What follows is a thread about tips from #GiftOfTherapy by Irvin Yalom.
Yalom believed this to be his gift to future therapists, and the tips are steeped in his experience with interpersonal/group and existential therapy.
There are total 85 chapters and I'll tweet 2-3 times/chap

intro: underlying assumptions

Group/interpersonal therapy: clients fall in despair as they cant form/sustain gratifying interpersonal relationships.

Existential therapy: clients fall in despair when they confront the harsh facts of human condition..the givens of existence. #GoT

Existential therapy is dynamic, rooted in underlying conflicts, some of which may be unconscious (these conflicts are not sexual like in Freudian sense) : some of the ultimate concerns that lead to conflicts are awareness of death, isolation, meaning in life and freedom. #GoT

Chap 1-40 are about the client-therapist relationship (therapeutic alliance: which has been shown to be the common and strongest factor, across types of therapies, that leads to good therapy outcome); Chap 41- 51 are about the ultimate existential concerns; more as we go #GoT

Chap 1: 'Remove the obstacles to growth':
This insight is drawn from the work of Karen Horney "If obstacles are removed, Horney believed, the individual will develop into a mature, fully realized adult, just as an acorn will develop into an oak tree." self realization is default!

This (that we are driven naturally towards self realization) is corroborated by modern research like Self Determination Theory (SDT) whereby all that needs to be done is provide the right nutriments for full flowering.
Yalom highlights the contribution of neofreudians like Fromm

However, the world provides some obstacles; some are created by ourselves; and therapy helps us move past those obstacles and on to the path of self realization.
That Yalom chose this as the first tip, says a lot about why we need to see humans as mostly strong/resource rich #GoT

Chap 2: 'Avoid diagnosis'
Diagnosis may be useful in psychiatric conditions like bipolar, schizophrenia etc; they are counterproductive in treating say 'borderline' patients in therapeutic contexts as the diagnosis becomes a self fulfilling prophesy & we ignore other aspects #GoT

The creators of past diagnostic systems were as confident as current DSM-V creators; diagnoses limits vision.
{in helplines, where there is even lesser scope for longish intervention, a diagnosis made in first 5 minutes may severely limit its helpfulness} don't pigeonhole #GoT

Chap 3: 'Therapist and patient as 'fellow travelers''
Yalom has a tragic, but realistic view of life. He mocks the notion of 'fully analyzed therapist', instead arguing that each therapist is on his own journey that is similar in ways to the patients. We are all in this together.

Yalom wants to abolish the distinction between them (afflicted) and us (the healers); "no therapist and no person is immune to the inherent tragedies of existence".
He illustrates this with a tale of healing by Hermann Hesse: 'Magister Ludi' whereby 2 healers heal each other #GoT

Chap 4: Engage the patient

Many patients have conflicts with intimacy: some fear it, believing themselves unworthy; others avoid it, believing they might be exploited/ abandoned.

Much of therapy involves the patient experiencing an intimate relationship with the therapist. #GoT

As this patient-therapist relationship is paramount, therapist should keep engaging patient to find out how the relationship is going?
A reflection question could be 'How are you and I doing today' : be curious and check in to figure what is happening within the relationship #GoT

Chap 5: Be supportive

"Question: What do patients recall when they look back, years later, on their experience in therapy?
Answer: Not insight, not the therapist’s interpretations. More often than not, they remember the positive supportive statements of their therapist." #GoT

Yalom encourages therapists to be generous with their praise/ endorsement when the client exhibits acts of courage etc. The therapist knows the client most intimately(warts and all) and when genuine supportive statements come from him they mean a lot to the client. Dont be stingy

some things you can praise: "their courage in facing their
inner demons, dedication to change, willingness to self-disclose, loving gentleness with their children, commitment to breaking the cycle of abuse, and decision not to pass on the “hot potato” to the next generation" #GoT

Chap 6: Empathy: looking out the patient's window
Yalom explains how its important to be able to look out the others window/indulge in 'accurate empathy': 1 of the 3 ingredients (along with unconditional positive regard and genuineness)identified by Carl Rogers 4 eff therapy #GoT

