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Introduction for The Gift of Therapy  

It is dark. I come to your office but can’t find you. Your office is empty. I enter and look around. The only thing there is your Panama hat. And it is all filled with cobwebs.

My patients’ dreams have changed. Cobwebs fill my hat. My office is dark and deserted. I am nowhere to be found.

My patients worry about my health: will I be there for the long haul of therapy? When I leave for vacation, they fear I will never return. They imagine attending my funeral or visiting my grave.

My patients do not let me forget that I grow old. But they are only doing their job: have I not asked them to disclose all feelings, thoughts, and dreams? Even potential new patients join the chorus and, without fail, greet me with the question: “are you still taking on patients?”

One of our chief modes of death-denial is a belief in personal specialness, a conviction that we are exempt from biological necessity and that life will not deal with us in the same harsh way it deals with everyone else. I remember, many years ago, visiting an optometrist because of diminishing vision. He asked my age and then responded: “Forty-eight, eh? Yep, you’re right on schedule!”

Of course I knew, consciously, that he was entirely correct, but from deep within me a cry welled up: “What schedule? Who’s on schedule. It is altogether right that you and others may be on schedule but certainly not I!”

And so it is daunting for me to realize that I am entering a designated later era of life. My goals, interests, and ambitions are changing in predictable fashion. In his study of the life cycle, Erik Erickson described the late life stage of generativity, a post-narcissism era when attention turns from expansion of oneself toward care and concern for succeeding generations. Now, approaching seventy, I appreciate the clarity of Erickson’s vision. His concept of generativity feels right to me. I want to pass on what I have learned. And to do it as soon as possible.

But offering guidance and inspiration to the next generation of psychotherapists is exceedingly problematic today because our field is in such crises. An economically-driven health care system mandates a radical modification in psychological treatment and psychotherapy is now obliged to be streamlined — that is, above all, inexpensive and, perforce, brief, superficial, and insubstantial.

I worry where the next generation of effective psychotherapists will be trained. Not in psychiatry residency training programs. Psychiatry is on the verge of abandoning the field of psychotherapy. Young psychiatrists are forced to specialize in psycho-pharmacology because third-party payers now reimburse for psychotherapy only if it is delivered by low-fee (in other words, minimally trained) practitioners. It seems certain that the present generation of psychiatric clinicians, skilled in both dynamic psychotherapy and in pharmacological treatment, is an endangered species.

What about clinical psychology training programs — the obvious choice to fill the gap? Unfortunately, clinical psychologists face the same market pressures and doctorate-granting schools of psychology are responding by teaching a therapy which is symptom-oriented, brief, and, hence, reimbursable.

So I worry about psychotherapy — about its deformation by economic pressures and about its impoverishment by radically abbreviated training programs. Nonetheless I am confident that, in the future, a cohort of therapists coming from a variety of educational disciplines (psychology, counseling, social work, pastoral counseling, clinical philosophy) will continue to pursue rigorous post-graduate training and, even in the crush of HMO reality, will find patients desiring extensive growth and change who are willing to make an open-ended commitment to therapy. It is for these therapists and these patients that I write The Gift of Therapy

Throughout these pages I advise students against sectarianism and suggest a therapeutic pluralism in which effective interventions are drawn from several different therapy approaches. Still, for the most part, I work from an interpersonal and from an existential frame of reference. Hence, the bulk of the advice which follows issues from one or the other of these two perspectives.

Since I first entered the field of psychiatry I have had two abiding interests: group therapy and existential therapy. These are parallel but separate interests: that is, I do not practice ‘existential group therapy’ — in fact, I don’t know what that would be. The two modes are different not only because of the format (that is, a group of approximately six to nine members versus a one-to-one setting for existential psychotherapy) but differ fundamentally in their frame of reference. When I see patients in group therapy I work from an interpersonal frame of reference and I make the assumption that patients fall into despair because of their inability to develop and sustain gratifying interpersonal relationships.

