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Dr. Irvin Yalom, the renowned existential psychotherapist and author, explains “The Evolution of Therapy” during his keynote address at the Talkspace Future of Therapy Conference 2016. In this interview by Dr. Iris Reitzes, Irvin Yalom reflects on the concept of death in psychotherapy, his career as an author and psychotherapist, and the role of technology in the future of psychotherapy.

Presented by:
Irvin Yalom, M.D.

Professor Emeritus of Psychiatry
Stanford University
@irvin_yalom

Interviewed by:
Iris Reitzes, Ph.D

Clinical Advisor
Talkspace
@irisreitzes

Iris Reitzes:
Hello Dr. Yalom.

Irvin Yalom:
Hello Iris, how are you?

Iris Reitzes:
I’m good. It’s an honor to have this talk with you today, and I would like to ask how you are today?

Irvin Yalom:
I’m just fine, yes, I’m having a freakish outburst of good health, so I’m feeling well.

Iris Reitzes:
That’s good. We can all appreciate it. We are sitting here in this room with a group of fine therapists who all work with Talkspace. They were all trained the traditional way, however, they’re all working in a completely different setting arrangement with their clients. They’re not sitting across from each other. They rarely see each other. They’re mostly texting to each other, and not at the same time. It is so different, and yet it seems that we always have some essential factors that really need to happen for the encounter to be therapeutic. I was wondering if you can share with us some of your perspective from 50 years in the field. What could be some of those nonspecific healing factors that need to happen in any kind of therapy? It’s a big question to begin with.

Irvin Yalom:
Sure, well let me just free associate about that a little bit. I’ve been doing therapy for a very long time. Of all the various schools of therapy, I would say, be at one end of the continuum of those who think that the nature of the relationship, the intimacy of the relationship, the work on the process, meaning what’s happening between the therapist and patient is the most important issue, so I focus very much on looking what’s going on between the patients, and me trying to get very intimate, so I would be the person who would probably be least interested in a context therapy format, and I have been for many years. I mean, some of my colleagues do telephone therapy, for example.

I know an analyst who moved to California, but kept all of her New York analysands, and would do her analysis over the phone. I felt very critical of that. You’re missing all these visual cues, how can you do that, but everything changed for me a few years ago when I got an email from a patient who I can’t even mention the place where she was, but she was on another continent where it was absolutely ice cold, in a northern hemisphere, and there wasn’t another therapist or MD within five or six hundred miles of her, and asking whether I would just do some Skype work with her.

Since there was no other alternative I agreed to do that. She couldn’t see anyone else, and she needed therapy, so I started working with her. I ended up having a very good experience with her. In fact, she had moved to that place to get away from everybody, and there is no way that she would have been willing to meet with me in a room face-to-face. There was no other alternative in a sense. So it ended up surprisingly well. I was very impressed with that, and since then I’ve had a real change of focus on that.

One of the things that has been most interesting to me about Talkspace is the fact that it’s counter-intuitive. I would have thought the major problem with Talkspace is that they would not be focusing on the here and now, what was happening between the therapist and patient, and yet compared with many of the new movements in psychotherapy with cognitive behavioral therapy they are far move involved in the nature, at least the way it’s done in this outfit. They’re far more interested, and nurturing of the here and now, and with patient relationship, so that’s been a change of heart for me entirely.

Iris Reitzes:
I was also surprised to see how much intimacy you can get even by writing. Sometimes, even, some of the patients are more able to expose them-self being a little bit anonymous.

Irvin Yalom:
That’s been a very important finding for me as well. I’ve been working with Nicole Amesbury, and supervising quite regularly now in the last couple of years, and that’s one of the things that I really found in my work with her as she’s talked about her patients. What has astounded me is several times I’ve heard her say the patients have said that they reveal things to her they never revealed to their face-to-face therapist. That’s quite remarkable.

One of the things is, of course, the anonymity that we don’t quite locate, but here they work with a face-to-face therapist for a year or two, and never revealed certainly these things that were very shameful. There’s another thing, too, which is that a patient can have a panic attack in the middle of the night, and immediately text the therapist. Now the therapist is not going to be reading that text, of course, may not be reading it for some hours, and responding for some hours, but still there is a sense that they can convey what they’re feeling much better than if they revealed several hours later, and try to recall what’s happening to them, so that was another kind of intimacy that occurs, too.

Iris Reitzes:
I agree. I think it’s like writing in a diary sometimes which is, basically, very old, and not new. Let me ask you something about being a therapist. It seems to me that choosing that kind of profession is not just a career choice. It’s also in a way maybe even a mission, and for so many of us I think we start thinking about it when we are younger. I was wondering if you will be willing to share with us maybe an event, or an encounter that you had in your youth that comes to your mind that maybe hinted, or inspired you into choosing this profession.

