Minciuni pe canapea - note de lectura

A fost o surpriză plăcută faptul că Editura Humanitas s-a decis să continue seria
romanelor lui Irvin Yalom. După publicarea în urmă cu mai mulţi ani a romanului
„Plânsului lui Nietzsche”, iată că a venit şi rândul „Minciunilor pe canapea.”

Foarte pe scurt, personajul principal este Dr. Ernest Lash, un tânăr psihoterapeut
care, inspirat de Seymour Trotter, un celebru dar controversat psihoterapeut din San
Francisco, doreşte să depăşească limitele impuse de tehnica standard şi să devină
perfect sincer cu pacienţii săi. Din nefericire, el incearcă să facă acest lucru cu cine nu
trebuie: soţia unuia dintre pacienţii săi, convinsă fiind că soţul ei nu ar fi părăsit-o
niciodată dacă nu ar fi fost ajutat de Dr. Lash, decide să se razbune pe acesta din
urmă, devenindu-i pacientă sub un nume de împrumut. In jurul lui Lash şi a
pacientei lui psihopate se ţes şi alte poveşti, cum ar fi cea a supervizorului acestuia,
Dr. Marshal, un psihanalist destul de ahtiat după bani şi putere, care intră la rându-i
în tot felul de încurcături.

Firul roşu al romanului, tema sa centrală, este autenticitatea sau transparenţa

psihoterapeutului. Cat de mult trebuie un terapeut să se reveleze pe sine in relaţia cu
un pacient pentru a face psihoterapia eficienta? Cat poate împărtăşi din gândurile şi
sentimentele sale? Cat de mult trebuie sa se abţină să o facă? Ce poate spune si ce nu,
când şi în ce condiţii? Aceasta e o temă majoră în scrierile lui Yalom. Şi daca ar fi să
dau un singur exemplu, într-una din cartile sale, „The gift of therapy”, chiar sunt
câteva capitole intitulate „The Mechanism of therapy – be transparent”, „Revealing
the therapist’s personal life – use caution”, „Revealing your personal life – caveats”.
Si binenţeles că şi în celelalte cărţi de psihoterapie pe care le-a scris – şi in mod
special in „The theory and practice of group therapy” şi „Existential psychotherapy” –
se regăseşte acelaşi efort de a clarifica acestă poziţie delicată a terapeutului, prins
între necesitatea de a se aduce pe sine în relaţia terapeutică şi teama de a nu face rău
pacientului, dezvăluind prea mult sau ce nu trebuie.

Yalom a incercat intotdeauna să iasă din tiparele psihoterapiei centrate pe tehnici, pe

idei fixe despre cum se „face” psihoterapie”, aspirând spre un mod autentic de a fi in
relaţie al terapeutului, capabil şi dispus să se re-inventeze pe sine, ca terapeut, cu
fiecare din pacienţii săi (şi lucrul acesta îl spune şi unul dintre personajele cărţii,
Seymour Trotter – „trebuie să fii suficient de îndrăzneţ şi de creativ pentru a fabrica o
nouă terapie pentru fiecare pacient”). In plus, Yalom nu a fost niciodată de acord cu
atitudinea psihanalitică clasică, in care psihoterapeutul sau psihanalistul se dezvăluie
pe sine cât mai puţin posibil. De altfel, Yalom satirizează destul de evident lumea
psihanalizei instituţionalizate. Intr-una din cărţile despre Yalom („On psychotherapy
and the human condition”), Yalom e citat spunând „Foarte des, in practica mea, văd
oameni care au avut parte de o experienţă anterioară neplăcută legată de
psihoterapie. Mereu şi mereu aud aceeaşi plângere: terapeutul era prea impersonal,
prea neimplicat, prea înlemnit. Aproape niciodată nu am auzit un pacient plângându-
se că terapeutul lui a fost prea deschis, prea interactiv sau prea personal (cu excepţia
terapeuţilor care şi-au exploatat sexual pacienţii)”.

Binenţeles, riscul de a fi greşit înţeles l-a preocupat şi l-a determinat să scrie extensiv
despre limitele unei asemenea transparenţe (îmi vine să spun că abia aici discuţia
devine cu adevărat interesantă). A făcut-o în mod serios în scrierile sale dedicate
profesioniştilor, folosind un anumit limbaj şi mod de exprimare, dar, iată, a făcut-o şi
în joacă, în acest roman. Intenţia lui Yalom a fost, aici, de a explora aceste limite în
toată complexitatea lor: riscuri şi tentaţii, dorinţele terapeutului, nevoile sale,
echilibrul fragil dintre a ajuta şi a abuza.

Dincolo însă de această temă centrală, mi-am mai notat şi altele:

- Terapeutul ca tămăduitor rănit („wounded healer”), prizată de multi autori psi
(Jeffrey Kottler, de exemplu);
- Psihoterapia, artă sau ştiinţă;
- Relaţiile sexuale dintre pacienţi şi terapeuţi, cu trimiteri la cazurile celebre din
istorie;
- Cat de inovativ poate fi un terapeut? In ce măsură îşi poate permite să ignore ceea ce
s-a făcut/scris înaintea lui?
- Conflictul dintre adepţii psihoterapiilor de scurtă durată, susţinuţi de asigurările de
sănătate (din SUA), şi cei ai terapiilor de lungă durată;
- Anxietatea in fata mortii, lipsa unui sens evident al vietii – teme fundamentale ale
psihoterapiei existentiale despre care Yalom a scris si un tratat;
- Cadru, limite, transfer, plata sedintelor neonorate de pacienti, relatii duale intre
terapeut si pacienti;

Acum, mi-e greu să ştiu cu ce ochi ar citi acest roman cineva nefamiliarizat cu
psihoterapia. Probabil ar descoperi cu suprindere multe aspecte nebănuite ale acestei
practici dar, in acelasi timp, mi-e teamă că ar putea rata importanţa multor chestiuni
teoretice puse in discuţie de Yalom prin intermediul personajelor sale. Tot aşa,
trebuie să recunosc, nu sunt in stare să apreciez valoarea literară a acestei cărţi:
cartea aceasta nu e pentru mine „doar” sau „in primul rand” fictiune. Fictiunea e
secundară, e doar un pretext pentru o discuţie despre câteva teme fundamentale ale
psihoterapiei. E mai degrabă o carte instructivă, cu valenţe educative, deghizată într-
un roman. Dar, recunosc, mi-aş fi dorit să o pot citi şi cu ochii unui cititor „laic”,
ignorand dilemele subiacente puse in discuţie şi lăsându-mă pur şi simplu purtat de
poveste.

Pe scurt, „Minciuni pe canapea” e una din acele cărţi din care fiecare poate lua ceea ce
isi doreste: o poveste buna sau idei de măcinat.

Este o carte care merita citita tocmai pentru ca se preteaza mai multor interpretari si pentru
ca lasa loc de intelesuri diferite pentru varii categorii de cititori, desi instincul imi spune ca
cei familiarizati cu lumea psihoterapiei inteleg mai mult din sensul pe care autorul a vrut sa il
redea decat noi, cititorii laici. :)

Cand scrisesem "pacienta psihopata" nu terminasem de citit romanul. Daca as

fi facut-o, probabil as fi ezitat sa ii pun o asemenea eticheta personajului
respectiv desi, daca tin cont de gradul mare de improbabilitate a sfarsitului,
Carolyn si-ar fi meritat oricum diagnosticul.
Finalul romanului, desi frumos si dadator de sperante, mie unul mi se pare
nerealist. In sensul ca mi se pare destul de improbabil ca o persoana cu un
make-up psihologic similar lui Carolyn sa faca un astfel de salt privind
intelegerea de sine si a relatiilor sale cu ceilalti. Pur si simplu, in realitate,
asemenea minuni nu se prea intampla. Un asemenea happy-end o salveaza nu
numai pe Carolyne, dar si pe terapeutul inovator si destul de nesabuit - dupa
parerea mea, in ciuda succeselor sale - care risca enorm si nu neaparat
necesar. Cum spuneam, in realitate lucrurile nu sunt chiar asa de simple...
 As mai adauga un aspect- ca tot am terminat ieri de citit cartea. Mi-a placut ca
a adus in discutie si posibilitatea ca psihoterapeutul sa cada prada complotului
si manipularii, in pofida capacitatii sale de a intrezari adevaratele si profundele
motivatii ale comportamentului uman. Faptul ca Ernest si-a continuat terapia
inovatoare, fara sa banuiasca catusi de putin rolul ascuns al lui Carol, sau
faptul ca insusi Marshal- za oan-ul terapeutilor- este pacalit grosolan de niste
escroci, sunt aspecte ce conduc, iar, catre demitizarea (chestie care lui Yalom ii
place tare mult- si mie-mi place) terapeutului. Marshal a iesit mai rau decat
Ernest, desi ambele lor situatii au fost extrem de periculoase, doar pentru ca
Yalom pare sa se fi plictisit un picut la final, si a zis sa traga un happy-end
multumitor. In realitate, chiar exista asa numitii "therapist killers" iar fisurile
caracteriale, slabiciunile dar mai ales aroganta, ii pot costa foarte scump pe
psihoterapeuti.

Un articol in presa romaneasca despre Yalom psihoterapeutul

Am gasit zilele trecute, in arhiva online a ziarului Adevarul, un articol foarte bun despre
Yalom si povestile lui - cum sa le spun, "despre psihoterapie" sau "psihoterapeutice"?
Articolul ii apartine Stelei Ghetie si se numeste "Omul din oglinda". Redau mai jos un scurt
fragment din acest articol - pentru varianta intregrala, trebuie sa mergeti la sursa.

"Irvin D. Yalom este profesor emerit de psihiatrie la Universitatea Stanford şi autorul a

numeroase cărţi de psihoterapie, printre care unele texte clasice (Existential Psychotherapy,
de pildă). Volumul Love’s Executioner & Other Tales of Psychotherapy reuneşte zece poveşti
detective despre sufletul omenesc, relatate „cu agerimea de povestitor a lui O. Henry şi cu
umorul lui Isaac Bashevis Singer", după cum notează San Francisco Chronicle.

Ce îl deosebeşte pe Irvin Yalom de alţi practicanţi ai psihoterapiei este refuzul de a adera la o

doctrină, oricare ar fi ea, în acest domeniu. Căci, spune autorul, „capacitatea de a tolera
incertitudinea e o primă calificare necesară în această profesie. ...Puternica tentaţie de a
dobândi certitudinea îmbrăţişând o şcoală ideologică şi un sistem terapeutic strict e
înşelătoare: o asemenea convingere poate bloca întâlnirea, incertă şi spontană, fără de care
nu există terapie eficace".
Yalom - O scurta autobiografie

M-am nascut in Washington, D.C., pe 13 iunie 1931, din parinti originari din Rusia (un mic
sat numit Celtz, aproape de granita cu Polonia), care emigrasera in America dupa Primul
Razboi Mondial. Pentru mine, acasa era zona centrala a Washingtonului, unde locuiam intr-
un mic apartament, deasupra bacaniei detinute de parintii meu. Pe vremea copilariei mele,
Washington era un oras segregat din punct de vedere rasial si am trait in mijlocul unui cartier
sarac de negri. Viata pe strazi era adesea periculoasa. Asa ca ma refugiam in lecturi si, de
doua ori pe saptamana, faceam un drum de-a dreptul periculos pana la biblioteca centrala
pentru a ma aproviziona cu carti.

