Ch. 9: Existential Isolation and Psychotherapy

Question 1

Therapist’s first tasks is to help the patient identify and apprehend what they do with others. (Questions)

Answer 1

Does the patient exclusively relate to those who can provide something for them?
Is his love focused on receiving rather than giving?
Does he attempt to know the other person fully?
How much of himself is held back?
Does he genuinely listen?
Does he use the other to relate to yet another (i.e. how many people are in the room)?
Does he care about the growth of the other?

Question 2

Eve & Risk-taking

Answer 2

Eve was a patient who had been coming to group therapy for 6 months

• Passive, keeping to the side, etc.
• After christmas, when many people were not present, Eve announced that she’s “not really feeling like having an intense session”
• Others expressed annoyance towards Eve and that she never engages
• Yalom asked Eve to engage any of the members and she platitudinously expressed her feelings to each one
• Yalom: “How would you rank your comments to each member on a 1-10 risk-taking scale?”
• “About 2-3”
• “What would it take to move up by 1 or 2?”
• “I would tell the rest of the group I was an alcoholic” (!!)
• “How did she feel coming to the group for so many months not being able to share that?”*
• Eve: “I feel lonely in the group and I can’t make myself known because of my drinking”
• Yalom asked her to turn around the formula: she did not hide herself because she drank, but she drank because she hid herself!
• Gradually Eve began to understand that she was relating to others for a specific function - to be protected and taken care of - thus, relating only partially

Question 3

what point is there in cultivating yet another “vacation cruise” relationship?

Answer 3

Anna was a borderline patient who felt relationships are phony
- Whenever she reached out to engage, her inner voice soon reminded her that nothing she said was a true feeling
- Yalom always urged her to engage and during one group session she became deeply involved with several members, weeping with and for one of them
- Yalom asked her to describe what her experience had been like at the end of the session
PS! Effective use of the here-and-now therapy always entails two processes: sheer experiencing and the subsequent examination of that experience.
- Anna noted that she had been alive for an hour!
. She could, for a short time, appreciate that relationships enrich one’s inner world
- One is altered through an encounter with another, even a brief encounter
- It becomes an internal reference point, an omnipresent reminder of both the possibility and reward of a true encounter

Careful: it is possible to err in the opposite direction and to avoid enduring intimate relationships by involving oneself only in brief encounters and the therapist must be attuned to this possibility.

Question 4

There is no “solution” to isolation

Fromm

Moustakas

Camus

Answer 4

However, our sense of isolation gives way to a compassion for the others and we are no longer so frightened

But compassion and its twin, empathy, require a certain degree of equilibrium - they cannot be constructed on panic.

Fromm: “the ability to be alone is the condition for the ability to love”

Moustakas: “Loneliness rather than separating the individual or causing a break or division of self, expands the individual’s wholeness, perceptiveness, sensitivity and humanity.”

Camus: “When a person has learned - and not on paper - how to remain alone with their suffering, how to overcome their longing to flee, then they have little left to learn.”

Question 5

Self-enforced isolation

Answer 5

Some recommend (at an advanced stage) periods of self-enforced isolation

First, important material may be generated
- Remember Bruce who had always distracted his terror with workaholism and sexual compulsiveness, saw a dead woman on her bed and nightmares

Second, patient discovers hidden resources and courage
Linda Sherby recommended a patient 24-hours in a hotel room without TV, books, people etc
“I’m still amazed at how together my head must be” after 9 hours
“It is obvious I am not going to go berserk, and I expect that you knew that all along. The sadness is becoming a part of me, and I doubt that it will be so easy to run from it again.”

Question 6

“It is the relationship that heals”

Patient Tom looked the therapist into the eye

Answer 6

If any single fact has been established by psychotherapy research, it is that a positive relationship between patient and therapist is positively related to therapy outcome.