Irvin Yalom:
I can answer that easily because I’m writing a memoir now. I’m doing what’s pretty age appropriate for someone in their 80’s, so I’m going back looking at my life, and I’ve been really spending a lot of time thinking about that very question. Seminal events for me occurred when I was about 14. My father had a coronary. It looked as though he would quite possibly die. My mother and I anxiously waited. Doctors made home visits in those days, so we were waiting for the doctor to come. My mother was really going berserk, and she was blaming me for this, saying, “You killed him.” And I was feeling terribly upset. Finally, we hear the doctor’s car crunching the leaves outside in Washington, D.C. where we lived. He came in, and he tasseled my hair. I had a lot of hair then, and then he put a stethoscope on my ears, so I could listen to my father’s heart, and he told me it was quite regular. He offered a lot of relief to me, and there was a part of me that was quite moved by this.

I still get moved when I think about it, but I had a sense I wanted to pass that onto others in some way. That’s really one of the major reasons I went into medicine at that point, so I went into medicine, but by the time several years passed from the time I was applying to medical school I had gotten tremendously interested in literature, in great thoughts of philosophers and writers such as Dostoyevsky and Tolstoy, and to me I was going to go into medicine, but at the same time I wanted to get as close as I could to Tolstoy, and to Dostoyevsky, so going into psychiatry was a natural place for me to go. That’s really one of the first inspirations that I had to go.

Iris Reitzes:
That’s very interesting. It sounds like us therapists meeting pain on one hand, and some comfort on the other is really what therapy is about the essence of it.

Irvin Yalom:
That’s right, and I still feel so to this day. Psychotherapy is an extremely fortunate profession for those of us in it because we really don’t have to give it up. If I were a surgeon, or something, I couldn’t possibly practice at this point. You can’t do a part-time surgeon. You got to be in a hospital, but I can do psychotherapy. I am doing it here, and I’m in my mid 80’s. I know relatively few psychotherapists who have retired. I don’t need the money. I’m doing this because I really love my work. It gives me tremendous satisfaction to be of help to people. As I get older and older, I feel I get better and better at it.

Iris Reitzes:
Actually, I think it’s the only profession where age is an advantage.

Irvin Yalom:
I think that’s very true. As you get older and wiser, of course, there comes a point that you get older and dumber if dementia sets in, but that hasn’t happened yet for me. I’m fortunate that way.

Iris Reitzes:
Let me ask you about the existential psychotherapy which you chose. Actually, you chose those philosophers, and you also gave it a framework, the existential psychotherapy. What made you choose this humanistic approach instead of all the methods that you started with the traditional methods? What was it about this approach?

Irvin Yalom:
I had a traditional approach. I took my training in Johns Hopkins, nearby, in Baltimore. I had the kind of thing that most residents did in those years. I got a traditional psychoanalysis from an Orthodox analyst. I was on her couch for 700 hours, but I think the main thing that I learned was that this sort of very distant, out of vision, because she sat at the end of the couch only offered interpretations. No personal kind of interaction. I thought this was a very bad model for psychotherapy. It was a costly lesson in a way, but I thought that there’s got to be a better model than that, so I began relating much more personally. I began disclosing more of myself to patients.

There came a time that I began to feel, I think, with Rollo May. He had an important book that came out when I was a resident called “Existence.” As I began reading that book it really changed things for me because I began to feel as we talked about the history of psychotherapy, and it starts in the 19th century. It starts with Freud. There was no psychotherapy before Freud. Freud was not the inventor of psychoanalysis only. He was the inventor of psychotherapy, but yet there were extremely wise philosophers who had for 2,000 years been talking about some of these very issues that we talked about.

I began thinking that I wanted to see how I could incorporate the great ideas of Western and Eastern philosophy into psychotherapy practice. The school that came closest to it are the philosophers of life, and I began looking at people like Sartre, like Camus, and like Kafka and Nietzsche, and began looking at these existential ideas. Then I started to think about writing a textbook for this field that didn’t exist really. I started off by thinking that by far our encounter with death, our looking at our own human fate was by far the most important issue in stirring up anxiety.

I couldn’t find any patients to talk about that though. I didn’t know how to ask them in a way, and I thought, “I’ll work with patients who have to think about that, and talk about that. People who have a terminal diagnosis, cancer,” and I started working for years with patients who had cancer, and began leading groups, and seeing them individually. When I was doing that, and thinking of all the anxiety about dying it suddenly dawned on me that I had 700 hours of psychoanalysis, and we never once talked about death, not a single hour.

Then I began to plunge more and more into this field, and began thinking, “We’ve got to talk about death to our patients.” Not every patient. Some patients are having marital problems, and that’s what we should focus on, but there are a lot of patients who are dealing with issues of death. They may not know that, but they have nightmares about dying, and they may be dealing with other sorts of issues that are kind of existential which is meaning of life that got introduced into our field very heavily by Viktor Frankl, but at the same time many of us begin to wonder about what the meaning of life is. As people begin retiring they really are facing that question. I see a lot of people at that age, at that point, and so I began writing about these existential issues at that point, and spent some years writing a book on existential therapy.

Iris Reitzes:
Actually, in your existential psychotherapy you mention four givens. Four major concerns of life, and you talk about mortality, and you talk about meaninglessness, and isolation, and also freedom. I would like to ask you a couple of questions about it. One, how do you feel about death at this point in your life? Did you come to terms with it? Then the other question is about freedom because freedom, the concept, does not really sound like something that should be a concern of life, so what do you mean by that, and also, how death applies to your life?