When, however, I operate from an existential frame of reference, I make a very different assumption: that patients fall into despair as a result of a confrontation with harsh facts of the human condition — the “givens” of existence. Since many of the offerings in this book issue from an existential framework that is unfamiliar to many readers, a brief introduction is in order.

Definition of existential psychotherapy: Existential psychotherapy is a dynamic therapeutic approach which focuses on concerns that are rooted in existence.

Let me dilate this terse definition by clarifying the phrase “dynamic approach.” Dynamic has both a lay and a technical definition. The lay meaning of dynamic (derived from the Greek root, dunasthi — to have power or strength) implying forcefulness or vitality (to wit, dynamo, a dynamic football runner or political orator) is obviously not relevant here. But, if that were the meaning of dynamic, then where is the therapist who would claim to be other than a dynamic therapist, in other words, a sluggish, or inert therapist?

No, I use “dynamic” in its technical sense which retains the idea of force but is rooted in Freud’s model of mental functioning which posits that forces in conflict within the individual generate the individual’s thought, emotion, and behavior. Furthermore — and this is a crucial point — these conflicting forces exist at varying levels of awareness; indeed some are entirely unconscious.

So, existential psychotherapy is a dynamic therapy which, like the various psychoanalytic therapies, assumes the presence of unconscious forces which influence conscious functioning. However, it parts company from the various psychoanalytic ideologies when we ask the next question: what is the nature of the conflicting internal forces?

The existential psychotherapy approach posits that the inner conflict bedeviling us issues not only from our struggle with suppressed instinctual strivings or internalized significant adults or shards of forgotten traumatic memories, but also from our confrontation with the “givens” of existence.

And what are these “givens” of existence? If we permit ourselves to screen out or ‘bracket’ the everyday concerns of life and reflect deeply upon our situation in the world, we inevitably arrive at the deep structures of existence (the “ultimate concerns,” to use theologian Paul Tillich’s term). Four ultimate concerns, to my view, are highly salient to psychotherapy: death, isolation, meaning in life, and freedom. (Each of these ultimate concerns will be defined and discussed in a designated section.)

Students have often asked why I don’t advocate training programs in existential psychotherapy. The reason is that I’ve never considered existential psychotherapy to be a discrete free-standing ideological school. Rather than attempt to develop existential psychotherapy curriculums, I believe it is preferable to supplement the education of all well-trained dynamic therapists by increasing their sensibility to existential issues.

Process and content. What does Existential therapy look like in practice? To answer that question one must attend to both “content” and “process” — the two major aspects of therapy discourse. “Content” is just what it says — the precise words spoken, the substantive issues addressed. “Process” refers to an entirely different and enormously important dimension: the interpersonal relationship between the patient and therapist. When we ask about the ‘process’ of an interaction, we mean: what do the words (and the nonverbal behavior as well) tell us about the nature of the relationship between the parties engaged in the interaction?

If my therapy sessions were observed, one might often look in vain for lengthy explicit discussions of death, freedom, meaning, or existential isolation. Such existential content may only be salient for some patients (but not all patients) at some stages (but not all stages) of therapy. In fact, the effective therapist should never try to force discussion of any content area: therapy should not be theory-driven but relationship-driven.

But observe these same sessions for some characteristic process deriving from an existential orientation and one will encounter another story entirely. A heightened sensibility to existential issues deeply influences the nature of the relationship of the therapist and patient and affects every single therapy session.

I am myself surprised by the particular form this book has taken. I never expected to author a book containing a sequence of tips for therapists. But, looking back, I know the precise moment of inception. Two years ago after viewing the Huntington Japanese gardens in Pasadena I noted the Huntington Library’s exhibit of best selling books of the Renaissance in Great Britain and wandered in. Three of the ten exhibited volumes were books of numbered “tips” — on animal husbandry, sewing, gardening. I was struck that even then, hundreds of years ago, just after the introduction of the printing press, lists of tips attracted the attention of the multitudes.