Pe vremea aceea nu exista nici un fel de consiliere sau indrumare profesionala disponibila:
parintii mei nu aveau practic nici un fel de educatie formala, nu citisera niciodata vreo carte
si intreaga lor viata se consumase in lupta pentru supravietuire economica. Citeam la
intamplare, mai mult in functie de ce imi pica in mana. Rafturile cu biografiii mi-au atras
atentie destul de devreme si am petrecut un an citind toate cartile de acolo, de la A (John
Adams) la Z (Zoroastru). Dar adevaratul refugiu l-am gasit in beletristica, o lume diferita si
mult mai satisfacatoare decat cea reala, o sursa de inspiratie si intelepciune. Destul de
devreme in viata am ajuns la ideea – la care nici acum nu am renuntat – ca a scrie un roman
este cel mai bun lucru pe care un om il poate face in viata.

Toti prietenii mei au intrat la facultatea de medicina sau au devenit parterii de afaceri ai
parintilor lor. Mie, medicina mi-a aparut ca fiind apropiata de lumea lui Tolstoi si Dostoevsky
si inca de la inceput am stiut ca vreau sa fac prishiatrie. Psihiatria se dovedea (si inca se
dovedeste pana in zilele noastre) nesfarsit de interesanta si provocatoare si intotdeauna m-
am apropiat de pacientii mei cu o anumita uimire fata de povestea lor. Cred ca trebuie
construita sau inventata o terapie diferita pentru fiecare pacient, pentru ca fiecare are o
poveste diferita. Pe masura ce au trecut anii, aceasta atitudine m-a indepartat tot mai mult de
centrul sau miezul psihiatriei asa cum se practica ea astazi, impinsa de puternice forte
economice in directii opuse celei dragi mie, si anume catre aplicarea unui diagnostic de-
individualizat (bazat pe simptome) si a unei psihoterapii scurte, uniforme, pe baza de
protocol.

Primele mele scrieri au fost sub forma unor articole in diverse reviste de specialitate. Prima
mea carte, “Theory and Practice of Group Therapy” a fost larg utilizata (700.000 de cópii) ca
manual pentru pregatirea psihoterapeutilor. A fost tradusa in 12 limbi si este acum la cea de-
a patra editie. Editura care mi-a publicat aceasta carte si, practic, toate celelalte care au
urmat, este Basic Books, cu care am avut o lunga si excelenta relatie. Cei care ii instruiesc pe
viitorii psihoterapeuti mi-au apreciat cartea despre terapia de grup pentru ca se bazeaza pe
cele mai bune dovezi empirice. Totusi, banuiesc ca o parte din succesul acestei carti se
datoreaza povestirii – unui sir de mici povestirii despre oameni, care curge de-a lungul
textului. De douazeci de ani tot aud studentii spunandu-mi ca se citeste ca un roman.

Au urmat apoi alte texte – “Existential Psychotherapy” (un manual pentru un curs care nu
exista la vremea aceea), “Inpatient Group Psychotherapy” (un ghid pentru conducerea
grupurilor terapeutice cu pacienti internati in spitalele de psihiatrie). “Encounter Groups:
First Facts” (Grupurile de Intalnire: primele date) este o monografie stiintifica care nu se mai
editeaza. Apoi, intr-un efort de a face mai bine cunoscute aspectele psihoterapiei existentiale,
m-am indreptat catre scrierea literara si in ultimii ani am scris o carte cu povesti legate de
terapie (Love’s Executioner), doua romane (“When Nietzsche Wept” si “Lying on the Couch”)
si o colectie de povestiri, adevarate, din terapie (“Momma and the Meaning of Life”).

Desi aceste carti au fost best-seller-uri pentru publicul larg si au fost adesea evaluate – atat
favorabil cat si nefavorabil – in functie de calitatile lor literare (“When Nietzsche Wept” a
castigat Commonwealth Gold Medal pentru cea mai buna opera de fictiune in 1993), intentia
mea a fost, atunci cand le-am conceput, de a scrie carti cu valoare pedagogica, carti de
povestiri din care se pot invata lucruri legate de psihoterapie. Ele au fost traduse in
numeroase limbi, in jur de 15-20. “When Nietzsche Wept” a fost, de exemplu, in topul celor
mai bune carti din Israel timp de peste patru ani. O antologie, “The Yalom Reader”, a fost
publicata de Basic Books la sfarsitul anului 1997. In afara unor fragmente din cartile mele
anterioare, aceasta mai contine si cateva noi eseuri personale care pot fi citite ca niste
introduceri, utile profesionistilor din domeniul sanatatii mintale, la cartile mele “Love’s
Executioner”, “When Nietzsche Wept” si “Lying on the Couch”. In prezent, lucrez la un
roman despre Schopenhauer (n.b. intre timp, romanul The Schopenhauer Cure s-a publicat
deja).

Sotia mea Marilyn, a obtinut un doctorat in literatura (franceza si germana) de la

Universitatea Johns Hopkins si a avut o cariera de succes ca profesor universitar si scriitor
(cea mai recenta carte a sa se numeste “A History of the Breast”, iar in prezent lucreaza la o
carte intitulata “History of the Wife”). Cei patru copii ai mei, toti locuind in zona San
Francisco Bay, au ales o varietate de profesii – medicina, fotografie, regie de teatru,
psihologie clinica. Am cinci stranepoti si altii sunt deja pe drum
 Nancy

In my fifteen-minute break—before seeing Nancy, my last patient of the day—I checked my voice
mail and listened to a message from a San Francisco radio station. "Dr. Yalom, hope you don't mind
but we've decided to change the format of our program tomorrow morning: We've invited another
psychiatrist to join us and, instead of an interview, we'll have a three-way discussion. See you
tomorrow morning at eight thirty. I assume this is all okay with you."

Okay? It wasn't okay at all and the more I thought about it the less okay it felt. I had agreed to be
interviewed on the radio show in order to publicize my new book, The Gift of Therapy. Though I'd
been interviewed many times, I felt anxious about this interview. Though the interviewer was
extremely skilled, he was highly demanding. Furthermore, it was an hour long, the size of the radio
audience was enormous and, finally, it was in my hometown with many friends listening. This voice
mail message further fueled my anxiety. I didn't know the other psychiatrist; but to juice up the
interview they had, no doubt, invited someone with an opposing point of view. I brooded about it:
The last thing I, or my book, needed was an hour-long hostile confrontation in front of a hundred
thousand listeners. I phoned back but there was no answer.

I was not in a good frame of mind to see a patient but the hour struck six and I escorted Nancy into
my office. Nancy, a fifty-year-old nursing school professor, first came to see me twenty years before
following the death of her older sister who had died of a brain malignancy. I remember how she
began: "Eight sessions. That's all I want. No more, no less. I want to talk about the loss of the dearest
and closest person in my life. And I want to figure how to make sense of life without her." Those
eight sessions clicked by quickly: Nancy brought an agenda to each session: important memories of
her sister, their three fights—one of which initiated a frosty silent four-year era which only ended at
the funeral of their mother, her sister's disapproval of her boyfriends, her deep love for her sister—a
love she had never expressed openly.

Her family was a family of secrets and silences; feelings, especially positive ones, were rarely voiced.

Her family was a family of secrets and silences; feelings, especially positive ones, were rarely voiced.

Nancy was smart and quick: A self-starter in therapy, she worked hard and appeared to want or need
little input from me. At the end of the tenth session she thanked me and left, a satisfied customer. I
wasn't entirely satisfied, however. I would have preferred more ambitious therapy and I had spotted
several areas, especially in the realm of intimacy, where further work could have been done. Over
the next twenty years she called me two other times for brief therapy and, repeating the same
pattern, used the time efficiently. And then, a few months ago, she phoned once again and asked to
meet for a longer time, perhaps six months, in order to work on some significant marital problems.

She and her husband, Arnold, had grown increasingly distant from one another and for many years
had slept in different rooms on separate floors of their home. We had been meeting weekly for a few
months and she had so improved her relationship with her husband and her adult children that, a
couple of weeks previously, I had raised the question of termination. She agreed she was getting
close but requested a few additional sessions to deal with one additional problem that had arisen:
stage fright. She was awash with anxiety about an upcoming lecture to a large prestigious audience.

As soon as Nancy and I sat down she plunged immediately into anxiety about her upcoming lecture. I
welcomed her energy: it diverted my attention from that damn radio show. She spoke of her
insomnia, her fears of failure, her dislike of her voice, her embarrassment about her physical
appearance. I knew exactly what to do and began to escort her down a familiar therapeutic path: I
reminded her of her mastery of her material, that she knew far more about her topic than anyone in
the audience. Though I was distracted by my own anxiety, I was able to remind her that she had
always sparkled as a lecturer and was on the verge of pointing out the irrationality of her views of her
voice and physical appearance when a wave of queasiness swept over me.

How hypocritical could I be? Hadn't my therapy mantra always been "it's the relationship that heals,
it's the relationship that heals." Hadn't I always, in my writing and teaching, beat the drum of
authenticity?

The solid, genuine, I-thou relationship—wasn't that the ticket, the significant ingredient in successful
therapy?

The solid, genuine, I-thou relationship—wasn't that the ticket, the significant ingredient in successful
therapy? And yet here I was—riddled with anxiety about that radio show and yet hiding it all behind
my pasted-on compassionate therapist countenance. And with a patient who had almost identical
concerns. And a patient who wanted to work on intimacy to boot! No, I could not continue with this
hypocrisy.

So I took a deep breath and fessed up. I told her all about the voice mail message I received just
before she entered and about my anxiety and anger for my dilemma. She listened intently to my
words and then, in a solicitous voice, asked, "What are you going to do?"

"I'm considering refusing to go on the program if they insist on this new arrangement."

"Yes, that seems very reasonable to me," she said, "you agreed to another format entirely and the
station has no right to make the change without clearance from you. I'd be really upset about that,
too. Is there any downside of your refusing?"

"None that I can think of. Perhaps I won't be invited back for the next book but who knows when or if
I'll write another."

"So, no downside of refusing and lots of possible downside in your agreeing to do this?"

"Seems that way. Thanks Nancy, that's helpful."

We sat together in silence for a few moments and I asked, "Before we turn back to your stage fright,
let me ask you something: How did that feel to you? This has not been our everyday hour."
"I liked your doing that. It was very important to me," she replied, paused for a moment to collect
her thoughts and added, "I have a lot of feelings about it. Honored that you shared so much of your
self with me. And ‘normalized': Your performance anxiety makes me more accepting of my own. And
I think your openness will be contagious. I mean, you've given me the courage to talk about
something I didn't think I'd be able to bring up."

"Great. Let's get into it."

"Well," Nancy looked uncomfortable and squirmed in her chair. She inhaled and said, "Well, here
goes . . ."

I sat back in my chair, eager with anticipation. It was like waiting for the curtain to rise on a good
drama. One of my great pleasures. A good story in the wings ready to make an entrance is like no
other anticipatory pleasure I know. And my anxiety and annoyance at the interview and the radio
station? What interview? What radio station? I had totally forgotten it. The power of the narrative
drowned all cares.