Irvin Yalom:
Sure, well, as for thinking about death, I haven’t really thought much about that for at least a few hours. I think about it very often at my age. I’ve had so much work with it I’ve gotten almost used to the idea, and it’s not filled with such terror for me as it has in the past, but it is something I live with all the time. This year has been a time of thinking about it a great deal because I’ve lost several close friends, and my sister, too, so it’s been very much on my mind.

The issue you mention about freedom is the whole question of how we deal with freedom. The freedom to carve out, and be the authors of own life. Sometimes that comes into practice. I have a patient right now that I’m working with who cannot make a decision is a question of who he will spend his life with, which woman he will spend his life with. He is in such turmoil about this, and he will behave in ways that causes the other to make the decision because he can’t face the idea that I’m making a decision that will influence the rest of my life.

In fact, it’s so difficult that we try to give up our freedom. Erich Fromm wrote a wonderful book called “Escape from Freedom,” by which he meant that we try to give up our freedom, and that’s one of the reasons for why dictators arise, and why we give up our freedom to them because in a sense freedom has a lot of terror for us, and it reminds us of the fact that we have to create it ourselves, that there’s this structure that’s in the world is partly self-created.

By isolation I really don’t mean by that the interpersonal isolation. What I mean by that the isolation of the fact that we create our own world. That’s something you may not be in touch with very much. I was very much in touch with it just a couple of months ago when I lost a very close friend, and in my grieving for him I had a scene that occurred to me. We were in medical school together, and every Saturday we used to play Pinochle with his uncle. He had a bachelor uncle, and we loved those games together. His uncle has long since died, but his uncle would start off by saying, “Oh, I don’t feel too well. There’s something wrong upstairs,” he’d point to his head which was our cue to take out our new blood pressure cuffs that we had just gotten in medical school. We’d each take his blood pressure, charge him $5, which he would soon win back in a Pinochle game because he was a very good player, so it was a wonderful memory I had, and then when I was grieving for my friend it suddenly hit me so hard.

The very obvious fact is that no one knows that memory, but me. That memory doesn’t exist in the world. It’s only in my mind. It’s created by me. I meant when I perish it will be totally forgotten. So that’s the sort of isolation that I’m talking about that we are thrown into the world alone, and we create our world to a much greater degree than we think we do. We think there’s hard reality out there, but it really exists just in the interconnecting neurons in our mind, so those are the four issues that I structured that textbook around.

Iris Reitzes:
That’s interesting when you spoke about freedom now. I was thinking about those people that when they are too anxious, sometimes death to be very religious, because they want someone to tell them what to do, and sometimes the freedom can be really a burden in that respect.

Irvin Yalom:
That’s exactly right. I was reading something my wife is writing. She’s writing a book about love, and she’s writing about Avvad. There’s a line in Avvad that I just read the other night which is, “Gods are very helpful. Let’s believe in them.”

Iris Reitzes:
Makes it easier. I wanted to ask you about your book, “The Gift of Therapy,” in which one of your valuable tips it says, “To create new therapy for each client.” I was wondering about it. Does that, maybe, can be a little bit threatening for new therapists? Is that too much freedom? What do you mean by that?

Irvin Yalom:
Yes, it is very threatening for new therapists. It gets different as you go further on and on. I’m always willing to try to experiment, do different things with different patients, but mainly what I meant by that is don’t put the patient in a system in a way where you can’t see certain things because you’re only looking at it from a psychoanalytic viewpoint, or Gestalt viewpoint, but keep your mind very open with what you’re doing. The only system I use is that we’re going to be examining our relationship together. The reason I do that is not that the patient and I are gonna have an ongoing relationship forever, of course not, but because what goes on between them, and intimate people in their life is replicated with me.

The major reason people come in for therapy is their problems in developing and maintaining a loving, intimate, nourishing relationship with others. Of course, that is very true in group therapy, too, where we see all the relationships with people in every different way kind of replicated in a group, so therapy is a microcosm of their life, and that’s why I want very much to examine what’s happening between the two of us.

Iris Reitzes:
So you give a relative freedom to every therapist to actually form a specific therapy for each of the clients. I think, therapists need to have self-confidence in themselves in order to do that, and sometimes throughout the process, I think, they get there.

Irvin Yalom:
It takes a long time, but I think you really learn about therapy once you’ve graduated from your program, and you begin to work with a lot of different patients. I always suggest to therapists that they get into therapy not only once, but several times during their life, and I used to choose therapists from a different school, so I’d see a psychoanalyst at one point. I’d see someone from another kind of middle school in Great Britain, or a Gestalt therapist, and you get a sense of what all the forms have to offer. What’s best for the patient is the kind of approach you should use.

Iris Reitzes:
Absolutely. I would like to quote something from Sarte in his book “Nausea.” He says, “For the most banal event to become an adventure, you must recount it. A man always tries to live his own life as if he were telling a story.” I was reminded by that quotation when I was preparing for the interview with you because I’m so curious about your interrelationship between being a therapist, and then telling a story about the therapy.

I’m wondering about how do you choose those interesting stories that you choose to tell us, and what happens in the therapy room? Do you sometimes look at a patient, and say to yourself, “This is a story that is worthwhile to tell,” or vice versa when you write about it do you sometimes get an insight, and you say to yourself, “I should use it in therapy.” How is your routine about writing, or telling the story of your therapy life?