Years ago, I treated a writer who, having flagged in the writing of two consecutive novels, resolved never to undertake another book until one came along and bit her on the ass. I chuckled at her remark but I didn’t really comprehend what she meant until that moment in the Huntington Library when the idea of a book of tips bit me on the ass. I remember that, on the spot, I resolved to put away other writing projects, to begin looting my clinical notes and journals, and to write a book of tips for beginning therapists.

Rainer Maria Rilke’s ghost hovered over the writing of this volume. Shortly before my experience in the Huntington library, I had reread his Letters to a Young Poet and I consciously attempted raise myself to his standards of honesty, inclusiveness, and generosity of spirit.

The advice in this book is drawn from notes of forty-five years of clinical practice. It is an idiosyncratic m�lange of ideas and techniques that I have found useful in my work. These ideas are so personal, opinionated and occasionally original that the reader is unlikely to encounter them elsewhere. Hence, this volume, in no way, is meant to be a systematic manual; instead, I intend it as a supplement to a comprehensive training program. I selected the eighty-five categories in this volume randomly, guided by my passion for the task rather than any particular order or system. I began with a list of over two hundred pieces of advice and ultimately pruned away those for which I felt too little enthusiasm.

One other factor influenced my selection of these eighty-five items. My recent novels and stories contain many descriptions of therapy procedures I’ve found useful in my clinical work but, since my fiction has a comic, often burlesque tone, many readers are unclear if I am serious or not about the therapy procedures I describe. The Gift of Therapy offers me an opportunity to set the record straight.

As a nuts and bolts collection of favorite interventions or statements, this volume is long on technique and short on theory. Readers seeking more theoretical background may wish to read my texts, Existential Psychotherapy and The Theory and Practice of Group Psychotherapy, the mother books for this work.

Being trained in medicine and psychiatry, I have grown accustomed to the term patient (from the Latin patiens — one who suffers or endures) but I use it synonymously with client, the common appellation of psychology and counseling traditions. To some, the term “patient” suggests an aloof, disinterested, unengaged, authoritarian therapist stance. But read on — I intend throughout to encourage a therapeutic relationship based on engagement, openness, and equalitarianism.

Many books, my own included, consist of a limited number of substantive points and then considerable filler to connect the points in a graceful manner. Because I have selected a large number of suggestions, many free-standing, and omitted much filler and transitions, the text will have an episodic, lurching quality.

Though I selected these suggestions haphazardly and expect many readers to sample these offerings in an unsystematic manner, I have tried, as an afterthought, to group them in a reader-friendly fashion.

The first section ( #1 - 41) addresses the nature of the therapist-patient relationship, with particular emphasis on the here-and-now, the therapist’s use of the self, therapist self-disclosure.

The next section (#41-51) turns from process to contentand suggests methods of exploring the ultimate concerns of death, meaning in life, and freedom (encompassing responsibility and decision.)

The third section (#52 - 76) addresses a variety of issues arising in the everyday conduct of therapy.

In the fourth section (#77-84) I address the use of dreams in therapy.

The final section (#84-85) discuss the hazards and the privileges of being a therapist.

This text is sprinkled with many of my favorite specific phrases and interventions. At the same time I encourage spontaneity and creativity. Hence do not view my idiosyncratic interventions as a specific procedural recipe; they represent my own perspective and my attempt to reach inside to find my own style and my own voice. Many students will find that other theoretical positions and technical styles will prove more compatible for them. The advice in this book derives from my clinical practice with moderately high to high functioning patients (rather than those who are psychotic or markedly disabled) meeting once or, less commonly, twice a week, for a few months to two to three years. My therapy goals with these patients are ambitious: in addition to symptom removal and alleviation of pain, I strive to facilitate personal growth and basic character change. I know that many of my readers may have a different clinical situation: a different setting with a different patient population and a briefer duration of therapy. Still it is my hope that readers may find their own creative way to adapt and apply what I have learned to their own particular work situation.