw how much my clients benefited not only from their newfound self-awareness but also from our more intimate therapeutic relationships, which developed as we focused on our interpersonal experiences of one another. An integration of an interpersonal focus with an intrapersonal focus became my preferred method for therapy (for further explanations see Krug, 2009; Schneider & Krug 2010). Working interpersonally also had an impact on my personal life in that I was more able to see the ways in which I created distance instead of closeness in my significant relationships—it challenged me to change that.
Working with Dreams
“Have you asked your clients about their dreams?” Yalom would frequently inquire of us. He relished working with dreams in consultation, believing that dreams “represent an incisive restating of the patient’s deeper problems, only in a different language--a language of visual imagery” (2002, p. 226). As I mentioned he often began our group by sharing one of his client’s dreams or one of his own, written down I think, as much for future use in one of his books as for his client’s file. Despite the challenges, learning to work with dreams has significantly enriched my therapeutic skill set. In the beginning, I was reluctant to work with dreams because I lacked formal training in “dream work.” I have to credit Yalom for demystifying it. Yalom admits to being very pragmatic about dream work, his fundamental principle “is to extract from them everything that expedites and accelerates therapy” (2002, p. 228). I decided I could do that, so I began to encourage my clients to dream and share them with me. My clients appreciate our dream work as an additional window into their subjective and relational experiences. Their dreams, rich with visual images provide us with concrete representations of their inner worlds and struggles.
Working with Existential Issues
Helping clients face their existential dilemmas that often lie just below the surface is a cornerstone of Yalom’s existential approach. He strongly believes in the significance of this work and, paradoxically, in the difficulty that it presents to therapists. He frequently reminded us that at the heart of many clients’ issues are unrecognized existential dilemmas. Sensitized to their presence, we helped our clients brush away everyday concerns to explore them.
As Cooper (2003) and van Deurzen-Smith (1997) acknowledged, Irv Yalom, in his texts and novels, has made the existential approach better known than any existential therapist has been able to do previously. That being said, according to van Deurzen-Smith (1997) Yalom is ironically the least existential because he merely uses the existential concepts to intensify confrontation instead of having them be guidelines for life. With all due respect to my colleague, my experiences suggest otherwise.
Throughout the years of consultation, Irv has not only urged us to be alert to our client’s existential issues but also to our own reactions that may be getting triggered. I recall an occasion when a group member was relating his work with an eighty-year-old man. Yalom suggested the group member reflect on how his client’s impending death and his associated feelings were affecting him. On another occasion, I “brought” a client to consultation caught in the throes of an existential crisis, deeply regretting the life path she had taken. “Perhaps she senses she will die having left too much life inside of her, “Yalom offered. “Instead of constantly looking back, turn her attention to the future. Help her focus on ways to avoid having more regrets two years from now.”
The “unlived life” is a concept of Friedrich Nietzsche (one of Yalom’s favorite existential philosopher’s) who wrote eloquently on the subject. In The Gay Science (2009; 1882) Nietzsche introduced an intriguing vision of life, which for Yalom has held great significance. Twice in consultation, Yalom related Nietzsche’s vision of “eternal recurrence.” Nietzsche’s notion asks: “If you were told you would have to live your life again and again would you rejoice or curse? If one can face such a prospect with enthusiasm, one has successfully created a good and meaningful in life, but if one faces such a prospect with dread, then one has left too much life unlived.
There was a memorable meeting in the fall of 2004, when Yalom shared how he used Nietzsche’s idea to help him cope with the prospect of a life-threatening illness. He faced this possibility for an entire month before finding out that the diagnosis was incorrect. He decided he said, “To live my life like the main character in my new book The Schopenhauer Cure” (2005). This character, a successful San Francisco therapist, fashioned it would seem after Yalom, is diagnosed with cancer and has one year to live. The therapist asks himself, how will I choose to live it?” Upon reflection he concludes that his life is being lived just as he wants it and decides to continue on, making no changes. Yalom told us that when he asked himself the same question, he realized that his feelings were similar to that of his character, specifically: he was presently living precisely as he desired.