Irvin Yalom:
That’s a good question, and it’s a difficult one for me to answer, but I’m doing a lot of thinking about it. I do have a strong sense of narrative. As I see a patient, and that means every patient, not just some, but there’s a story in here. I want to find out what happens. One of the first examples I have of this was when I started teaching group therapy at Stanford I did something that was very unusual in those days. I had the students watch my group every week through a one-way mirror. The group was an hour-and-a-half. These were busy first year psychiatric residents. They groused and complained, and didn’t want to stay the whole time, and everything, and they hated studying, but gradually they began to say, “Hey, there’s stories in here. There are things going on.” Then they began to call this exercise, this group, they would call it “Yalom’s Peyton Place.” Peyton Place was a soap opera.

Iris Reitzes:
Yes, I’m from those days.

Irvin Yalom:
Right, so interested in what was going to happen next week. After a few months the attendance got to be 100%. Everyone was coming back to see what was going to happen, so how does this story begin to work out? I do have that sense of a story. Recently, there’s been a little revival of that in medicine, a big revival. You will see medical schools all over the country now that are having courses in the medical humanities where the students are being re-exposed to art, or re-exposed to literature. At Stanford there are events where the students produce their own writing, or their own dancing, or something like that.

There’s research that shows if a medical student reads a story that’s given to him beforehand then the patient, at the interview, they’ll have a lot more empathy for what’s going on in that patient. The same thing is true in medical journals. Medical journals used to have a lot of case histories. That’s a story of the whole patient, what’s happening. In recent years that’s struck out, and it’s been replaced with a long series of lab studies and lab results, and now those case histories are coming back into medical journals because there’s something doctors learned from reading about the story of the patient that isn’t conveyed in just the lab theory.

When I began writing the stories, the first book I wrote of stories, well, actually, my group therapy textbook, I have a lot of stories. I began to learn that that was a very important way to teach about psychotherapy, and when I wrote “Love’s Executioner,” in fact, every book I have written I have thought of it in my own mind as I am teaching through the story. These are teaching stories, teaching tales, and the same thing is true with novels. Every one of the novels I’ve written has been a teaching novel, maybe with the exception of the Spinoza tale which I’m not thinking so much of a teaching novel, and even in that one I had a therapist in a way for Spinoza, and a therapist for Rosenberg the Nazi. I couldn’t get too far away from that. I mean to teach through stories because I think it’s a very effective way to teach, and a strong way to learn.

Iris Reitzes:
Do you have a routine in which you write? Do you write after each therapy session, or how do you do that?

Irvin Yalom:
I do take notes on each patient after they leave. I never say 10 minutes. I always keep 20 minutes, or so, in between. I dictate a summary of the patient, and then I used to for many years, the first 30 years or so of my practice if I thought,”Hey, there’s an interesting idea for writing in here. I’ll put that in a second folder,” so I did a double-entry bookkeeping, if you will. Then when I started writing, say, “Love’s Executioner,” I had a huge folder, Ideas for Stories, and I began to use these for all the shorter stories that I read, so that’s how I kept them. My folder is empty right now, and I worry about not having another book to write because I’ve been writing continuously for the last 40 or 50 years.

Iris Reitzes:
I’m sure you will continue. Actually, you mentioned “Love’s Executioner,” and that’s the first book that I have read of yours, right at the beginning of my career, and for me that was really a revelation because it gave me permission to be myself which means to be imperfect, to go beyond theory, to go beyond technique, and that was really freedom for me.

Irvin Yalom:
You’re a great reader because that’s exactly what I was hoping would happen.

Iris Reitzes:
Thank you, and I was wondering which book is your favorite one, and also, if you would have to pick up one book that would have your fingertips, will have your major message, what that should be?

Irvin Yalom:
That’s a great question to ask me. I’m writing a memoir because I’m re-reading all my books now, and it’s been a tremendous experience for me to do that. The book I put right at the top that I found myself most interested in a way is a book that’s not read a whole lot, but it’s called “Momma and the Meaning of Life.” That book has some of my very best stories in it. There’s a story about grief, important lessons, advanced lessons in the therapy of grief. It’s also got the best short story I’ve written in there about my mother, “Momma and the Meaning of Life.” It got mixed reviews because a lot of the reviewers got very upset by the fact that one of the stories had a talking cat in it. The therapist is doing therapy on this cat, so it is true. I have a couple of fiction stories, and they don’t like fiction, and non-fiction together like that.

Iris Reitzes:
It’s too confusing for them.

Irvin Yalom:
That’s right, but anyway, that’s a kind of book that I would …

Iris Reitzes:
Wow, that’s interesting.

Irvin Yalom:
Each book I wrote I looked back to it. It’s a very important experience in my life. I’m listening to it on Automatebook right now, “Lying on the Couch.” That book sort of has a lot of myself in it in all the characters. All the names in there are people that I’ve known. I write about a swindler when there was a real swindler in my real life. I know when I finished writing that book my wife had in big capitals, “Isn’t there anything else about your sexual fantasies you want to talk about?” Yeah, that has a lot of myself in it.

