The grand old man of American psychiatry on what he has learnt about life (and death) in his still-flourishing career
At 83, Irvin D Yalom is an unorthodox and tireless practioner of what he calls 'existential therapy'
There are not too many writers who could include the phrase "the meaning of life" in the title of a book and actually go some way to delivering on that promise.
A little over 10 years ago I was reeling from the death of my father. In the house of a close relative, a counsellor, I picked a book off the shelf with the title Momma and the Meaning of Life: Tales of Psychotherapy. It was by Irvin D Yalom, a writer I had encountered before through a novel called When Nietsche Wept. (he has also written novels about Schopenhauer and Spinoza.) I picked it up and read the title story, although, being the true account of Yalom's sessions with a patient, perhaps "story" is not the correct word for this particular work. Either way, Momma and the Meaning of Life shook me to the core and its message is as vivid today as the moment I sat there, shaking with grief both real and implanted, reading it.
Admittedly, there can at times be what some might dismiss as a greeting-card sentimentality in Yalom's books. But when the central themes are death, existentialism and the darkest recesses of the human psyche, you'd have to be particularly hard-hearted not to forgive a little sugar coating. What is not in doubt is that for someone who is not primarily an author, Yalom is one hell of a writer.
Yalom, for the uninitiated, is a practising psychiatrist who is also the emeritus professor of psychiatry at Stanford University. Over more than 50 years in practice, he has imparted his unique wisdom to hundreds of patients and also found the time to write four novels, four collections of sessions and a number of textbooks for practitioners – at least one of which, The Theory and Practice of Group Psychotherapy (1970), is still widely used today.
A little more on that "unique wisdom". Yalom is not one of those who sits back and lets his patients do all the talking. He can be brutally honest and occasionally confrontational. Behind the "You can call me Irv" bonhomie, there is a sharp-as-a-tack mind which tackles patients' problems with a Holmesian clarity. He will evoke his favourite writers and philosophers and often "suggests" (which in Yalom speak means "insists") that his patients read them. Despite his advancing years, Yalom is still, as his website will tell you, available for private-practice individual therapy at his offices in Palo Alto and San Francisco. His writing, too, shows no sign of slowing down, although since his 2008 book Staring at the Sun: Overcoming the Terror of Death, it has become more and more fixated on that inevitable subject.
His latest collection, Creatures of a Day, takes its title from a philosophical meditation by the Roman Emperor Marcus Aurelius and continues Yalom's practice of borrowing wisdom from the past to illuminate the modern condition. From remarks to patients in these sessions and asides to readers, what becomes clear from reading Creatures of a Day is that Yalom is keenly aware of his own mortality. And indeed there were a couple of times over the course of our conversation when his concentration wavered: at one point he referred to the interview as "our session".
What follows, then, is my "session" with the good doctor.
You are known as an "existential psychotherapist", what does that mean exactly and how did that come about?
I started out in psychiatry in 1957. In America you go to medical school, have a year of internship and then you start a residency. I took three years at Johns Hopkins Hospital [in Baltimore, Maryland] and while there I came across some very fine professors and became interested in a philosophical approach.
I remember reading a book by Rollo May called Existence and felt myself rather stimulated by that because I did not feel that either the orthodox psychoanalytical or the psycho-medical approach were sufficient to account for the kind of issues I was seeing in patients.
That book was the first acquaintance I'd had with the European tradition of existential analytic thought. It included translations of authors who were unknown to us back then: people such as Binswanger and Gebsattel and other Europeans who were therapists as well. What that meant to me was that there was something wrong with the way the history of psychotherapy had been taught in the US.
We had been taught that the history of our field had its foundations in 19th-century psychology, especially in the work of Freud and Jung. But it seemed to me that this was a grievous error, because philosophers and thinkers since the beginning of recorded history were dealing with issues that are relevant to the field of psychiatry.
So I began reading a lot of philosophy: Plato, of course, Epicurus especially, and believed that many of the things that they were saying needed to be incorporated into our field. I concluded that we needed to not be so narrow in our thinking of what the human condition is.
How did you go about applying that in practice?
From the very early days of seeing patients, I noticed that many of them seemed to be concerned with issues of their mortality, and so the philosophy training I had taken began to seem rather important to me. I also began to write a good bit during my training. I wrote a lot of articles for professional journals on various topics – especially group therapy and working with people with sexual disorders – and then I went to Stanford [in California] where I would spend my entire professional career. I was professor of psychiatry at Stanford from 1962 until I retired in 1994.
When did you start writing?
I wrote my first textbook in 1970. It was called The Theory and Practice of Group Psychotherapy and, over the years, many students told me that they enjoyed reading it because there were so many stories in there; often just a paragraph or a page of something that happened in a group session. I smuggled them in and students tell me that they were happy to put up with the dry theory because they knew that there might be another story coming round the bend. It keeps them reading.
Since making that discovery, you've branched out into other forms of writing
With almost every book I've written, my secret target audience is the young therapist. In this way I am staying in my professorial role; I'm writing teaching stories and teaching novels. My latest book, Creatures of a Day, is intended to teach young therapists about how to do therapy. But – like all of my books, hopefully – it is also a good read that will be of interest to anyone who is in therapy or just interested in the subject.