"Your mentioning your book, The Gift of Therapy, gives me the opportunity to tell you something. A
couple of weeks ago I read the whole book in a single sitting, till three a.m." She paused.

"And?" I shamelessly fished for a compliment.

"Well, I liked it but I was . . . uh, curious, about your using my story of the two streams."

"Your story of the two streams? Nancy, that was someone else's story, a woman dead these many
years—I described her in the book. I've used that story in therapy and teaching for more years than I
can remember."

"No, Irv. It was my story. I told it to you during our first therapy, twenty years ago."

I shook my head. I knew it was Bonnie's story. Why, I could still visualize Bonnie's face as she told me
the story, I could see her wistful eyes as she reminisced about her father, I could still see the violet
turban around her head—she had lost her hair from chemotherapy.

"Nancy, I can still see this woman telling me the story, I can . . ."

"No, it was my story," Nancy said firmly. "And what's more, it wasn't even my father and me. It was
my father and my aunt, his younger sister. And it wasn't on the way to college—it was a vacation
they took in France."

I sat stunned. Nancy was a very precise person. The strength of her assertion caught my attention. I
turned inwards searching for the truth, listening to the trickling of memory coursing in from outposts
of my mind. It was an impasse: Nancy was certain she told me this. I was absolutely certain I heard it
from Bonnie. But I knew I had to remain open-minded. One of Nietzsche's marvelous aphorisms
entered my mind and served as a cautionary tale:

"Memory says, I did that. Pride replies, I could not have done that. Eventually memory yields."

"Memory says, I did that. Pride replies, I could not have done that. Eventually memory yields."

As Nancy and I continued to talk, a new and astounding thought dawned. Oh, my God, could there
have been two stories? Yes, yes, that's it. There must have been! The first story was Bonnie's story
about her father, her yearning for reconciliation, and their unsuccessful drive to college; the second
story was Nancy's two-stream story about her father and aunt. Now, all at once, I realized exactly
what had happened: My gestalt-hungry, story-seeking memory had conflated the two stories into a
single event.

It's always a shock to experience the fragility of memory. I've worked with many patients who have
been destabilized when they learned that their past was not what they had thought it was. I
remember one patient whose wife told him (at the breakup of their marriage) that, throughout their
three-year marriage, she had been obsessed with another man, her previous lover. He was shattered:
All those shared memories (romantic sunsets, candlelit dinners, walks on the beaches of small Greek
islands) were chimerical. His wife was not there at all. She was obsessing about someone else. He
told me more than once that he suffered more from losing his past than from losing his wife. I didn't
fully understand that at the time but now, as I sat with Nancy, I could finally empathize with him and
appreciate how unsettling one feels when the past decomposes.

The past: wasn't it a concrete entity, unforgettable events etched indelibly into stone-like leaves of
experience? How tightly I clung to that solid view of existence.
The past: wasn't it a concrete entity, unforgettable events etched indelibly into stone-like leaves of
experience? How tightly I clung to that solid view of existence. But I knew now, I really knew, the
fickleness of memory. Never again would I ever doubt the existence of false memories! What made it
even more confounding was the way I had embroidered the false memory (for example, the wistful
look on Bonnie's face) which made it entirely indistinguishable from a real memory. All of these
things I said to Nancy along with my apology for not having obtained her permission for the story of
the two streams. Nancy was untroubled by the issue of permission. She had written science fiction
stories and was well aware of the blurring of remembrance and fiction. She instantaneously accepted
my apology for publishing something of hers without her permission and then added that she liked
her story being used. She took pride in it having prove helpful to my students and other patients.

Her acceptance of my apology left me in a mellow mood and I told her of a conversation a few hours
previously with a visiting Danish psychologist. He was writing an article about my work for a Danish
psychology journal and asked whether my intense closeness with patients made it more difficult for
them to terminate. "Given the fact that we're near termination, Nancy, let me pose that very
question to you. Is it true that our closeness interferes with your ending your meetings with me?"

She thought about it for a long time before responding, "I agree. I do feel close to you, perhaps as
close as with any other person in my life. But your phrase, that therapy is a dress rehearsal for life,
which you said so many times—I think you overdid it by the way . . . well, that phrase helped keep
things in perspective. No, I'm going to be able to stop soon and keep a lot from here inside me. From
day one of our last set of meetings you did keep focusing on my husband. You did keep focusing on
our relationship, but scarcely an hour passed without your moving over to the intimacy between me
and Arnold."

Nancy ended the hour by giving me a lovely dream (remember Nancy and Arnold slept in separate
rooms).

"I was sitting on Arnold's bed. He was in the room and watching me. I didn't mind his being there and
was busy with makeup. I was taking off a makeup mask, peeling it off in front of him."

The dream-maker inside of us (whoever, wherever, he or she is) has many constrictions in the
construction of the finished product. One of the major constrictions faced is that the dream final
product must be almost entirely visual. Hence, an important challenge in the dream work is to
transform abstract concepts into a visual representation. What better way to depict increased
openness and trust with one's spouse than to peel off a mask about-a-very-similar

issue.">Discussion

Second, there is the matter of effectiveness: I believe that my preoccupation with my personal issues
was hampering my ability to work effectively. Third, there is the factor of role modeling. My
experience over decades of doing therapy is that such revelation inevitably catalyzes patient
revelation and accelerates therapy.

After my self-revelation there was, for a few minutes, a role reversal as Nancy offered me effective
counsel. I thanked her and then initiated a discussion of our relationship by commenting that
something unusual had just happened. (In the language of therapists, I did a "process check.") Earlier
I made the point that therapy is, or should be, an alternating sequence of action and then reflection
upon that action.

Her response was highly informative. First, she felt honored by my sharing my issues with her—that I
would treat her as an equal and accept her counsel. Second, she felt "normalized"—that is, my
anxiety made her more accepting of her own. Last, my revealing served as a model and an impetus
for her further revealing. Research confirms that therapists who model personal transparency
influence their patients to reveal more of themselves.

Nancy's response to my disclosure is, in my clinical experience, typical. For a great many years I have
worked with patients who have had an unsatisfactory prior experience in therapy. What are their
complaints? Almost invariably, they say that their previous therapist was too distant, too impersonal,
too disinterested.

I believe that therapists have everything to gain and nothing to lose by appropriate self-disclosure.
I believe that therapists have everything to gain and nothing to lose by appropriate self-disclosure.

How much should therapists reveal? When to reveal? When not? The guiding in answering such
questions is always the same: What is best for the patient? Nancy was a patient I had known for a
long time and I had a strong intuition that my genuineness would facilitate her work. Timing was an
important factor as well: Self-disclosure early in therapy, before we established a good working
alliance, might have been counterproductive. The session with Nancy was an atypical session and I do
not generally reveal my own personal disquiet to my patients: After all, we therapists are there to
help, not to deal with our own internal conflicts. If we face personal problems of such magnitude that
they interfere with therapy then obviously we should be seeking personal therapy.

That said, let me add that on countless occasions I have gone into a session troubled with some
personal issues and, by the end of the session (without having mentioned a word about my
discomfort), felt remarkably better! I've often wondered why that was so. Perhaps because of the
diversion from my self-absorption, or the deep pleasure of being helpful to another, or the boost in
self-regard from effectively employing my professional expertise, or the effect of increased
connectivity that all of us want and need. This effect of therapy helping the therapist is, in my
experience, even greater in group therapy. All of the reasons noted above are in effect but there is an
additional factor in group therapy: A mature, caring therapy group in which members share their
deepest inner concerns has a healing ambiance in which I have the privilege of immersing myself. 

From The Gift of Therapy

Ruthellen
This was your first case presentation.
Josselson:

Irvin Yalom: Right. I was pretty anxious about it. I remember my patient very clearly—a red-headed,
freckled woman, a few years older than I. I was to meet with her for eight weekly
sessions (the length of the clerkship.) In the first session she told me she was a lesbian.

That was not a good start because I didn't know what a lesbian was. I had never heard
the term before. I made an instant decision that the only way I could really relate to her
was to be honest and to tell her I didn't know what a lesbian was. So I asked her to
enlighten me and over the eight weeks we developed a close relationship. She was the
patient I presented to the faculty.

Now I had been to several of these conferences with other students and they were gut-
wrenching. Each of these analysts would try to outdo the other with pompous complex
formulations. They showed little empathy for the student who was often crushed by the
merciless criticism.
 I simply got up and talked about my patient and told it as a story. I don't think I even
used any notes. I said here's how we met. Here's what she looked like. Here's what I felt.
Here's what evolved. I told her of my ignorance. She educated me. I was profoundly
interested in what she told me. She grew to trust me. I tried to help as best I could
though I had few arrows of comfort in my quiver.

At the end of my talk there was a loud long total silence. I was puzzled. I had done
something that was extremely easy and natural for me. And, one by one, the analysts—
those guys who couldn't stop one-upping each other—said things to the effect of, "Well,
this presentation speaks for itself. There's nothing we can say. It's a remarkable case. A
startling and tender relationship." And all I had done was simply tell a story, which felt so
natural and effortless for me. That was definitely an eye-opening experience: Then and
there I knew I had found my place in the world.

This memory is perhaps a life-defining moment for Yalom. As he remembers and talks
about it, he is deeply moved. In some ways, his work ever since has been about telling
stories, stories about his encounters with people as a therapist, stories that instruct us
about how to connect meaningfully with others. He has retained his essential humility—
he still allows others to teach him about their reality as he tries to encounter them in
their deepest being and offer them a relationship in which they can heal. This moment
also marked for Yalom a route out of the anonymity he had experienced throughout his
education. Despite his academic successes, no one had recognized that he had any
particular talent and he had only the vaguest sense that he had some special ability. For
the first time, he was recognized—and for doing something that his teachers had never
seen done before.

RJ: Where did you get the courage to do that?

It didn't feel like anything courageous, as I recall—but this is over fifty years ago—I didn't
have other options. It was my turn to present a case, this was my way to present a case.
IY:
Whenever afterward I presented a case, whenever I presented at grand rounds or a
lecture, I had the audience's full attention. I always had that ability.

So this moment when you told the case to the analysts and they were silent, they were
unable to respond in their usual ways and start to compete with each other with
RJ:
formulations, you felt that they saw in you and that you had done something worth
noticing, something important?

Oh, yeah, for sure. If I try to understand it now across all those decades, I think it was
because I was talking about a psychiatric case, but speaking in a whole different realm, a
IY: literary, story-telling realm. And their formulations had no sway. The jargon, the
interpretations, all that had nothing to do with the story I told them. Of course that's my
view: I'd love to go back in time and learn what they were really thinking.

RJ: There are so many different ways to tell a story, including the usual case presentation
 which is also a way to tell a story. But this was a different way to tell a story.

I didn't know anything about telling a story or what telling a story meant in any kind of
IY:
technical way, but I somehow knew how to put things together to create a drama.

RJ: With yourself in it.