Iris Reitzes:
What would you say your primary identity is? A therapist or an author?

Irvin Yalom:
I’m in between. I am a writer. Ever since I’ve been a teenager I’ve thought of myself as a writer. I do therapy every single day, and love it.

Iris Reitzes:
Each one is as meaningful as the other would you say?

Irvin Yalom:
Absolutely.

Iris Reitzes:
So you have a dual life, actually.

Irvin Yalom:
I have a dual life.

Iris Reitzes:
That’s very nice, that’s very rich. Let me ask you something about we therapists work with our personality, and our subjective experience that’s usually the major vehicle in therapy. I was wondering, what in your personality contributes mostly to therapy, and also, if you can say something about personal challenges that you might have, and what do you do with them in therapy?

Irvin Yalom:
It’s hard to answer that. I’m very inclined to be open, and self-revelatory. I think that started off really because I did so many groups early, even in training, I led groups. In those days the doctors would call patients by their last name, and the patients would call one another by their first name. It got very awkward for me. Everybody called me Dr. Yalom, and I’d sometimes be calling them by their first name, so I ended up saying, “Just call me Irv,” which again, was not done in those days. You have to remember, when I started off in the field psychotherapy was entirely owned by the medical profession.

Only psychiatrists did psychotherapy. Psychologists, then, with the rise of Carl Rogers, and others started to do psychotherapy, but for many years a psychologist was not permitted to do psychotherapy unless he or she were supervised by a psychiatrist, so it started off in that way, and it was a much more formal relationship. I always wanted to be much more informal. They call me by my first name in groups. I tend to be much more revealing about myself because I thought I really wanted to work on the relationship with someone. In other words, I learned from my analysis how not to do therapy, which was an important lesson in a way.

Iris Reitzes:
You know, I met you once in life. I came to your house, and I can say that my impression, and my feeling after that hour was that what was most appealing to me, I should say, was your curiosity, and your openness, and looking like really outright. There is no way of feeling that you are all those wonderful things about you, you’re really just a very modest man. That’s how it felt to me, and very curious in everything that I was saying. That was really a great feeling.

Irvin Yalom:
Yes, I am very curious. I’m not too interested in impressing people. I get a lot of email everyday. I’ve had large numbers of books sell around the world, so people idealize me, but I do not take that seriously. I belong to several groups here. I belong to a therapist support group like a leaderless therapy group for 25 years, and I don’t believe for a moment that I’m a better therapist than any of these other guys in the group, so I just don’t take the idealization seriously. We have a need for there to be a wise old man who knows everything in our field, and I’m picked for that by many people, but I don’t take it seriously.

Iris Reitzes:
It’s good for you. Your wife, Dr. Marilyn Yalom, is also a very distinguished author. She is a feminist writer, and she is a historian. I was wondering how her ideas influence your ability to understand women in therapy, and also if you want to share how she influenced your life in general.

Irvin Yalom:
She influenced my life tremendously. I’ve known her since I’ve been 15, but she was never interested in science, or psychology. She was always a literature lover. She got her PhD at Johns Hopkins in German and French literature. I was a resident at that point when she got her doctorate, but here, listen to this. What her degree was in her dissertation comparative literature, she worked on, “The Myth of the Trial in Camus and Kafka,” so here she was working with two major, existential writers, so you could see how I’m already being introduced at home to the whole field of existential writers through her.

She has been a tremendously important influence now, and even to this moment as last night she is reading my memoir telling me what a terrible chapter this is, and I’m reading her new book. She’s writing a book on the whole symbol of the heart, how the heart got to be depicted like this valentine heart, and when did that start back in the 13th century, or so, and doing a medieval history of the emergence of the heart, and when the heart began to be equated with love. She’s in a different field from mine, but nonetheless, we read each others chapters writing all the time.

Iris Reitzes:
It’s never a dull moment between the two of you.

Irvin Yalom:
Never a dull moment. She wrote a book on the history of the Chess Queen, and I’m an avid chess player, so I love that. She wrote a history of the breast, and I’ve always had a breast fetish. I encouraged her, I think, writing that book. We work very closely together.

Iris Reitzes:
We started talking about your family, so let me ask you about you have four grown children. They all have very interesting professions, but I’m thinking about us therapists even when we are doing group therapy that really does not mean that we are necessarily doing the right thing with our children. I can say for myself, I’m trying. What kind of a father were you, are you, and what did you learn from fatherhood? What did you learn from your children, maybe, you implemented it back into therapy?

Irvin Yalom:
I think I could have been a better father. I was tremendously involved in my work at that time. There was a movie made about me, and my work, and family called, “Yalom’s Cure.” It’s not shown much in the U.S. just in a few film festivals, but it’s very widely shown in Europe in many theaters there.

Iris Reitzes:
Yes, here as well, too.

Irvin Yalom:
Israel too, so one of the scenes was they were interviewing my youngest son, Ben, who is a theater director now. I have a separate studio 100 feet from the house where I write, and see patients, and they were asking him, “Did you go down and see your father during the day when he was writing?” He just looked, “What? Are you kidding?” He was fearful of interrupting me, and that astounded me that my son would be frightened of interrupting me, so I’m beginning to think that perhaps I was not inviting him enough.