A couple of the patients in the title story of Creatures of a Day are dealing with issues that, again, are age-old issues. One is a patient who felt he was mired in his law practice; in doing something that he really didn't want to do but felt that he had to because he was supporting his family and elderly parents. It occurred to me that this was a very intelligent and philosophically inclined man and that he might do well to read Marcus Aurelius's Mediations. Aurelius was selected to be a Roman Emperor but he really wanted to be a philosopher. So all his life he was doing something out of duty rather than what he truly wanted.
Another patient in that same story was deceiving me in not telling me many things about himself. I asked him why he felt he'd had to deceive me. He replied that he wanted me to have a certain image of him and he didn't want to blemish that. Again, I thought about Marcus Aurelius and especially the paragraph from which the title of the book is drawn: that we are creatures of a day and soon to be forgotten. I thought, what difference would it make what image I have of him in my 80-year-old mind; everything is so ephemeral and transient.
I suggested to both of these patients that they read Aurelius and they did, and the story goes on from there. What's interesting is that I suggested they read the same thing but they picked very different things out of what they read. And I think the same is true of the therapy situation and the therapy relationship – you set up a certain kind of relationship with people where they are going to be honest and authentic and take risks every session and I think people will take out of that situation very different things.
Has the world changed a great deal since you started out?
Certain rituals have: people are marrying and having children later, especially in the part of the world that I'm in. But the issues that I see are very human issues and they do not change a great deal from generation to generation. I don't like to make generalisations about society as a whole because these days I see such a small section of it. Someone working in a hospital environment might give you a different answer, but I haven't dealt with patients in a hospital for some time.
Your approach is not entirely orthodox, is it?
It is not what you might call "normal practice". I tend to be somewhat eclectic and try to focus on the individualised need for each patient. I find the idea of some kind of manual, especially with the new wave of cognitive behavioural therapy – where you try to give certain questions to patients each session – to be really going in the wrong direction. It loses sight of the individuality of each patient.
Are you still in therapy yourself?
It is, of course, mandatory for people entering this field to have a long personal experience with therapy. I know I certainly have and have come back to it several times whenever I have had some kind of crisis in my life.
The last time I did that was when I started to see patients with cancer. That created a lot of anxiety in me and when I started thinking back to the therapy I'd had, including 700 hours of formal psychoanalysis, I was astounded to learn that I had never once talked about my own death, despite the fact that it enters your thoughts and dreams often.
At that point [in the early 1990s] I went back into therapy with Rollo May, and I saw him for a couple of years. That was very useful to me and it gradually allowed me to work more comfortably with people who were in mortal distress.
One such patient, Ellie, is another of the people in my new book and is the only one whose name I have not changed. Ellie was representative of many of the patients I have seen who had a fatal illness and, over the years, I have learnt many things from them.
One of the most important things was from a patient who said to me what a pity it was that he had to wait until now, when he was riddled with death, to learn how to live. And I have used that phrase many times: hoping that if you introduce people, in an appropriate way, to their mortality that might change the way they live and allow them to trivialise the trivia in their life.
How precisely does a person learn how to live?
I think living well is the key: trying not to build up regrets for the things we didn't do in our lives; to try to live a regret-free life in which we feel satisfied in what we're doing; and to try to be kind to ourselves and not disappointed in ourselves.
Have you been able to that?
I feel I have done that quite well and continue to be kind to myself. For example, there may be patients when you are younger and seeing a lot of them who will eat up the energy of 10 people. They get to you: you're worried about them, you're worried about suicide, they attack you, they are difficult to live with. They can move quickly from idealising you, to hating you and it is very difficult to establish a relationship with these people. As I've got older I have become more careful in who I select to see.
I have set up an invisible shield around myself now through selection. Every patient I see at this point comes to me because they have read something I've written. That has changed my practice. Certainly, I'm seeing a very literate group and a group of people who are interested in the kind of things I am writing about.
Are there other ways in which your own advancing years have changed the way you practice?
I don't see anyone, with one or two exceptions, for long therapy any more. I tell people when I start that I can only see them for a year. I'm very old now and I don't want anybody to become dependent on me because I'm not going to here that much longer. I start off by saying that this is "time-limited therapy" and I remind them of that again when we are six months through. It's a good way to practice.
Sometimes, you can have problems with termination of patients and letting go, but here you've worked through the termination right at the start. I think in some ways this can speed up therapy and make things more efficient. It imparts a message that the patient had better work harder.
You've written about overcoming the terror of death. How's that going?
I've thought about it and delved into it for so long that I don't have the same terror that I once did. When I wrote that book I specifically used the word "terror" – not the fear or anxiety, because I doubt that ever vanishes. I'm obviously getting towards the end of my life and I'm aware of this. But it doesn't paralyse me and it doesn't terrify me anymore. As a matter of fact, I'm living quite well at the present time. I feel very calm and probably psychologically better than I have for most of my life.
A regret-free life?
Well, I always wanted to be a writer. Maybe, had I been bought up in another generation, I might have just gone into writing rather than medicine – which is not to say that I didn't also have a great attraction towards the idea of being a healer. Fortunately, I've been able to combine the two in ways I could never possibly have imagined.