Oh, with myself in it. How I met her, how I didn't know anything about her being a
lesbian, how baffled I was, how I guessed she must feel to work with a therapist who's
IY: admitted that he's totally ignorant of her lifestyle, how she must have worried about my
accepting her, how I must have given to her some representative of the whole world
who knew nothing about her and who possibly might ostracize her in some way.

You didn't judge her, or pathologize her, or do something like that. You were able, in
RJ:
fact, to engage with her in a very human way.

Yes. I think that's true. I did not ostracize her—just the opposite, my confessing my
IY:
ignorance drew us closer together—a relationship forged in honesty.

As opposed to the psychiatric way or psychoanalytic way that would look at her as a
RJ:
carrier of symptoms and pathology.

That's right, case formulations which focus narrowly on pathology were very distasteful
IY:
to me.

RJ: It was distasteful even in medical school.

Even in medical school—I didn't like the distant disinterested stance of many
IY:
psychiatrists I encountered.

But you were still clear you wanted to go into psychiatry even though what they were
RJ:
doing was not something that you felt was at all appealing.

That's right. Once or twice I wavered because there were so many things I liked about
medicine. I liked taking care of people, liked passing on to them what Dr. Manchester
IY:
had passed on to me. But I never seriously entertained doing anything else in medicine.
So I was committed. At this point, I was already starting to read a lot about psychiatry.

I am impressed by how much philosophy you have read and integrated in your work as a
RJ:
therapist and a writer.

I spent 10 years reading philosophical works and writing Existential Psychotherapy. It

was a good friend, Alex Comfort (a man known for The Joy of Sex but who wrote over
fifty scholarly books) who advised me it was time to stop reading and start writing. But
IY:
I've continued to read philosophy ever since. Existential Psychotherapy was a
sourcebook for all that I've written since then. All the books of stories and the novels
were ways of expanding one or the other aspects of Existential Psychotherapy.

RJ: But you don't think about Existential Psychotherapy as being a school of psychotherapy?

IY: No. I never have. You cannot simply be trained as an existential psychotherapist. One has
 to be a well-trained therapist and then set about developing a sensitivity to existential
issues. I've always resisted the idea of starting an institute or a training program. I have
such a strong pull towards writing. I really love to write.

With the widespread success of your case story books and then your first novel, did you
RJ:
then start writing more to the general public?

No, I always thought my audience was the young therapist, young residents in psychiatry
IY:
and student psychologists and counselors.

So you never thought about writing to the general public? They would be eavesdropping
RJ:
as you spoke to therapists.

Yes, they would be eavesdropping because they had been in therapy or were interested
in the topic of therapy. I think the Love's Executioner book description proclaimed that
IY: this book was for people on both sides of the couch. And I also thought people in
philosophy would be interested, especially in the Nietzsche book and the Schopenhauer.
That psychobiography of Schopenhauer was original—there's no other work like that.

How come you chose Schopenhauer? With Nietzsche it's clearer to me, because you are
RJ:
so close to his philosophy.

Schopenhauer was always in the background. You have to remember that he was
Nietzsche's teacher. (I mean intellectually—they never met.) But Nietzsche turned
against him eventually and that break fascinated me for a long time. It was of great
interest to me that they started from the same point, the same observations about the
human condition, but one became life-celebrating and one life-negating. So what was
that all about? I suspected it was driven by character, or personality, issues.

And also Freud was interested in Schopenhauer. He was the major German philosopher
IY: when Freud was educated. A great many of Freud's major ideas are sketched out in
Schopenhauer's work. His work was very rich. He wrote voluminously about so many
other topics such as politics, musicology, and esthetics but I concentrated solely on his
writings about life and existence.

You have to recognize the human condition before you can figure out how to deal with
it. Schopenhauer can inform us about the futility of desire and the inevitably of oblivion,
but eventually it's the Nietzschean idea of embracing life that is the viable answer to this
dilemma.

In so many of your stories as well as the novels, there is a recurrence of the themes of
RJ: sex obsession and love obsession. Can you tell me about how come this captured your
interest?

IY: I've always been struck with the idea of romantic love and losing oneself in the other in
that way, which I've often characterized as "the lonely I dissolving into the we." And
therefore you lose the sense of personal separateness and find comfort in the lack of
loneliness. That's why I've always been intrigued with Otto Rank's formulation of going
 back and forth between the poles of life anxiety and death anxiety. And also Ernest
Becker, who is very Rankian, and developed Rank's ideas in his wonderful book, The
Denial of Death.

So I've always been interested in this idea of romantic love and also in religious
submission, which is similar—both relate to the ultimate concern of isolation. And this
issue of obsession was a predominant theme in Nietzsche.

I had a patient recently who was obsessed about a woman who had broken off with him
but he couldn't get her out of his mind and he went and read the Nietzsche book and
came back and said it did him more good than the two years of therapy we had done.

RJ: So we strive to be autonomous but have difficulty dealing with our separateness?

Yes, and also underneath much compulsive activity is a lot of death anxiety. Often the
IY:
death anxiety is overlooked because of other issues such as rage.

So in the pain of existential isolation, the lonely I is connected to rage which is connected
to death anxiety. And the fear and the rage is about both aloneness and death. We are
RJ:
thrown into this finite existence alone. In your Nietzsche novel and in some of the
stories, the aim is to help people give up the obsession.

IY: Helping them find some more authentic way of relating to others.

RJ: Do you see love obsession and sex obsession as the same thing?

I see them as first cousins. In The Schopenhauer Cure, Phillip's anxiety was assuaged by
the sexual coupling, but the relief was evanescent. In romantic love, life can't be lived
IY:
without this person and if you lose her, you're in continual grief—that's been the
problem for many of my patients.

RJ: How do you distinguish between authentic meaningful connection and love obsession?

The basic distinction lies in rationality, not thinking in irrational terms. A love obsession is
highly irrational. It's ascribing things to the other that aren't there, not seeing the other
IY: as the other is, not being able to see the other person as a finite, separate person who
doesn't have magical powers. A love obsession comes from the same stuff as religion,
ascribing powers to the other.

Don't you think that when people love one another, they do some of that—a certain
RJ:
amount of idealizing, making the other person very special?

IY: I think that a true love relationship is caring for the being and becoming of the other
person and having accurate empathy for the other person where you are trying to care
for the other person in every way you can. But that may not be the focus of a love
obsession. Like the first story in Love's Executioner—where one of the dyad did not even
know the other was having a psychotic experience. People will fall in love with someone
they hardly know. In true love, you see the other person accurately as a human being
like yourself. You fall in love with someone by seeing who they are and what they are so
 they aren't forced to be someone they're not. For me, the kind of love relationship I
want to espouse is one where one's eyes are wide open.

RJ: So that would be a measure of the rationality of the relationship.

IY: Yes.

In your most recent book, Staring at the Sun, you return to the theme of death. I wonder
RJ:
why now?

I'm dealing more with this because of my age. I'm 76 now, an age when people die and I
IY: see my friends aging and dying. I see myself on borrowed time. I spoke about much of
this in Staring at the Sun.

RJ: What has it meant to write this book at this age?

I've been so inured, so plunged into the topic. Originally I was going to write a series of
connected fictional stories about dealing with death anxiety. I had been reading a lot of
Plato and Epicurus and I thought I would write a series of stories with some connection. I
was inspired by a Murukami book called After the Quake in which all the stories were
connected by one thing: the Kobe earthquake. I had six stories in mind and my plan was
to start each story with the identical nightmare about death. In each story the dreamer
wakes up in a panic about dying, leaves the house and searches for someone who can
help him with his death anxiety. The first story was set in 348 BC and the dreamer goes
out in search of Epicurus. A second story would involve a minor Pope of the middle ages,
then in Freud's time, then more contemporary stories. But I spent so much time
researching the first story on Epicurus, reading about what the ancient Greeks had for
breakfast—what's a Greek café like, what clothing was worn, then I started reading
novels about ancient Greece, a novel about Archimedes, and about the priestesses at
Delphi—until six months had elapsed and I realized that the background research would
take years and I reluctantly gave up the idea, which I thought was a splendid concept.
IY:
Perhaps one of the readers of this interview will write it some day.

So I went to the other project I had in mind, a revision of Existential Psychotherapy. I

reread it carefully and underlined things I wanted to change and organized a course of
students who would read it with me and help me to select the dated material, but, in the
end, I was overwhelmed by the task, especially the scope of the library research looking
up the empirical research on the ultimate concerns that has been accumulating in the
twenty-five years since I first published this book. So I gave that up and wrote a book on
what I had learned about an existential approach in the years that have passed since I
wrote the textbook. Next my agent, noting that seventy-five per cent of the book
addressed death anxiety, suggested that I might write a tighter book if I concentrated
only on death anxiety. Finally the book underwent one more metamorphosis when my
publisher suggested I direct it more to the general public. I agreed to do so but insisted
upon a final chapter directed at therapists. I believe the strongest chapter is a personal
chapter dealing with the development of my own awareness of death.

RJ: Would you say that doing this book makes you even less fearful about death than when
 you started it?

I think so. But writing about death anxiety wasn't an effort to heal myself about it. I've
never been that consumed with death anxiety. It was more of an issue a long time ago
when I started working with cancer patients. I don't think I've been unusual in my degree
of death anxiety. Now I feel like I've become effective in dealing with patients with death
anxiety and am confident that I can offer help.

Irv shared with me a number of email letters he gets daily from people all over the
world. These are heartfelt (often heart-rending) letters from people expressing
their appreciation of the ways in which his writings have changed their lives.

"It is not enough to say that your words moved me or affected me. When at the end
[of The Schopenhauer Cure] Pam placed her hands on Phillip and told him what
IY: he needed to hear—the words on the page began to blur, all I could do was lean
my head back, swipe at the onslaught of tears and wait for my faculties to return.
It was the catharsis I needed." Or from another: "I know I am alone and finite, but
I feel connected to the rest of humanity in reading your books because everyone
else, I realize, is in the same boat—and thanks for that insight/comfort." And from
a professor in Turkey: "I'm writing to you in appreciation of keeping me excellent
company through the rough hours of the day: when you are alone, or even worse
(better?) when you think you are alone . . . I usually start my lessons with a saying
or a thought of yours in order to boost my class—and me—to open a new window
and see things a little bit different."

Other letters are from people longing to find some salve for their emotional pain,
some of what he has provided his own patients. He answers each of these letters
personally, acknowledging their meaning for him or, when he can, offering
counsel.
RJ: What have these letters meant to you?

I feel I have another, a second therapy practice. I know I mean a lot to some of my
readers. I'm aware that they imbue me with a lot more wisdom than I have and they long
to connect with me. I try to answer every letter, even if it's just to say thank you for your
note. This correspondence makes me unusually aware of my readership. I took an early
retirement from the Department of Psychiatry ten years ago. One of my main reasons
was that psychiatry had become so re-medicalized that my students had little interest in
IY:
psychotherapy and instead were far more interested in biochemistry and
pharmacological research and practice. I didn't really have students who were interested
in what I had to teach. So I now feel that my teaching is done through my writing. I don't
miss classroom teaching because I feel that I now have this whole other way of teaching.
I consider my writing teaching and getting this correspondence keeps me aware of that
all the time.

RJ: What message do you try to convey in response?