Then my daughter is interviewed, and she is saying that my wife and I put our bond first, and bond with the children second. She’s done it differently in her life, but the fact is that we did do that, and maybe that was not the children’s best interest. She said she put her bond with her children first, however, she ended up getting a divorce, and she wonders, “Well, maybe there’s something to be said for that.” As it’s turned out, all four of my children have been divorced, and remarried now in very good marriages. Many people ask me, especially, after the film when I speak to audiences there, why does that happen? I don’t have a good answer for it except that when Marilyn and I were just getting married and young I didn’t know anyone who ever got divorced. It was unheard of in our culture. Very few marriages ended in divorce that now well over 50% of the marriages end in divorce.

Iris Reitzes:
It sounds like you’re not staying married because you’re not used to get a divorce, but it’s really a choice. You’re really fortunate in your marriage.

Irvin Yalom:
I’m very fortunate. I bless my good fortune everyday. Sometimes I wonder as I’ve been writing this memoir, and thinking I have led a very unusual life. I’m so bound, tied to my wife all the time. Can I really understand some of my patients who live alone, or are unable to, you know, can I really understand what life is not having this significant other in your life, and that’s a question I ask myself all the time in that way.

Iris Reitzes:
By the way, I tend to agree with you. I think something about relationship is so essential to life, yet talking about your divorced children, I think, nowadays we live so much longer, and we stay young so much longer, and so in that respect many relationships are just maybe a chapter. There’s a chapter one, and chapter two, and that does not necessarily mean a failure.

Irvin Yalom:
That’s happened for a lot of people I know, and my children, too.

Iris Reitzes:
Let me ask you a little bit about Talkspace. We spoke before about the advantages, and I would like to ask you if you think there are any disadvantages to this form of therapy?

Irvin Yalom:
The more that I work with my supervisee there’s a lot of feelings I’ve had about Talkspace. One thing I should say, supervision is amazing with Talkspace because where else will you ever get a text of everything that’s said between a patient in therapy. If I supervise students for doing psychotherapy they come, and they tell me about their last session with the patient, but it may be very far from reality, unless you watch a video. They tell me what’s happened, but I really don’t see it. The idea of having a whole text of therapy is quite a wonderful opportunity, not only for supervision, but also for research. I know that there’s research in process right now, but you’ve got tremendously rich data, everything that’s happened between the patient in the text, so that’s one thing.

Another thing is the patient has available everything that’s been said. Nicole tells me about a patient who pastes on her refrigerator some things that they’ve said in the text, so that’s something that’s new. What I want to say is it is not the same as my doing therapy, but it’s something interesting, it’s something else, but I have more and more respect that something interesting is going on between them and their patients. I’m very interested in what’s going on even though it’s something that I myself don’t do, and I’m not sure I could do it. It takes a different set of skills, and a different kind of learning that has to go on.

Iris Reitzes:
This is incredible. I asked you about disadvantages, and you gave me so many advantages, that’s beautiful. That’s okay, I’m glad to hear that.

Irvin Yalom:
The disadvantage is you don’t see the patient’s facial expression unless you’re doing a video.

Iris Reitzes:
I’m sure they compensate for it somehow, but I agree with you that it’s so different.

Irvin Yalom:
One other thing about this thing that we’re talking about. When I first started working with Talkspace my vision was people well then do texting, but then they graduate onto doing audio. They graduate onto doing visual. There’s a kind of a grading. I don’t believe that anymore because some of the people do very well just with texting, and as I say, they might not do with video at all, and many of them don’t choose to do videos. They prefer to do the texting. That amazed me when I first heard that. I’ve got to get used to the idea. I have gotten used to the idea that something different is happening. It’s not the same kind of therapy I do, but it’s a therapy of worth.

Iris Reitzes:
Yes, definitely, I’m glad you say that. I would like to ask you what would be your predictions of the future of the field? We have medication on one side, and neuroscience on one side. I know now that in universities the clinical psychology departments really use neuroscience. It’s a major field, and they put a lot of emphasis on that. That’s on one side, and on the other side we have spiritual counseling and coaching, so what do you think should be the unique contribution of psychotherapy evolving over time?

Irvin Yalom:
That’s such a hard question for me. The psychotherapists I deal mainly with are psychiatric residents, and the field of psychiatry has changed so much. The residents learn less and less about our kind of therapy, about intensive therapy, and more and more residencies are teaching only cognitive behavioral therapy. I’m very uninterested in cognitive behavioral work, although, I suspect it has its place as well. Every once in a while I begin to see swings. Recently, there has been a swing where our Stanford residents want to learn more and more about this kind of therapy, so we’re seeing them more often.

It’s hard for me to know what the future of the field is going to be. Things are happening in neuroscience in the field. I was at a conference of continued study education of psychiatrists just a couple of months ago. I was the only speaker in two days. About 16 different speakers, I think, I was the only speaker who mentioned the word psychotherapy in that, but there were some interesting things going on. The whole issue of magnetic interventions, which is a way of kind of using drugs, but not having any of the side effects of drugs, so that may be a whole new opening up field, but I don’t think there’s ever going to be a disappearance of psychotherapy.