"Patients profit enormously simply from the experience of being fully seen and fully understood"; thus focus on clients past, present & future.
By focusing on client's past we can appreciate how he sees the world, and not just to find what is the cause of his underlying maladies

"If, for eg., patients have suffered a long series of losses, then they will view the world through the spectacles of loss.They may be disinclined, for example, to let you matter or get too close because of fear of suffering yet another loss" Awareness of past builds empathy #GoT

Chap 7: Teach Empathy
Yalom stresses that many clients have interpersonal problems fueled by their lack of empathy & its upto therapists to teach the client how to be empathetic. This can be done in therapeutic relationship itself: was the client accurate in gauging feelings? #GoT

Chap 8: Let the patient matter to you
Do you think about your clients between sessions? Should you? Yalom believes that its but natural, at times, to think of our patients between sessions, including seeing them in dreams; and one should self disclose that to the patients #GoT

This fact, shared with the client, that they indeed have some impact on the therapist and that the interactions have the power to shape/ influence therapist experience, makes the client feel as if they matter. This feeling of mattering needs to be nurtured and not snuffed. #GoT

Chap 9: Acknowledge your errors
Yalom references Winnicott (diff. b/w good and bad mothers is not commissioning of errors, but what they do subsequently) to drive home the point that a good therapist acknowledges his erroneous interpretations/ actions etc, while a bad one fudges

This is important because acknowledging your errors
1) makes the client see you as more authentic and genuine
2) makes the client feel as if they matter
{3) and I will also add makes the client see the therapist as a 'fellow traveler' full of human frailty} #GoT

Chap 10: Create a new therapy for each patient
Yalom highlights how the standardized/ manualized therapies, that can be compared against say pharmacotherapy & can be replicated, lead to less effective therapeutic outcomes as there is loss of spontaneity/ therapist discretion #GoT

"At its very core, the flow of therapy should be spontaneous,forever following unanticipated riverbeds; it is grotesquely distorted by being packaged into a formula that enables inexperienced, inadequately trained therapists (or computers) to deliver a uniform course of therapy."

Yalom references Jung's proposition that each client is unique with his own inner world, language and symbols, and thus requiring a new therapy language 4 each client. Yalom extends this proposing that each client needs a unique therapeutic approach best suited to her needs. #GoT

Chap 11: The therapeutic act, not the therapeutic word
Most of us view therapy as 'talking therapies', but Yalom cautions that most powerful impact (as seen from clients perspective) is due to supportive acts like checking in by phone on a suicidal/ depressed client. #GoT

He gives several examples where we can show our caring attitude: maybe we write a letter of appreciation to a client who shared her work of fiction with us; or just out of respect for the client we do things like aura therapy for them(which Yalom did, despite not believing in it)

Chap 12: Engage in personal therapy
Its well known that ones own self is the most valued tool available to the therapist, however Yalom contends that most therapist just do minimal mandatory self analyses, sufficient enough to get them licensed, but it should be lifelong instead.

"Therapists must be familiar with their own dark side and be able to empathize with all human wishes and impulses".

To quote Fromm, “I am human and let nothing human be alien to me”.

Personal analyses or therapy provides a window to look at those blind spots of self #GoT

Yalom emphasizes that while undergoing personal therapy, it may be important for the therapist to undergo different types of therapies that broaden his self awareness and also to match the type of therapy to his particular stage of life and the problems he is confronting. #GoT

"A personal therapy experience permits the student therapist 2 experience many aspects of the therapeutic process from the patient’s seat: the tendency 2 idealize the therapist, the yearning 4 dependency, the gratitude toward a caring listener, the power granted 2 the therapist."

Chap 13: the therapist has many patients; the patient, one therapist
Yalom acknowledges the unfairness of situation and advises to be transparent about this when asked 'do you think of me outside the sessions, like I do about you' , he draws analogy with teacher student asymmetry

{I'll go beyond what Yalom says and draw the analogy further; while the teacher may not think so much of the students after school hours, while in class each student is precious and unique to her, and she usually is able to convey that feeling; the same needs 2 be conveyed by us}

Chap 14:The here-and-now: use it, use it, use it
Instead of focusing on what happened in the patients past or what is happening in her life, the here-and-now emphasizes to focus on what is happening right now (therapeutic hour) and in the here (the mutual space/ relationship) #GoT

Chap 15: Why use the here-and-now?
1) most problems are interpersonal. {'hell is other people'};2) the therapeutic relationship is a microcosm where sooner or later the clients interpersonal deficits would start manifesting. Hence, instead of digging old graves, use here-and-now!