The most vital difference in Armenian eggplant dishes and in psychotherapy are the “throw-ins”, the “off the record” contributions
These most frequently occur in the therapist-patient relationship

Patient Tom looked into the therapist’s eye and said: “If you give me up, then there is no hope for me.”
- Sorrow, hatred, pity and inadequacy in therapist, but also “I was at that moment closer to him than I had ever been to any person on earth”

A therapist saw an acutely ill patient for an emergency session on Saturday for hours despite hunger and tiredness

A therapist held a weeping patient in his arms while the patient was waiting for cancer test results

Question 7

Every Day Gets a Little Closer: A Twice-Told Therapy

Answer 7

Yalom and patient made agreement to both write notes of therapy (later published as Every Day Gets a Little Closer: A Twice-Told Therapy) and to seal the notes in a locker, to be read later

• Yalom thought the most important things were his clever interpretations
• Surprisingly, what she appreciated were the small personal touches - a warm look, a compliment, unswerving interest, asking her opinion

Question 8

How does the relationship heal?

Answer 8

1. As “dress rehearsals”

2. As real relationships themselves

Question 9

Illumination and facilitation of other relationships

Two objections

Current relationships

Answer 9

The relationship with the therapist is a shadow play, reflecting the vicissitudes of a drama that transpired long ago

Two objections though:

• First, there is no evidence that uncovering and understanding the past is mutative
• Second, viewing primarily through transference negates the truly human and truly mutative nature of the relationship

Another use is to help understand current or future relationships

• To most patients, the therapist embodies images of authority - teacher, boss, parent supervisor, judge
• Helping the patient improve relationships to such individuals can already be helpful

Question 10

The “real” relationship between therapist and patient

Antidote to transference

Answer 10

There is enormous benefit to developing a real relationship as opposed to a transferential one.

Transferential, as Kaiser put it, means that the patient does not relate with his true self but engages the therapist in such a way as to escape isolation and to effect fusion

The antidote? Kaiser: “communication”

• “It was the ability to communicate freely that prevented the universal conflict from forcing a person into the restrictive delusionary pattern of neurosis”
• Kaiser believed that the therapist healed simply by being with the patient

Question 11

Kaiser cited four important personality characteristics for the therapist

Answer 11

I: an interest in people
II: theoretical views on psychotherapy that do not interfere with their interest in helping the patient to communicate freely
III: the absence of neurotic patterns that would interfere with the establishment of communication with the patient
IV: the mental disposition of “receptiveness” - being sensitive to duplicity or to the noncommunicative elements in the patient’s behavior

Question 12

Psychotherapy for most patients is a cyclical process

Answer 12

Being able to relate deeply to the therapist may already mean that the patient has changed

• The patient learns that the potential for love exists within them and experiences feelings that have lain dormant in dissociated realms for years or decades
• It opens up not only to the other but to itself as well
• No matter that the relationship to therapist is “temporary” - the experience of intimacy is permanent

Question 13

The therapist can often be the only person who really knows the patient

The patient comes to the therapist in terror of existential isolation

Answer 13

The darkest secrets, illicit thoughts, vanities, sorrows, passions
Still being fully accepted by someone who knows all of this is enormously affirmative

The patient comes to the therapist in terror of existential isolation, relates deeply to the therapist, and then, strengthened, is led back to a confrontation with existential isolation

• The therapist helps to apprehend responsibility for one’s own life, that only the patient themselves can alter their predicament
• Another way the therapist leads the patient back to isolation is by showing what one cannot get from other people
• The ultimate rescuer is seen in the full light of day as only another person after all
• Optimally the patient learns from the fullness of the encounter that patient and therapist and everyone else are brethren in their humanness and their irrevocable isolation

Question 14

I-Thou relationship vs Therapist-patient relationship

Answer 14

There is one major aspect that is different between an I-Thou relationship and the therapist-patient relationship: reciprocity

• The patient comes to the therapist for help - the therapist does not come to the patient
• The therapist should have the ability to experience the other as fully as possible, while the patient has challenges with exactly that plus is also looking to relief suffering
• The therapist has thus what Buber calls “detached presence”
• The therapist will be in two places at once - at the patient’s and his own
• The patient however will only be at his own side

Question 15

Carlos Sequin: “psychotherapeutic eros”