IY: As I said, some simply express appreciation for the writing or tell me it was meaningful to
them and I simply state that I feel good that my writing had a positive impact.
Sometimes I say that writers send their books out like ships at sea and that I'm delighted
 that a book arrived at the right port.

There are other readers who ask for help for some personal issue and, if appropriate, I
urge them to seek therapy. Some write a second time thanking me for being
instrumental in their obtaining help. Some readers comment that their current therapy
isn't helping and ask for email therapy. I don't do therapy by email and urge them to be
direct with their therapist and to express these sentiments openly. I even suggest that
concealing these feelings may be instrumental in their therapy not being useful. Their job
in therapy is to share all their feelings and wishes with their therapists. Able therapists
will welcome this forthrightness. My main message though is to let them know that I've
read their letter.

It makes me so sad to hear that you had students who didn't want to learn what you had
RJ:
to teach. What does this say about the future of psychotherapy?

I do feel there is a pendulum swinging, even in psychiatry. I do hear about more

programs starting to introduce therapy again. Many contemporary therapists are trained
in manualized mechanical modes—all of which eschew the authentic encounter. After
some years of practice, however, a great many of these therapists come to appreciate
the superficiality of their approach and yearn for something deeper, something more far-
IY:
reaching and lasting. At this time therapists enter postgraduate therapy training
programs or supervision. Or they learn by entering their own therapy. And I can assure
you they never never seek a therapist who practices mechanical, behavioral or
manualized therapy. They go in search of a genuine encounter that will recognize the
challenge inherent in facing the human condition.

RJ: From Afterword

IY: In 2005, Irv and I went to visit Jerome Frank, Irv's mentor and friend, who lived in a
nursing home nearby my own home in Baltimore. We had been visiting him, separately
and together, over many years, as he steadily declined with age. Even as his physical and
mental impairments progressed, Jerry was always professorially dressed in suit and tie.
"Tell me what you're working on," Jerry would usually ask Irv when we arrived, and they
would embark on lively conversation about Irv's work and whatever Jerry was reading at
the time. (My role was usually to sit and smile and enjoy the warmth of their connection.
I knew Jerry far less well and for less long, of course.) On this particular occasion, Jerry
was not wearing his suit and, after a few moments, it became clear that his mental
decline was far worse. In fact, we soon realized that he didn't know who we were. I was
very embarrassed and unsure what to do, and I left the conversational challenge to Irv.
He tried a few topics to engage Jerry and found that Jerry could still remember some
people from the distant past and they talked some about them. But then, Irv's genius
asserted itself in the flow of this difficult interaction and he asked, kindly and
compassionately, "What is like for you, Jerry, to be sitting here talking to people when
you aren't sure who we are?" Always the here and now! And Jerry understood and
responded to the care in the question. "I'm glad of the company," he said, "and you
know, it's not so bad. Each day I wake up and see outside my window the trees and the
 flowers and I'm happy to see them. It's not so bad." Once again, Irv had penetrated to
the existential core of Jerry's experience, and he did so by daring to speak the simple
reality of our being together. Perhaps the message of his whole corpus of work is just
this. It's all we have.

Childhood temperament is the elephant in the living room of child psychotherapy. Just
as the influence of substance use and abuse on clients' behavior problems was often minimized by
psychotherapists before the 1970s, the importance of temperament in children's behavior problems
is becoming an increasingly essential part of child and family therapy.

After 30 years of working with children and parents, I am convinced that, barring developmental
disorders or a major family tragedy, most children who come to therapy have higher-maintenance
temperaments (i.e., frequently described as difficult, spirited, or challenging) that frustrate typical
parenting approaches.1 Some parents are unable to effectively deal with certain children who try
their patience despite having no such difficulty with their other children. Here I will focus on one
aspect of childhood temperament, frustration tolerance, its relationship with Oppositional Defiant
Disorder (ODD), and how such concerns can be worked on in therapy with children and their parents.
I will also examine the important role played by the therapist's inevitable personal reactions in the
therapeutic proces rked with James R. Cameron, Ph.D. at the Preventive Ounce 2, we observed that
children with low frustration tolerance are at risk for becoming oppositional. We saw that parents
often responded to these kids in ways that exacerbated their problematic behavior. ODD has also
been related to the child's temperament and the family's response to that temperament. This model
helps therapists work with the child's temperament, the parent's style, and the interaction between
the two.

In the same vein, Barkley3 states that "children who are easily prone to emotional responses (high
emotionality) are often irritable, have poor habit regulation, are highly active, and/or are more
inattentive and impulsive and appear more likely . . . to demonstrate defiant and coercive behavior
than are children not having such negative temperamental characteristics." He also notes that
"immature, inexperienced, impulsive, inattentive, depressed, hostile, rejecting, or otherwise
negatively temperamental parents are more likely to have defiant and aggressive children."

 ODD . . . is a pattern of negativistic, hostile, and defiant behavior lasting at least 6 months.
 In males, the disorder has been shown to be more prevalent among those who, in the
preschool years, have problematic temperaments (e.g. high reactivity, difficulty being
soothed.) ODD . . . usually becomes evident before age 8 years and usually not later than in
early adolescence . . .
 The oppositional symptoms often emerge in the home setting but over time may appear in
other settings as well. Onset is typically gradual, usually occurring over the course of months
or years..Often loses temper, often argues with adults, often actively defies or refuses to
comply with adults' requests or rules, often deliberately annoys people, often blames others
for his or her mistakes or misbehaviors, is often touchy or easily annoyed by others, is often
angry and resentful, and is often spiteful or vindictive.

low frustration tolerance are adamant in wanting to end the cause of their frustration as quickly as
possible. When they are having a hard time with a task (e.g., homework, some tasks they don't
immediately understand, or a toy or game that they can't make work the way they want), they find
that the best way to eliminate their frustration is to stop trying and do something else instead. If they
want to do something and their parent (or another adult) won't let them do it, the best way to
eliminate their frustration is to act in ways that might get the adult to change their mind and leave
them to their own desires and interests.
It is worth noting that except for being spiteful and vindictive, ODD traits and behaviors listed in the
DSM represent how many children usually act when they don't want to do what they are told to do.
It is worth noting that except for being spiteful and vindictive, ODD traits and behaviors listed in the
DSM represent how many children usually act when they don't want to do what they are told to do.
The children that meet DSM criteria are diagnosed with ODD, but they could also likely be children
with low frustration tolerance who are acting oppositionally in an effort to eliminate their frustration.
The behavior that a parent or adult calls oppositional may also, in fact, be a child's age-appropriate
response to a developmentally inappropriate limit set by the parent or environment.
ke their kids' frustration tolerance better or worse? Note that it is important to allow the child to be
frustrated with life pressures and stresses rather than preventing age-appropriate frustrations.
Indeed, a key task of parenting is to help children gradually take on more difficult tasks so they learn
how to tolerate frustration as well as regulate emotional reactions. The work on how optimal levels
of frustration relate to learning,5 how attachment develops,6 and how managing affect in disorders of
the self7 point to the importance of parents helping children learn how to manage frustration.
Clearly, parents make the situation better or worse by how they interact with their child. Parents
make things better by setting appropriate limits, managing their own anxiety, reinforcing positive
behaviors, and understanding the motivations of the child. Certainly, parents can behave in ways that
make matters worse via what I call the Argument Trap and the Overly Helpful Parent.

way a parent can worsen the situation is by arguing with the child too much when the child doesn't
do what he is asked. Here, the parent, after setting a limit for their child, keeps responding to the
child's objections in an effort to have the child understand the parent's logic. This attempt to explain
the limit and convince the child of its necessity often results in the child becoming more upset. The
parent may then even punish the child for not complying with the limit. But since the child's goal is to
remove the frustrating limit, as long as the parent and child are arguing, the child can hope that the
parent changes their mind. If the parent gives in, the child is being taught to argue again next time. If
the parent punishes the child, then the child has an additional reason to blame their parent for not
removing their frustration.

To help a child with low frustration tolerance accept limits, the parent needs to let the child complain
about the limit and have the last word, even if the last word is provocative. The parent needs to stick
to the limit (unless there is good reason to give in) and not try to convince the child to agree with the
limit. The child is less likely to keep arguing if the parent is not responding in kind. The parent ideally
needs to set a limit, repeat the limit in as calm a voice as possible, suggest alternatives for the child,
and then stop talking about the limit. Restrictions and/or time-outs can be helpful in calming the
child, but when the child becomes highly agitated, these methods are often ineffective. In this case,
the parent's goal is to shift the child from complaining about a limit to finding something else to do
since the child can't do what they want. Thus, the argument is avoided, the child is re-engaged in an
activity, and the child learns to better cope with their reactions and emot parents inadvertently
increase their children's low frustration tolerance is by helping their children too much when their
children are faced with challenging tasks. Parents naturally help their children countless times each
day. But low-frustration-tolerance children will often ask for help without trying enough on their own
before seeking help. They tend to give up too soon without really testing themselves, and want the
adult to jump in and solve the problem or complete the task at hand. When the parent helps too
quickly, the child learns to immediately resort to fussing when frustrated, because this yields the
desired results. Remember: removing the frustration is the primary goal for the low frustration
tolerance child; solving the problem itself takes on secondary importance.

To help the low-frustration-tolerance child persist at a task such as homework, the parent needs to
answer the child's questions when the child is able to listen to the answers. The parent also needs to
help the child learn skills for dealing with frustrating situations, such as taking a break or dividing up
the homework in smaller chunks and doing one part at a time. When children are upset and
frustrated, they don't listen well (if at all!) until they have calmed down.

The parent's role is to help the child learn how to handle frustrating situations, not to quickly solve
the frustrating situation for the child.

The parent's role is to help the child learn how to handle frustrating situations, not to quickly solve
the frustrating situation for the child. For example, when a parent has been helping a low-frustration-
tolerance child too much with his homework, backing off from helping may lead to the child receiving
worse grades for a while. But when a parent takes too much responsibility for getting homework
done, the child doesn't take enough responsibility and does not learn how to cope with frustration. It
is more important to teach the child to take responsibility and to learn how to do homework than it
is to help the child complete any particular assignment.
oppositional behavior develops in this fashion is that

parents who don't understand how to handle typical low frustration tolerance behavior have
inadvertently reinforced that behavior many times over many years before that behavior becomes
oppositional.

parents who don't understand how to handle typical low frustration tolerance behavior have
inadvertently reinforced that behavior many times over many years before that behavior becomes
oppositional. Many parents of children who meet the criteria for ODD could actually be diagnosed as
having Argumentative Punitive Disorder (or APD—this is not an actual diagnosis, by the way) because
they often lose their temper, argue with their children, blame their children for their ineffective
parenting, are easily annoyed by their children, and are angry or resentful toward their children. One
of the main goals of therapy is to help parents manage their frustration when their children become
frustrated. Below, I present several therapeutic guidelines for working with these kids and their
parents.

 Who to meet with? Therapists need to work with the parents as well as the children on a
constituent basis, preferably every session. I generally meet with the parent (or parents)
before I see the child. We discuss what has happened since the last appointment, how to
understand what has happened, and how the parent might try to work with the child before
the next appointment. Then I meet with the child alone. Sometimes I meet with the parent
and child together—after seeing each of them separately—if there is some issue I think we
need to discuss.