Chap 16: Using the here-and-now: grow rabbit ears
Small, idiosyncratic responses to similar stimuli can be a clue 2 the unique, inner world of the client. Say your tissue paper ran out during the session; one may take affront, another may joke/chide, while another gift you a pack

The point being that everyday events that happen in therapy, like how the client greets you, whether they refer to last session ,how they start and end session etc , everything that happens in the here-and-now, is a rich source of data- you just need to pick it up #GoT

Chap 17: search for the here-and-now equivalents
When a client presents with a dysfunctional relationship, first instinct is to identify his role in transactions and any underlying unconscious motivations, to identify past patterns and suggest exploring alternate behaviors #GoT

A better approach is to search for whether the same sort of problem is manifesting in say therapeutic relationship. Does the person who fears dependence on partner, also fears dependence on therapist? Addressing the fear of dependence in therapeutic relationship more helpful #GoT

Chap 18: Working through issues in the here-and-now
Look for key words, patterns exhibited, feelings expressed etc in the here-and-now and intervene therein by calling attention to the issues and working through them in the here-and-now. #GoT

Chap 19: the here-and-now energizes therapy
Esp with reference to group therapy, one can either discuss some there-and-then problem like suicidal ideations of participants (in a 'take turns' way); or the group can discuss the process of therapy involving here-and-now observations

The latter groups, also known as encounter groups (Rogers terminology), are where people reflect on each others behavior and provide feedback, and yearn to put away their facades and become intimate. Such groups are more energizing, lively and fruitful. Same holds for ind therapy

Chap 20: Use your own feelings as data
A therapists awareness of his immediate feelings have vast implications for therapy. Is the client boring you, is he wearing you down? How much of the boredom is due to your internal factors(known from self therapy) and what is due to client

If he is boring you and the problem is in the client, does he show similar patterns in his other relationships? Does he tune out people? Irritate them? By addressing your here-and-now feelings with the client, you can start addressing the issues in your clients behavior #GoT

Chap 21: Frame here-and-now comments carefully
One needs to be caring/sensitive while providing here-and-now feedback; eg. instead of saying that the person was boring, you could say that I felt distanced/ tuned out. "talk about how you feel, not about what the patient is doing"

chap 22: All is grist for the here-and-now mill
Sometimes we need to address the here-and-now behavior there & then. Sometimes its better to park it/ address it later when the client/ therapist is more collected; (eg. someone weeps during session, you might address reasons later)

Chap 23: Check into the here-and-now each hour
Its v imp. to keep checking with our clients how are we doing and how they are experiencing the space between us. Also in the first session itself, at the end, you may like to know what were expectations and were they fulfilled? #GoT

Chap 24: What lies have you told me
Many a times, clients during therapy, share that they had concealed things from someone or lied to/ deceived someone; at such points Yalom encourages us to ask the client what aspects of themselves they had hidden from us or lied to about? #GoT

Any discussions of such concealment leads to a fruitful discussion in therapy, opening up a new pathway of intervening. This is extension of rabbit ears principle whereby you look for clues in here-and-now and build upon them to strengthen/address the therapeutic relationship.

Chap 25: Blank screen? Forget it! Be real.
A few therapists assume that they need to be a blank screen on which the client can project his transference; by not letting their personality shine out, the client is facilitated in projecting her early parental relationships on them.

However, this is unhelpful. One needs to move away from using current distortions to recreate past, towards understanding the past in order to work on the present therapeutic relationship. In the latter framing, the focus is on the here-and-now & therapist authenticity necessary

Some believe that recreating past using blank screen methodology and providing insights about original trauma to clients are helpful in therapy and so they don't self disclose; it is a pity however as therapist disclosure models and leads to client disclosure, which is v. useful.