Answer 15

Therapist-patient relationship’s special sort of love
- Non-reciprocal
- However, this is not fixed - as therapy proceeds the improving patient becomes increasingly aware and caring
- This love is indestructible aka “non-conditional”
- Other kinds of love can be eroded: friends might find out that they don’t have much in common anymore and a lover will ultimately cease to love when their love is not returned
- The therapist will care despite rebelliousness, narcissism, depression, hostility
- In fact the latter might increase care because they indicate how much one needs it
- Genuine caring
- It’s not the humanitarian caring a doctor feels for a sick person
It’s an authentic caring for not a sick person, but for another person

Question 16

Imposing vs Unfolding

Answer 16

Imposing one’s attitude and opinions upon another (and in such a way that the other deems them to be his or her own views)
- This is the way of the “propagandist”

“Unfolding”: one uncovers what was there all along

• The way of the educator and the therapist
• One helps the other unfold not by instruction but by “meeting”; not a director but a “possibilitator” (facilitator is a better word innit)

Question 17

Diagnostic evaluation

Danger?

Answer 17

No therapist would deny that there is a place for diagnostic evaluation

• E.g. whether patient is suffering from organic illness or from toxic condition
• Or whether one is suffering from an affective disorder of biochemical etiology (e.g. endogenous depression or manidepressive diathesis) that requires pharmacological treatment
• Is the patient’s condition of such severity - e.g. with sociopathy or paranoid schizophrenia - that there is little likelihood of them benefitting from psychotherapy?
• Destructive tendencies to self and others must be ascertained
• The therapist can also make determinations about a patient’s fragility and ability

Too often diagnostic categorization is a stimulating intellectual exercise whose sole function is to provide the therapist with a sense of order and mastery

Question 18

Therapist Self-disclosure

Freud’s objections

Singular focus on transference

Answer 18

A therapist who is to know a patient must do more than observe and listen; he or she must fully experience the patient.
- That requires opening op, but what to open up about?

Freud’s reasons for why should a dispassionate role be strictly prescribed:

• First, therapist will lose control of the situation and be swept along by what a patient wishes rather than what a patient requires
• The second reason is the belief that transference is the linchpin of psychotherapy

A singular focus on transference impedes therapy because it precludes an authentic therapist-patient relationship

• One, it negates the relationship as the relationship is considered only as a key to understanding other more important relationships
• Second, it provides therapists with a rationale for personal concealment - which in turns leads to reduced genuineness

Question 19

It is important that the self-expression of the therapist is in the service of the growth of the patient

Sexual relations

Answer 19

From “psychotherapeutic eros”, or Greek term agape or Latin caritas - a love that is devoted to the welfare of the other
Therefore it follows that
- The therapist must keep some things to themselves
- That they say nothing that may be destructive
- That they respect the principle of timing - attending to the pace of therapy and what the patient is ready or not ready to hear

The latter self-restraint also applies to getting involved with the patient, losing objectivity and resulting in irresponsible behavior

• Sexual relations are always destructive for the patient
• Such therapist has not heeded the patient’s needs but their own needs
• Such therapists rationalize that the patient needed sexual affirmation
• “I have yet to hear of a therapist becoming sexually involved with one who might really need sexual affirmation - that is, with one who is remarkably unattractive, physically deformed, or surgically mutilated.”

Question 20

Response to concerns about cost and packed schedule

Answer 20

Another reason to remain hidden are the incongruities like the cost of therapy and the therapist’s packed schedule

Questions

• “Do you love me?”
• “If you really care for me, would you see me if I had no money?”

Yalom says he thinks only one response: complete presence

• At the same time, awareness of Buber “One cannot live in the pure present, the I-Thou, it would consume us”
• Nevertheless it is important to repeatedly during the hour to bring oneself back to the present

“What time is it? How much longer to go? I suddenly rebuke myself. I give my mind a shake. Whenever I think of how much time remains in the hour, I know I am failing my patient. I try then to touch her with my thoughts. I try to understand why I avoid her. What is her world like at the moment? How is she experiencing the hour? How is she experiencing me? I ask her these very questions.”