 Breaking the Cycle of Arguing: Parents need help learning how to avoid being
argumentative-punitive. They need assistance finding the middle ground between too many
limits/not enough limits and too much help/not enough help. This takes time and work to
find an approach that is tailored to particular parents and their child.

 Encouraging Parents: Since one of my therapeutic goals is to increase the parent's ability to
help their child gain more frustration tolerance, I continually encourage parents and
reinforce their attempts to find more effective ways to work with their child. I keep
reminding parents and children that they are meeting with me to learn new ways to deal
with their family problems because the way they are handling matters is not working. It is
crucial to encourage and engage the child's parent since they are the ones who usually bring
the child in, pay for the sessions, and do the majority of the work every day.

 Validation of Parent Frustration: It is also crucial to validate the parents' feelings of

exasperation, anger, and frustration. I empathize with the parents and acknowledge that I
would feel similarly if I were parenting their children. I explain again how low frustration
tolerance works and encourage the parents to handle their children's oppositional behavior
differently even when they feel angry, exasperated, and/or frustrated.

 Talking to the Child about being Responsible: I find it helpful to talk with the children (in
language that makes sense to them) about being more responsible for what they are
supposed to do instead of complaining so much about what their parents are doing or not
doing. I often remind children that if they do as they are told, even if they don't want to,
their parents are more likely to let them do more of what they want to. Learning how to
 negotiate effectively with parents is a valuable tool for any child, and particularly for these
children.

 How long is therapy? The length of therapy is highly variable depending on the age of the
child, the extent of the child's low frustration tolerance, and the parent's ability and
motivation to understand how they have been contributing to the problem. If the parent-
child dynamic changes quickly and the child is able to respond, treatment may be briefer, but
often there are entrenched problems in the family that are best worked on over a longer
course of consistent thera on-tolerance children and their parents has also frequently left me
feeling exasperated, angry, incompetent, and . . . you guessed it, frustrated. For instance,
when a parent and I discuss at one session how important it is not to argue and yell at the
child about homework, and then the parent comes to the next session and reports another
escalating homework argument that ended with the child swearing at the parent and the
parent calling the child derogatory names, I sometimes feel like arguing and yelling myself. I
start thinking: the parent is provoking the child's defiant behavior, the child is not being
responsible about homework, I am not facilitating positive change in the family, etc. It is very
easy to get sucked into this escalating family system.

I have come to see my reactions to the parent and child as similar to the reactions the
parents and child are having to each other.

My feeling that I am not a competent therapist mirrors the parents' feelings that they are not
competent parents. My feeling of exasperation parallels the parents' feeling of not knowing what to
do when their children continue to be oppositional. My angry feelings mimic the children's feelings at
their parents' inability to manage their own behavior or their not getting their own way all the time.

Understanding and managing these personal reactions help me understand the child and their
parent's frustrations more fully, making my limit-setting and direct intervention more empathic. It
also helps prevents a critical or punitive therapeutic approach which mirrors the parent's approach,
which is both ineffective and off-putting to the family.

I invite psychotherapists who work with children to consider the possibility that ODD is
temperament-based low-frustration-tolerance behavior that well-meaning but uninformed parents
have inadvertently mismanaged. I believe that psychotherapists who add this approach to their work
with oppositional children will increase their effectiveness and be better prepared to manage their

Does Your Child Have Low Frustration Tolerance?

There is no valid and reliable test that can definitively determine whether a child has low frustration
tolerance. Temperament questionnaires, observation and reflection, comparison with other
children's behavior in the same situation, and parents' willingness to examine their own feelings
about a child can help parents and therapists reach an informed opinion about a child's level of
frustration tolerance. Here are some questions for parents to consider:
  What is your child's temperament? Energetic-positive, energetic-difficult, passive-low energy,
easy going?
 Does your child get frustrated more easily than other children the same age?
 Does your child get easily frustrated when you set limits? O, does your child get easily
frustrated when you want your child to stop doing what they are doing and do something
else instead? (Note: Some children are slow to adapt to transitions, changes and intrusions,
and are likely to get frustrated when asked to stop what they are doing and do something
else. Their response should not be confused with that of children with low frustration
tolerance, who will complain when a limit is set but may generally not complain when a
family routine is changed, the day's schedule is changed, or if you interrupt them when they
are doing something. Of course, a child can be slow to adapt to changes and also have low
frustration tolerance.)
 Do you give in more often than you think you should when your child complains about a
limit? Do you find yourself getting annoyed because your child keeps testing limits?
 Is your child able to play alone or with friends in their own room or do they always have to
be with you? Do you often tell your child to "go play" while you try to finish a task?
 Has your child's frustration tolerance decreased suddenly? Has something happened recently
(e.g., the birth of a sibling, a change in teachers, a death, a divorce, an illness) that could have
upset your child and made your child more easily frustrated about things than previously so?
If so, your child's frustration tolerance should improve as you both deal with the feelings
associated with the event or change that has occurred.

Many of us have experienced the complexity of a child therapy case in which the parents are not
amenable to change. If the parents are resistant, the pathological parent-child relationship is highly
unlikely to improve. In my own practice, I have found this to be an issue particularly with children
who have been neglected and abused, but it arises in many of my child and adolescent cases,

regardless of the presenting problem.

Certainly, when dealing with a child's disruptive behavior and a parent's feelings of frustration or
even clear hostility toward the child, the most successful intervention is usually some form of family
intervention. Family therapy has long been our primary approach to behavioral problems with
children and adolescents, with strong evidence of its efficacy. And the integration of family therapy
and individual treatment has been standard practice for years, as it is not uncommon for individual
members of the family to require separate but parallel help.

But I have found over the years that such parallel help is not always successful. In some cases,
parental problems pose such serious difficulties for the child or adolescent that a drastically different
approach is necessary. Consider the angry 11-year-old who has begun acting out, and who will soon
enter the wider, more demanding world of adolescence, where his difficulties with authority could
easily escalate. If his parents are also hostile and uncooperative in therapy, it often becomes a
question of time; there may be some chance that the parents would benefit from an intervention
effort, but not without the passage of more time than the child can afford.

The issue becomes, then:

When do we shift from trying to work within the parent-child relationship to seeing the child as a
separate entity needing to find a way to protect him- or herself from the negative impact of a
destructive parent?

When do we shift from trying to work within the parent-child relationship to seeing the child as a
separate entity needing to find a way to protect him- or herself from the negative impact of a
destructive pareThe following three cases exemplify how major differences in parent-child
relationships impact the treatment process with families, and how the child's perception of
acceptance versus rejection is a key factor in this. Jane, the first case, has a mother able to work
separately on her own problems in a way that aids the family therapy process. The second case,
Mike, is at the other end of the continuum with a totally destructive parent. The third case, Roberta,
falls in the middle, where the parents are trying to be part of the family therapy effort, but the
adults' personal difficulties block the therapeutic process. The parents of Jane and Roberta contacted
me at my private office seeking help for their girls, while the mother of Mike came to a community
clinic where the local courts often sent youngsters and their parents for assistance.

Jane

Jane's mother and father were in a constant battle with nine-year-old Jane as she fought every rule
and requirement they imposed. She had become increasingly uncooperative in school, and her peers
were rejecting her. As family treatment progressed with the use of behavioral contingencies, Jane's
mother reported that she was unable to follow through on negative consequences: she had a great
deal of difficulty saying "no" to Jane. During an individual session she explained that she wanted Jane
to grow up to be her friend. She feared that being firm with her now would make Jane "hate" her
later on. Jane's mother had had a very traumatic relationship with her own mother. Jane's maternal
grandmother had a serious substance abuse problem and Jane's mother went through years of
feeling angry with her. The grandmother died without having reconciled with her daughter. Jane's
mother's painful past relationship with her own mother was controlling her perception of her
daughter ("she will learn to hate me"); in turn, this perception was interfering with her ability to be a
parent to Jane.

This mother, although angry and frustrated, was bonded with her child and desired a better
relationship; she was certainly not a hostile and rejecting parent. She was amenable to treatment
and learned in individual work how her past experience was interfering with her relationship with
Jane beyond just the issue of saying "no." She learned that changing Jane's current behavior required
that she make some changes as well. As Jane's mother worked on her own issues, the family work
progressed quickly.

Mike

In contrast to Jane's story, Mike's mother followed a court order to seek therapy for her 14-year-old
boy who avoided school, stayed out as late as he wished, affiliated himself with a gang, and was
finally arrested for stealing bikes from neighborhood children. The court placed him on probation
with clear instructions that if he did not go to school, was not in his home by a specific time in the
evening, and/or continued any contact with the gang members, his probation would be revoked and
he would be incarcerated in a juvenile facility. Mike felt that his mother hated him and wanted him
"put away." His mother refused to attend family or individual sessions herself, stating that only Mike
needed help. She frequently called the probation officer to complain about Mike's behavior and
avoided contact with me. Many of her complaints about Mike were issues that could have been
handled by working directly with her and Mike together, with the help of his probation officer. I
explained my professional opinion to his mother, but she refused to be involved. She stated that she
did not have the time and believed that Mike was simply "evil."

We had started family treatment by working out an agreement regarding what was expected of Mike
(e.g., getting himself to school on time, when to be home, the kids he had to avoid, the kids he could
spend time with) and what his mother should do to reward his cooperation (increasing his allowance
and TV game time were the "rewards" he wanted). Mike's mother, unfortunately, failed to cooperate
with this agreement; this, combined with her emotional rejection of him, led to Mike seeing the
agreement as a farce.

His mother's view of him had determined Mike's view of himself, which factored significantly into his
destructive behaviors. He felt rejected by his mother and struggled with feelings of worthlessness as
a result. On one level, he appeared to blame his mother, and made angry statements about how
wrong he felt she was. At a second level, however, he blamed himself and had to deal with feelings
of depression. At times he entertained self-destructive thoughts, but denied any actual plans to harm
himself.

Unfortunately, Mike's justified anger at his mother's rejection left him eager to maintain a
relationship with his gang friends. Eventually his mother spotted him talking to one of them and
reported it to the probation officer, who revoked his probation and sent him to a juvenile facility,

Roberta

In a third case, Roberta, a 13-year-old girl, was living with her father and stepmother. She was trying
to maintain contact with her mother, but her mother lived with a boyfriend who had been found
guilty of sexually abusing Roberta. He had been incarcerated for a few months, and was again living
with Roberta's mother, but now was not permitted to be home when Roberta visited. The mother
admitted that she did not believe the abuse had occurred, and blamed Roberta for all the personal
and legal difficulties she and her boyfriend had gone through as a result of the accusations.

Roberta's father, on the other hand, had married a younger woman who related to Roberta as a
sibling rather than an adult. Roberta's father greatly enjoyed and depended upon the devotion of his
young bride. He thought that the only way his life could proceed happily was if his daughter would
cater to his wife's demands. He perceived his daughter's adolescent struggle for independence, along
with her competition with his wife for his attention, as serious threats to his personal happiness.

Roberta was in an almost continuous rage as she struggled to deal with how "unfair" she said her
mother and father were, how "disgusting" she said her stepmother was, and how "dangerous" she
reported her mother's boyfriend to be. She continuously fought any expression of authority by all the
adults in her family. She was increasingly defiant in school, and had also become sexually active with
several neighborhood boys.