These insights arose from Yalom's work with group therapy where modeling transparency and authenticity is paramount; he used to share weekly summaries (post group session) with participants where he would reflect on his feelings, process, errors etc, which they found useful #GoT

Chap 26: Three kinds of therapists self-disclosure
Yalom believes that self-disclosure is more beneficial than harmful, but still there are apprehensions around it as therapists don't differentiate b/w sharing about 1) process of therapy 2) here-and-now feelings 3) personal life

Chap 27: The mechanism of therapy- Be transparent.
People like to believe in magic, mystery, authority, & sometimes therapists couch their process in mystery/ magic;however Yalom insists on total transparency as to how therapy is supposed to work with the client(via here-and-now)

Chap 28: revealing here-and-now feelings: use discretion
Yalom advises not to be transparent for its own sake about our feelings etc but to always think whether such sharing will benefit the therapeutic process/ client. Your feelings are valuable data, but to be used judiciously.

Chap 29: revealing the therapists personal life- use caution
Yalom is someone who errs on the side of more sharing than less, and believes it is helpful; he shares anecdotes of how he shared the news of his mothers death with a therapy group & they processed it and it was useful

Chap 30: revealing your personal life- caveats
Many therapists fear that once they let a client in, the client will become ever more curious/ demanding and there will be no stopping him from exploring their innermost desires; this however is an unfounded fear as per Yalom. #GoT

Most clients respect boundaries and do not push beyond what is shared; however he cautions therapists not to share anything that can make them feel embarrassed etc if made public as some clients badmouth their previous therapists and clients are not governed by conditionality

Chap 31: therapists transparency and universality
The rationale for self-disclosure is that it leads to feelings of 'we are in this together' in clients. Clients often come to therapy believing their problems are unique, however they need to be made aware of the human universals.

Chap 32: patients will resist your disclosures
Many clients desire magic, mystery, authority and want their therapists to be ethereal; they actively resist getting to know the all too human side of the therapist; however the therapists must show his frailty and human limitations.

Chap 33: avoid the crooked cure
A crooked cure is when the client is magically cured by transference as she assigns magical powers to the idealized therapist. Instead what helps is when client believes that progress is due to her own powers/ sources within herself. #GoT

Chap 34: on taking patients further than you have gone
Can only a fully analyzed therapist help his clients?Or can someone who is himself struggling with issues still help others?Yalom quotes Neitzsche“Some cannot loosen their own chains yet can nonetheless redeem their friends.”

Yalom links back to Horney's principle that if a therapist successfully removes obstacles, the self realization drive will take over and the client may display acts of courage/ growth/ integration that even the therapist does not show. So one may lead further than one has been.

Chap 35: On being helped by your patient
Wounded healers are effective as they can empathize better with the client and participate more personally in the therapeutic process. Yalom admits that sometime when he is feeling down before a session, he emerges recharged post it #GoT

Help from the client comes in many forms. " Sometimes it is the result of sheerly being effective in my work, of feeling better about myself through using my skills and expertise to help another. Sometimes it ensues from being drawn out of myself and into contact with another."

Help also comes more directly. Harry Sullivan used to say therapy is a discussion of personal issues between two people, one of them more anxious than the other. Sometimes clients provide support to therapists esp during bereavement faced by therapist etc ; lets be open to it!

Chap 36: Encourage patient self disclosure
Yalom stresses that much of what we do in therapy, like creating a safe environment, exploring dreams/fantasies is to encourage the client to disclose self, a process that is crucial for establishment of therapeutic relationship/ therapy

He distinguishes b/w vertical disclosure which is about going in depth about what is being revealed (exploring say more occurrences), and horizontal disclosure which is about the process of disclosure -why now, why not earlier, how hard it is to share etc. Both are important #GoT

One thing Yalom stresses, especially in group therapy context, is the impatience of some participants if one participant is not transparent early on and reveals something only quite late; he says its never too late and one should be welcoming of such self disclosures even if late

Chap 37: feedback in therapy
Here Yalom latches on to the concept of Johari window stressing that therapists role is to expand the public self of the client and shrink all the remaining three (blind, secret, unconscious) esp the secret self by encouraging client self disclosure.

He also lists useful feedback tips- let it be about here-and-now behavior ; given soon after the event; also it should refer to feelings and reactions generated in therapist rather than attributing motives to clients actions. The whole idea being they know their impact on others.