I think what I’m doing, the kind of work I do with my patients, people talking about fears of aging. It’s not that they have any clinical depression, or clinical mania, or bipolar disease. These are simply exigencies of life, exigencies of relationship. How do they form relationships? Why is it that they are always alone? Why is it they are so frightened of isolation? Why are they in terror, and cannot stop working like me? And then grief, and how you deal with grief? That’s not a medical condition. That’s not what you’re going to be treating medically. You got to work through this relationship, and work through what it means to let go, and what it means to face death and isolation. There’s always gonna be a need, and a place for these, and we need people who are trained in this.

Iris Reitzes:
So what you’re saying is we’re gonna stay here for a while.

Irvin Yalom:
We’re gonna stay here forever, I hope.

Iris Reitzes:
Forever. So let me just tell you this. You give everyone, you give all of us so much, to millions of people. What would you like us to wish for you?

Irvin Yalom:
I want to give you one more thing. I want to say that I’m in my 80’s right now, and actually, I am enjoying life except for a very sore knee at the moment, but I’m enjoying life, and feel more settled with myself. I’m always doing work on myself. I’ve seen a lot of therapists. I’m kind of feeling better than I felt any other time in my life, so there’s good news ahead as we age.

Iris Reitzes:
I just wish you to continue to do that. Thank you so much, but before we end some people would like to ask you some questions from the audience, and I really thank you for this interview.

Audience Member 1:
Dr. Yalom, thank you so much for sharing all of that. Actually, I was interested just going back to that patient. I have a patient that is also in turmoil with this type of decision. I was just wondering in terms of technique how are you working with that patient, of course, in the relational aspect of what’s happening between you, but in this difficulty in deciding between which direction he’s gonna go?

Irvin Yalom:
Yes, I know, I tried almost everything with him. Right now I’m currently looking, as I often do with patients, the whole issue of regret. He’s in this situation, and he has a lot of regrets about this relationship, about staying in it this long, for example. About not being willing, and able to make any changes, or not being willing to get out of this relationship, so his life is full of regrets. I like to pose the question to him. Let’s just suppose we’re going to meet a year later, and what new regrets would you have built up over this year, and then the question that has more leverage which is, how can you imagine living a regret free life? A life where you’re not constantly building more and more regrets, so that’s where I’m working with him right now.

What is so fearful about making a choice? Get used to the idea that alternatives exclude. Sometimes it’s impossible to let go of things, so you let yourself stay in a state of ambivalence. I reminded this patient recently of something I wrote about somewhere. It may have been in existential therapy this old medieval story of Buridan’s ass. An ass, a donkey that was caught in between two sweet smelling sacks of hay, and there was the sweet smelling hay on one side, and sweet smelling hay. He couldn’t decide which one, and then, eventually, starved to death. I reminded him of that situation of how hard it is to exclude one thing, and is that something that he’s involved in? I don’t know what to do next week. I’m working with him everyday, but I keep trying to do what I can with it. There’s not a neat solution for it, but I think the idea of regrets is the strongest handle that I have with him right now.

Iris Reitzes:
Thank you. Who else?

Audience Member 2:
Hi, I’m Amy, Talkspace therapist, and I have a question about motivation. Specifically, how do you stay motivated with your patients you’ve been seeing for a very long time? Some of the things that I’m finding is we get stuck in this loop of storytelling, and it’s sometimes very difficult to feel like you’re being productive, so how do you find the internal motivation, and how do you steer a conversation in a way that feels productive like you’re helping your client?

Irvin Yalom:
I often want to start with a question. I usually wait for the patient to start, but if I ever start the session it would be with a question about, “I wonder what feelings are left over from our session last week,” because that increases the continuity between sessions. “What did you feel about how we worked last week, and what issues we worked on? What feelings do you think we should have worked on last week?” If you move to working on the relationship, and what’s happening in our process because if you feel stuck there’s a sense that the person also feels stuck, and we have to work on that stuckness between us, so if it feels repetitious to you, I’m sure that if you ask the right questions of the patient they will talk about it feeling repetitious, too.

The other thing, if you’re stuck, too, I go back to another device that I use. I’ve written about it, but I use it very often in my therapy. I start therapy with the patient, and I will say it many times during the course of therapy. I take a look at the concept of risk. You will do better in therapy if you take a risk every session, and once that is clearly established, and repeated several times, I’ve always got a great device to turn back to which is, “Remember when I told you about taking a risk each session? Tell me, what risk have you taken today?”

Or maybe, that’s too strong, I’ll say, “What have you come closest to taking a risk today?” And they say, “Well, I haven’t done that yet.” “Well, how could you do that today? What was that closest period, and what stopped you from taking a risk today?” So taking people where therapy is stuck, and you’re not motivated, they’re not taking anymore risks, so I think that may be a powerful handle for working with patients. If you feel kind of stuck with a patient that means they’re not bringing up new material. I hope that helps.

Audience Member 2:
Yes, thank you.

Iris Reitzes:
Yes, one more.

Audience Member 3:
Hi Irv, my name is Rick, I’m a Talkspace therapist.

Irvin Yalom:
Hi Rick.