All of the intra- and interpersonal issues in this family were potentially amenable to treatment.
However,

the parents were each involved in complex, competing relationships that resulted in therapy moving
forward at glacial speed, while the child continued to struggle and act out.

In this case, Roberta's perception of rejection was based on the negative communication from her
mother and father that represented their own frustrations. The long-term conflict between Roberta
and her parents served for her as evidence of rejection. The young girl was not in a position to
recognize that her parents' behaviors were reactions to other complex issues in their lives, and not
indicative of their love for her or lack thereof.

In addition to anger at the adults in her life, Roberta expressed strong feelings of sadness, including
self-destructive thoughts, which were difficult for her to share with me. Fortunately, these stayed at
the occasional "thought" level and never progressed to self-destr

These types of cases are serious in terms of the potential for both antisocial acting out and self-
destructive behaviors. And many of these cases do not respond at all, or much too slowly, to the
usual attempts at family therapy. By "usual" I am referring to interventions that aim for the
maintenance of an improved family unit. Such therapy facilitates changes in the child's behavior
partly through internal changes the child makes, and partly as a result of positive intra-family
changes. But what about the cases where intra-family changes may not occur at all, or only after it is
too late for the child developmentally?

I have found that, in these situations, the only way to counteract the effects of a child perceiving
himself as rejected, and hence unworthy, is for the youngster to perceive the rejecting behavior of
his parent as evidence of his parent's deficiencies rather than his own.

The issue is not limited to dealing with the child's anger. In other cases, rejection may not be a major
issue. For example, a child who has experienced the affection and acceptance inherent in a normal
parent-child relationship, now an adolescent, is struggling with her parents over money, dating,
homework, etc., and says things that hurt her parents. In this case, we are not dealing with the same
anger issue. This child's angry interactions with parents and their inappropriate responses can often
be dealt with successfully in therapy. Parents and child learn to deal with their mutual
misinterpretations, develop alternate and more acceptable ways of expressing anger, and establish
agreements regarding major conflict areas. By contrast,

in the cases I am discussing here, the child's anger, although a problem, is not the major issue. The
real issue is the depressive effect of emotional rejection.

Therefore, the issue is not only that of managing anger but also of dealing with the destructive
effects of parental rejection. The power of that rejection is based on the child's underlying belief that
the rejection means that the child is an unworthy person. The issue is now how to confront that
underlying belief and assist the child in rejecting it.

One approach is to foster the psychological separation of child and parent by helping the child to
recognize the ways in which his parent(s) have failed to meet the child's needs. The therapist also
helps the child understand that his needs for attention, age-appropriate independence, etc., are
normal. In this manner, the therapist is able to assist the child in rejecting his parents' negative
perception of him. It is helpful, in this process, to find examples of ways in which the parents do
things or provide things that only a parent who loves their child would do. The child can then
recognize the parent's inability to meet his needs, while rejecting the validity of the parent's
perception. The child finds other means of validating his worthiness.

By this time, the therapeutic process has greatly reduced the parents' emotional impact on the child.
The child must now recognize the harmful effects of his own angry or frustrated responses to his
parents, then learn to manage those responses in order to foster appropriate parent-child
interactions.

old high school student. For several years, school personnel had described him as consistently
performing below his capacity, always passing his subjects but never doing more than was absolutely
necessary. He recently started smoking marijuana with some frequency, and his relationship with his
divorced parents (both successful professionals with busy careers) was becoming increasingly
stormy.

Separately, each parent complained that there were no problems so long as George always got his
own way. If either of them objected to his hours, wanted to see him put more effort into school
work, questioned him about finding drug paraphernalia in his room, or made any other demands on
him, George would swear at them, slam doors, break objects, and storm out the door. Sometimes,
when that happened, he would go to the other parent's home and just settle in there. The "receiving
parent" usually just accepted his presence and avoided asking any questions so as to avoid another
emotional explosion.
George
George was an only child whose parents separated when he was five years old. In therapy, he
recalled many fights between his parents in which he was the central figure.

He insisted that the fights between his parents went on for days and could be instigated by almost
anything he did. As he explained it, "they got divorced because they hated me."

George was unable to think positively about his future. The prospect of attending college, which both
of his parents encouraged, was acceptable to him as long as he was allowed to live far away from
both parents and was given enough money to be "comfortable." He was only interested in schools
that had a "party – party" reputation. He refused to discuss his ideas about long-term goals or career
interests.

I first met with George and both his parents together, then saw each of them for two private sessions
apiece to obtain a history and for diagnostic purposes. The first treatment approach was family
therapy involving all three parties. We started by dealing with such issues as George's need for his
parents to respect his independence, and his parents' need for him to respect their authority. We
struggled to find compromises that might reduce the conflict between them. The family failed to
progress, and ultimately it became clear that each parent had significant psychological issues of their
own that seriously impacted all the possible dyads—mother-father, mother-son, and father-son. The
parents could not move away from blaming each other for every issue they had with their son. As
they persisted in their angry recriminations and constant fault-finding with each other, George
showed increasing disdain for each of them. George interpreted their behavior as simply reinforcing
his perception that they blamed him for all of the family's problems.

I advised each parent that they could benefit from individual counseling, but they both refused,
insisting that the problem was only with George. I terminated the family sessions and changed the
therapy plan to weekly individual sessions with George and a family meeting every five or six weeks
to review the current status of their family life.

In the individual sessions, George expressed his anger at his parents and his negative feelings
towards himself, referring to himself as the cause of his parents' divorce and continuing conflict. I
began to interpret some of George's behavioral descriptions of parent-child interaction as indicators
of faults in his parents.

I suggested that some of George's memories, if they were accurate, described parents who certainly
loved their child but whose behavior strongly indicated personal weakness or deficiency. I confronted
George's idea that he caused the divorce with the argument that George's early childhood behavior
represented a normal range of pestering child behavior that all parents have seen. I suggested to
George that his parents' responses to his behavior represented inadequacies in parenting skill.

As his descriptions moved to more recent interactions between his parents, I suggested that it was
not surprising that they divorced, as they clearly had significant difficulties dealing with each other.
George described a battle going on in which his father was screaming at his mother about her
spending money. His mother then retaliated by blaming him for wasting money on a bike for George
that she said George did not use enough. George felt that they were again fighting about him and
that it was his fault. I strongly suggested that none of these battles between his parents could
possibly be blamed on George, and in this case his mother was only mentioning George and his bike
as ammunition in her fight with his father.

As George began to accept that his parents had real deficiencies, he started to examine his more
recent conflicts with each one. At times, he would place total responsibility for an incident on the
parent. For example, he expected his mother to ignore his drug use and just allow him to smoke his
marijuana in the living room. She had objected, a screaming match ensued, and George walked out
of the house. He complained that she "was old fashioned and didn't understand the modern world." I
told George I was surprised that he did not seem to understand that no responsible parent would
ever ignore their son's drug use. Even if the son is a legal adult, every person has the right to decide
what is and is not allowed in their own home. He challenged me for my own views, and I shared with
him many examples of my exercising parental authority with my own sons. The real issue here, I
explained, was not that of smoking marijuana, but was actually his impulse to challenge his mother's
authority. He was behaving as if his mother was just one of his teenage buddies. I told him that the
solution was not for him to stop using marijuana, but rather for him to stop throwing it in his parents'
faces.

The real issue here, I explained, was not that of smoking marijuana, but was actually his impulse to
challenge his mother's authority. He was behaving as if his mother was just one of his teenage
buddies.Using this type of confrontative approach, we were able to keep a reasonable focus on
George's own contribution to many parent-child conflicts. This approach had two goals: developing
the skills necessary to manage future interactions with his parents, and improving George's
awareness that his ability to anger his parents (and others) was based on his behavior, not their
innate hatred of him.

As George explored his memories of his family life, he discovered many experiences that he could
easily interpret as each parent demonstrating their love for him. After a while, he was able to accept
the possibility that activities and experiences like Little League and family trips to foreign places
might have been motivated by their wish to make him happy, and that such a wish might indicate
parental love. Slowly, he began to perceive his parents' negative behaviors as expressions of their
own emotional difficulties. He understood their outbursts of anger toward him as being reasonable
and expected responses to his own obnoxious behavior, instead of evidence of a basic hatred of him.

We next focused on his learning to care for himself and depend less on his parents. I helped him
understand that his happiness—and he had a right to be happy—could no longer be determined and
influenced by his parents. He needed to take charge of his own life. He began to perceive school
success, for example, as something he was doing for himself and not for his parents. This process is,
in part, congruent with the developmental process of adolescence. In George's case, it was also a
response to the real issue: that his parents' difficulties prevented them from providing him with
emotional support or practical guidance. Finally, George independently contacted the college and
career guidance services available at his school and found the staff more able to respond to his
anxieties about his future than his parents. He began to think critically about what he wanted from a
post-high-school education.
tue of his age, 15-year-old George was at the beginning of a developmental stage that entails
building independence, greater self-reliance, and increased separation from parents. Hence, the
therapy process was supported by developmental realities.

But what if George had been eight years old instead of fifteen? How could this approach possibly
work? The phenomenon of pseudo-maturity is well known.

The phenomenon of pseudo-maturity is well known. Young children dealing with neglect, for
example, often demonstrate role reversal and become the parent. We describe these children as
having "lost their childhood." They have difficulty trusting others, are emotionally insecure, and often
exhibit symptoms of depression. The therapy approach described above, applied to a child as young
as eight, would appear to promote the development of pseudo-maturity, and this is indeed a
possibility.

In this type of case, we must respond to the dependency needs of the younger child while dealing
with the need to separate from the parents. The case of Jamie provides an excellent example of how
this can be done. Jamie, age eight, was the oldest of two children. Her parents complained that she
was resistant, uncooperative, and a discipline problem. They seemed overwhelmed by her insistence
on staying up later than her bedtime, arguing about what they fed her, and refusing to allow them to
monitor her homework. If they argued about homework too much, she simply refused to do the
work. At first, we worked on behavioral contracts with clear expectations and rewards that Jamie
could earn. But her parents could not stay consistent with the program; each expressed feeling
overwhelmed by having to do such things as reward their child. They simply wanted Jamie to take
care of any issues related to school, eating, dressing, bathing, and so on, without their involvement.
They also continued to express anger whenever a complaint from school, for example, required their
time and effort.

I looked for what was positive in Jamie's life and what made her happy. She expressed a desire to
have a closer relationship with a female teacher she admired, and I encouraged that. This changed
her relationship to her homework: instead of seeing it as grounds for a power struggle with her
parents, Jamie came to recognize the hopelessness of that interaction. Through this new relationship
with her teacher, she was finally able enjoy the emotional satisfaction of academic success. As
Jamie's grades improved, her emotionally destructive interactions with her parents diminished.

The emotional turmoil in the lives of Jamie's parents made even the purchase of a bike a serious
issue for therapy. Questions about the type and size of the bike, which accessories to get (if any), and
where they should purchase it, resulted in major distress for her parents, and certainly for Jamie as
she tried to deal with them over an object that was very important to her.