A Focus on Our Own Existential Issues
Reflecting on my journal entries, I realized that 2004 and 2005 were traumatic years for many of us in the group. Collectively we bore the loss of parents, a tragic auto accident, a tumor removed and an erroneous cancer diagnosis. I was touched by how honestly and lovingly Yalom invited each of us to express our feelings about these experiences, and how he shared his own with us. By doing so he embodied his belief in the value of therapeutic transparency. His disclosures never failed to move me. With each lived experience, our group moved to a deeper level of connection and intimacy. The following excerpts from my journal recorded 1/25/05 are about my own experiences that illustrate this point. My father died on 12/28/04, a week after our latest meeting. The entire group knew he had died, but, with the exception of my two closest friends, the group didn’t know the whole story. I’d actually found my father dead in his apartment. Unwilling to live his remaining years tethered to a dialysis machine, he’d shot himself.
Driving to the meeting I wasn’t sure if I would reveal to the group my excruciatingly difficult experience. It took a leap of faith to trust that they could to handle it. My trust was rewarded as each responded with sensitive understanding, thoughtfulness and support. Moreover, two members followed with disclosures of their own about how their mother and father respectively chose to end their lives instead of being compromised by their illnesses. Yalom told us about a dream he had after his mother had died (also published in Momma and the Meaning of Life, 1999). The group ended with hugs all around. It was one meeting I will never forget.
We are all just fellow travelers. The harsh experiences that befell our little group in those years speak to the uncompromising truth of Yalom’s statement. We must not separate ourselves from our clients (or consultees). To do so is to deny that we too must face and bear the harsh realities of existence. Those harsh realities are less burdensome when we create a sturdy community of close friends amongst our colleagues. Over the years, as our group grew closer, we were lovingly there for one another when the inevitable vicissitudes of life knocked at our doors. I am grateful that our consult group has decided to continue, even without our beloved leader.
Closing Thoughts
Recently I completed a text for APA with my co-author Kirk Schneider titled Supervision Essentials for Existential-Humanistic Therapy (Krug & Schneider, 2016). In one of these chapters, Kirk and I described the mentors who influenced our development as supervisors and teachers of Existential-Humanistic therapy. Not surprisingly I pointed to James Bugental and Irvin Yalom as being “most prominent in shaping my therapeutic values, attitudes, and style…” (p. 111).
This narrative certainly confirms how Yalom consistently embodied his values and principles in our consultation group. From his engagement with our group process, to his personal disclosures, to his fellow traveler demeanor, to name a few, Irv created a safe and intimate space, a space that nurtured my psychological transformation. At a recent brunch with Irv, I mentioned that he and Jim were perched on each shoulder, reminding me as I wrote, “that abstract ideas do not transform, but lived experiences do.” (p. 115). Thank you, Jim, and thank you Irv!
References
Bugental, J. F. T. (1976). The search for existential identity. San Francisco: Jossey-Bass.
Cooper, M. (2003). Existential therapies. London: Sage.
Krug, O.T. (2009, Summer). James Bugental and Irvin Yalom: Two masters of existential therapy cultivate presence in the therapeutic encounter. Journal of Humanistic Psychology, 49(3), 329-354. http://dx.doi.org/10.1177/0022167809334001
Krug, O. T. & Schneider, K. J. (2016) Supervision essentials for existential-humanistic therapy. Washington, DC: American Psychological Association.
Nietzche, F. (2009, original publication in 1882). The gay science (the joyful wisdom), translated by Thomas Common. Digireads.com Publishing.
Schneider, K.J., & Krug, O.T. (2010). Existential-humanistic therapy. Washington, DC: American Psychological Association.
Van Deurzen-Smith, E. (1997). Everyday mysteries: Existential dimensions of psychotherapy. New York: Brunner-Routledge.
Yalom, I. (1980). Existential psychotherapy. New York: Basic Books.
Yalom, I. (1999). Momma and the meaning of life. New York: Basic Books.
Yalom, I. (2002). The gift of therapy. New York: HarperCollins.
Yalom, I. (2005). The Schopenhauer cure. New York: HarperCollins.