Audience Member 3:
The question I have is that since clients don’t always know what’s in their best interests, and therapists should always be weary about imposing their own values onto the client, how can you know when they’ve reached the optimal level of functioning that they’re capable of?

Irvin Yalom:
Could you give me a little bit of a clinical example of somebody that you’re thinking about that underlies that question.

Audience Member 3:
Sure, for instance, when somebody is coming up towards what would normally feel like, “Well, I think we’ve covered everything,” but what I find with Talkspace is that a lot of times people will then start bringing up other things, and I wonder how could all of us know that we’ve covered everything, I guess, is what my question is.

Irvin Yalom:
If they’re keeping up bringing up other things, whereas, you think they’ve dealt with their problems then it sounds like to me that they don’t want to let go of you, and that they’ve become somewhat dependent on you in a way, so then that’s something to work on, and how you feel about me. There’s a corollary to that is that they’re not getting something from relationship outside in their life, and they’re depending on you for that, so maybe trying to take a look at that transition what they’re getting from other people. What is it they get from you they don’t get from others? That might be a place to start.

That’s probably the direction that I would go to. It’s nice that they want to keep on seeing you, and you can keep on working with them for a long time, but you’ve got to be able to work with this concept of transfer of learning. You’ve got to transfer what they’ve learned in their relationship with you to people outside their life, and so I want to keep working on them, building up some kind of network. If they can’t, and they’re constitutionally unable to, then that’s when therapy may go on for decades, and it’s not necessarily a bad thing either that you serve a function for them for a very long time. I used to gasp when I’d hear of therapists who were seeing someone for 20 or 30 years, but I’ve seen many cases of it now where I understand it completely.

Audience Member 3:
I come out of a managed care background, and actually worked on the dark side of the force for a while for Magellan, and that’s something that I had ingrained in me that, “Well, adjustment disorder, that’s 15 sessions or less, or else you got to do a managed care review.” Now here with Talkspace, I realized, I’ve been here 17 months, and I have people who started with me from the beginning, and they’re still with me. I know that I’m fulfilling a need for them, and that’s a good point. Thank you. I appreciate that.

Irvin Yalom:
Current your patients. I always ask patients about who your confidantes are. Is there someone else in your life who you really are able to tell everything, almost all the things you’ve told me because I think it’s important that people have confidantes in their life. Maybe once they begin to form those confidantes than they can begin to let go of you.

Audience Member 3:
Okay, thank you Irv.

Iris Reitzes:
Irv, thank you so much. Again, inspiration and learning. I hope to see you again next year in the next conference. I’m sorry, here is another one question if you’re willing.

Audience Member 4:
Thank you so much. I’m sorry to be so bold and interrupt, and insist on one last question, but given that you are an incredible facilitator of groups this is one of the things that I’ve been really curious about in breaking through with Talkspace is how to deliver the therapeutic experience online? Personally, I’ve mostly done it successfully in person. I’m curious what you would hope that if we could develop something like this what do you think is the most important element that gets translated, that’s happening therapeutically? If we can figure this out what are the pieces that we must bring over, and we must not lose in a group therapeutic setting?

Irvin Yalom:
Are you talking about doing groups online?

Audience Member 4:
Yes.

Irvin Yalom:
It’s kind of hard to do.

Audience Member 4:
Yes, I’m playing with it, and there are some things that are missing. I’m just curious what you would think what would be most important not to lose?

Irvin Yalom:
It’s hard because with anonymity then you don’t see other people’s faces in the group, and you can’t really distinguish all those voices. Talkspace started off with doing groups, and I know they didn’t work out very well. They had little symbols because most people didn’t want to show their face, so you just never got a picture of the six other people in the group. Curiously enough, there’s a kind of Talkspace-like outfit in China now that’s contacted me, and they’re doing a lot of groups. They feel they’re having a good success for that, but I had trouble with the platform because I don’t know how you’re gonna see these other people’s face.

Maybe you have to get people to agree. If I were doing it I think I’d want to get agreement from the others that they would be able to be seen by the others, and the others would see them. After all, people do that in groups all the time. You establish some kind of agreement with them which is confidential, and the group remains that way. They don’t have to know any details of your life. They don’t even have to know your names, but at least you can see the person, the six or seven people on there. Remember what I said earlier, the fact is that the group is a microcosm of their life, so all their interpersonal problems are going to get repeated in the group.

Anyway, I love the power of groups, and I’ve been in a group, as I mentioned to you, for about 25 years. I encourage therapists. I wish there were a way for Talkspace therapists to have their own kind of group for them that would meet once a week. Maybe there’s a platform you could start off. Here’s an idea. Start off with that idea of let’s have a platform of seven study therapists where you see the other’s face, and let them do a kind of leaderless therapy group, and then you’ll get an idea of how to begin to do it with clients, and it will be very nourishing for you if you have a group.

I’m just writing about this group now. The people have given me permission in the group. We promised never to talk about the group outside, but now people are giving me permission because no one wants this group to die. It’s such a valuable group they want other groups like this to start up, and if you could have a Talkspace group of seven Talkspace therapists that would be a really good thing. We’d write it up, and I’d help you with it in any way I could.

Audience Member 4:
Thank you.