In treatment, Jamie learned that she was incorrect in her perception that her parents wanted to deny
her the bike because they loved her sibling more. She found many memories where her parents had
given her things, had fun with her on vacations, and showed pride in her accomplishments.
Independently, I learned from the parents that these memories were accurate. I directly stated to
Jamie that these were the things that parents who loved their child did for them. I also explicitly
interpreted to her that, regarding her parents' more negative behavior, they clearly had difficulty
making decisions without exhibiting anger and confusion. This was behavior that she had often seen.
Jamie did not express the need to know why this happened, but was comforted by seeing the
behavior as a problem the parents had, and not her responsibility.

I have found that direct statements to a child, such as those above to Jamie, are the best way to deal
with a child's misperceptions. In Jamie's case, they would quickly result in our talking about major
issues. And, as with any therapist-offered interpretation, Jamie might reject what was offered, then
follow up with more of her feelings about the situation.

There is always the danger that a younger child will agree with you simply because you are the
powerful adult, but I have found that my patients, even quite young ones, are very comfortable in
questioning or challenging any of my input. It is a matter of the quality of our relationship during
treatment.

With my help, Jamie did the necessary research and presented to her parents a firm package of bike
type, size, price, and a local bike store where it was available. Her parents quickly bought her the bike
and not another word was said. Her Girl Scout leader became the adult who assisted with bicycle
maintenance and with whom she shared her biking adventures.

I could meet some of Jamie's dependency needs, but, of course, no therapist should try to fulfill that
role. The therapy process required helping her find other child-adult relationships to fill this void. At
the same time, Jamie needed to learn that her Girl Scout leaders, teachers, and a grandmother who
lived close by could help, but also had their limitations. We addressed her jealousy of the Scout
Leader's own children and of the other children in her class that her teacher

Complications

This model calls for recognition that, in some cases, the relationship between parents and child is a
damaged one, and that the primary culprit is the parents' emotional makeup. The cases described
here have involved a single-parent home, or two-parent families where both parents are the
problem. In other cases, one parent might be amenable to change while the other is not. The
"amenable" parent's growing awareness of the other parent's pathology and consequent destructive
impact on the child often results in worsening marital discord, and sometimes separation and
divorce. In those cases, my work with the child is assisted by getting the parents to see someone
specializing in marital therapy. I found this assistance to be essential, and in these cases successful
marital therapy allowed me to be successful with the child. Unfortunately, when the disturbed
parent refuses marital counseling, that parent usually wants to terminate the child's therapy as
parents' difficulties are long-term and extremely resistant to any intervention, but children move
along a developmental timeline that waits for no one. In these cases, individual work with the child
may have to become the primary intervention, and the normal process of a child's psychological
separation from the parent may have to be accelerated.

There are potential problems with this approach that a therapist needs to be aware of. Therapy
patients of any age can become dependent on the therapist to a degree that interferes with their
progress. I believe that children are even more vulnerable in this regard. Needy children struggling
with difficult parents can easily provoke rescue fantasies in the therapist. I have seen, for example,
young therapists I was supervising jumping in and doing things for the child-patient when they should
have been assisting the child to develop the skills to function independently.

A major potential stumbling block is the parents' response to the increasing independence of the
child. Problems can occur if the child expresses that independence by openly rejecting the parents'
authority. For example, if Jamie had announced to her parents that they need not bother to make
any rules in the house because she would only follow what her scout leader said was appropriate, we
would certainly have seen increasing conflict between them. The treatment process includes the
child's learning how to disagree with parents in ways that avoid such difficulties.
In closing, I wish to stress that this approach is one the therapist must choose only after family
therapy has already been tried energetically without success. What I have described here is

compromise in which we must give up family therapy's power to move the whole family forward, in a
last-resort effort to rescue the child.

In his recent book The Gift of Therapy: An Open Letter to a New Generation of Therapists and
Their Patients, psychiatrist and writer Irvin Yalom recalls a poignant encounter with one of his cancer
patients. The woman is embarrassed by her hair loss after chemotherapy, and during one of her
therapy sessions, she reveals that she would like a sign from Yalom that her baldness does not
repulse him. Yalom, who has always admired this patient for the intelligence that illuminates her
features, tells her he's not repulsed at all. In fact, he asks if he can act on his impulse to run his
fingers through the lovely gray strands of hair remaining on her head. The result is a warm, intimate
moment that is cathartic for both.

Such moments, related in his latest book, The Gift of Therapy, serve as vivid arguments for breaking
down the walls that separate patient and therapist. Directed to a new generation of therapists and
their patients, Yalom is a keen advocate for unmasking the therapist. One of the main reasons that
patients fall into despair is that they are unable to sustain gratifying relationships. According to
Yalom, therapy is their opportunity to establish a healthy give-and-take with an empathetic

counselor; one who is not afraid to show his or her own vulnerabilities.

A professor emeritus of psychiatry at Stanford University and the author of several widely read books
and novels on psychotherapy—including the best-selling therapeutic memoir Love's Executioner and
various classic textbooks on group psychotherapy and existential psychotherapy—Yalom's insight
into this world throws open the secret door to therapy, both for counselors and the patients who
visit them.

What we see behind Yalom's door is a far cry from the stereotype of a therapist. From comic strips to
Hollywood features, the analyst is often portrayed seated behind a desk or a notebook, literally out
of reach and out of sight of the person being analyzed.

As patients, we perceive that person sitting across from us as a powerful and impenetrable figure, yet
we're expected to reveal ourselves up to their scrutiny. Within the charged atmosphere of the 50-
minute therapeutic hour, our psyches are exposed, while the therapist maintains an enigmatic mask.

This may be the traditional model of psychoanalysis, but Yalom challenges it as ineffective and
ultimately unhealthy. Real treatment, he says, requires an intimacy between therapist and patient
that is born from a solid bond of trust. After all, a patient regularly entrusts a therapist with intimate
revelations, so the therapist must be able to respond with true spontaneous empathy rather than
stock therapeutic phrases. Nor does empathy evolve in a vacuum. "Friendship between therapist and
patient is a necessary condition in the process of therapy," says Yalom, and he encourages the
therapist to "

let the patient know that he or she matters to you.

let the patient know that he or sh ometimes letting the patient matter can be a challenge. In his book
Love's Executioner, Yalom describes an incident with an Argentine patient who is in the last stages of
incurable lymphoma. Because "Carlos" was isolated and depressed, Yalom sent him to a therapy
group led by a female colleague, thinking that Carlos might form some personal connections to help
him through the challenges of his last months of life. Instead, Carlos' obsession with the female
patients alienated everyone in the group. After several of the women brought up their painful
experiences with rape, Carlos voyeuristically interrogated them about intimate details and then
declared the assaults "no big deal." Furious, the therapist asked Carlos to leave the group.

Although repelled by Carlos' behavior, Yalom persuaded the group leader to let him work with him to
see whether he might be able to change his attitude. Carlos defended his prurient interrogations to
Yalom, leering that, "All men are turned on by rape," and "If rape were legal, I'd do it . . . once in a
while." Sitting in silence for a few minutes, Yalom wondered whether Carlos was as depraved as he
sounded, or whether his crudeness was partly bluster. "I was interested in, grateful for, his last few
words: the 'once in a while,'" he recalls. "Those words, added almost as an afterthought, seemed to
suggest some scrap of self-consciousness or shame." Knowing that his patient was close to his
teenage children, Yalom decided to turn the tables on him.

"All right, Carlos, let's consider this ideal society you're imagining and advocating. Think now, for a
few minutes, about your daughter. How would it be for her living in this community—being available
for legal rape?" At that point, Carlos' macho mask begins to crumble. He winces visibly and stammers
that he wouldn't like that for her. What he wants, he says, is for his daughter to have a loving
relationship with a man, and to have a loving family. Again, Yalom presses him to confront his own
words: "But how can that happen if her father is advocating a world of rape?

If you want her to live in a loving world, it's up to you to construct that world—and you have to start
with your own behavior.

If you want her to live in a loving world, it's up to you to construct that world—and you have to start
with your own behavior." The discussion was so difficult for Carlos that he became faint, but shortly
thereafter he was able to change his cynical approach to other people. Following this breakthrough,
he was able to rejoin the group that had rejected him and, in the months before his death, to enjoy a
number of close, supportive friendships with the women and m any other intimate relationship,
Yalom feels that it is important for both parties to admit when they have made an error or blunder.
He notes that when he has owned up to his own limitations and lack of understanding, it has often
led to an important breakthrough in therapy.

Such was the case when Yalom found himself extremely uncomfortable while counseling a chatty,
obese woman suffering from depression—another story he relates in Love's Executioner. He takes us
through his challenging journey to understand his resistance to treating "Betty," beginning with his
family and its line of "fat, controlling women," to his need for a scapegoat in his high school years in
racially segregated Washington D.C., in which he was regularly attacked for being white and Jewish.
(Yalom recalls that he, in turn, could look down on the "fat kids": "I supposed I needed someone to
hate, too," he reflects. "Maybe that was where I learned it.") In the process of therapy, Yalom
persuades Betty, who deflects most of his questions with a joke, to stop trying to "entertain" him and
to talk about her life with the seriousness it deserved. When she does, he eventually conquers his
discomfort and comes to feel an enormous respect and liking for his patient. And, after some months
of treatment, Betty is able to overcome her depression and achieve a more comfortable weight for
hersel ent during therapy doesn't stop with sharing his own biases. By occasionally visiting patients at
home, Yalom says he has learned important information that he's been able to put to good use in
therapy. For example, one severely depressed patient was for months unable to move beyond the
initial phases of grieving over his wife's death. When Yalom made a house call, he found that the
patient had so saturated his environment with material reminders of his wife—to the point of
keeping the ratty sofa where his wife had died on prominent display in the living room—that his own
personality had all but disappeared.

Together, patient and therapist worked out a series of changes in the house that would help free the
patient from some of the invisible chains that Because building trust and intimacy takes time, Yalom
is critical of the current trend towards short stints of behavioral therapy. While they may work in
some instances, he allows, there is no substitute for ongoing, weekly sessions in which a caring
doctor and a troubled patient engage in a "dress rehearsal for life." Although the "life" in question is
usually the patient's, Yalom feels that if change does not occur in the therapist as well, the therapist
is not working effectively.

Forty-five years of clinical practice have led Yalom to note that

the patient and therapist are "fellow travelers" in therapy—they're both human beings dealing with
essential problems of existence and must work cooperatively to solve them. The therapist must be
able to "look out the other's window." Learning to actively empathize with a patient's experience is
the most important gift a therapist can give a patient, Yalom says.

Certainly the world of analysis and therapy have changed dramatically from the days of glorifying the
neutral, distant and emotionally removed therapist with a pipe in hand. In particular, Yalom's works
pose a far-reaching question: Is it time for psychoanalysts and psychotherapists to reveal more of
themselves to their patients? And, in addition to challenging their patients to grow, should they
remember to treat them with empathy and simple human kindness beyond that of the detached
professional caring? In The Gift of Therapy, Yalom makes the brave assertion that the therapist is
responsible for bringing his or her own humanity to the forefront of the therapy. After all, this may
be the most valuable gift that the therapist can offer the client.