Chap 38: provide feedback effectively and gently
1. get a buy-in from clients as to their openness to receive feedback about here-and-now behaviors 2. Always talk about *their* behavior, *your* reactions/ feelings, and how this dynamic is affecting *your* desire to get close.

Chap 39: increase receptiveness to feedback by using 'parts'
If a client asks a generalized question:'do you like me', get specific: talk about parts of the client that draw you in & parts that repulse you. You may like to draw attention to the client to their dysfunctional parts

Sometimes the opposite may be true. To a suicidal client, you may like to draw attention of the client to his part that brought him to therapy and wants to live; {this may be especially relevant to suicide prevention helplines, gently making that part stronger that led to call.}

Chap 40: Feedback: strike when the iron is cold
Here Yalom emphasizes that feedback is best served cold; it should be given not when the client is in throes of the malfunctioning behavior, but when she is in opposite/ different state and more likely to notice her normal pattern.

Chap 41: Talk about death
Fear of death is a universal fear, and though we overtly deny death, it seeps into our dreams and fantasies. Many therapists think that discussing death is best avoided as 1) we cant do much 2) the client maybe already anxious 3)don't scratch if no itch

However, this gives the impression that death is too terrible (even to discuss). Much of therapy involves finding meaning in life and this can only be achieved by acknowledging the centrality of death; learning to live well is to learn to die well; thus death is legitimate issue

Chap 42: Death and life enhancement
Literary works like story of Scrooge in A Christmas Carol, show how confrontation with death reforms a person/ makes them re-prioritize; cancer patients become wiser; "though the physicality of death destroys us, the idea of death may save us."

Terminally ill patients move from everyday mode of existence(wondering about how things are) to a being mode(wondering that things are) & this is good 4 therapy. While not all patients r terminally ill, they may be facing bereavement, aging etc & this provides a lever for change

Often bereavement in therapy is addressed by helping make the clinet overcome grief/ loss, return back to normal functioning etc; however death of the other, forces us to confront our own death and when worked through properly can lead to new levels of maturity and wisdom. #GoT

Chap 43: How to talk about death
Yalom advises to talk about death and death anxiety in a matter of fact way- asking questions like when did the client first became aware of death? Which funerals he has attended? How does it manifest in dreams/ fantasies? remain equanimous/ calm

Its useful to dissect and ask what the fear of death is actually about - for some its about fear of obliteration, for some fear of afterlife, some the process of dying, while for others its a concern about how that will affect survivors. The therapist should show equanimity #GoT

Chap 44: Talk about life meaning
Yalom is an existentialist believing that humans are thrown into a world devoid of meaning; but as they are meaning-seeking they need to create a meaning for their own life & at the same time deny authorship; assuming meaning was always out there!

Many people (1/3 as per Jung} seek therapy because of lack of meaning-they may complain of life being pointless, lacking coherence/significance; feeling empty, lacking passion etc; at the core, many despite achievements, feel bored & need ever new materialistic goals to feel good

Many methods exist to make people think about meaning- one such is thinking about their tombstone epitaph. {I use this in my workshops}. People inevitably discover purposes like altruism, creativity, self actualization when they reflect on meaning; self-transcendent purposes best

Yalom advises approaching meaning obliquely in therapy; he advises plunging into one of the possible meanings, particularly self transcendent one, and removing obstacles to engaging in that purpose. 'One must immerse oneself into the river of life and let the question drift away'

Chap 45: Freedom
Yalom say that out of the 4 ultimate concerns, freedom as evoking anxiety is a little hard to grasp. Freedom associated with choice, willing , decisions & responsibility has a darker side. At the end of the day, we are responsible for ourselves & are self-created

'Through the accretion of our choices, our actions, and our failures to act, we ultimately design ourselves. We cannot avoid this responsibility, this freedom.' Also as the world is without a base/ structure, we are free/ responsible to provide a structure to the world out there.

All this freedom evokes anxiety- & though the term freedom may not be discussed in therapy, its derivatives like responsibility, willing, wishing, deciding etc are all too apparent topics that are addressed. As per Sartre 'we are condemned to freedom' & we need to come to terms.

Chap 46: Helping patients assume responsibility
If the client believes the causes of their problems lie outside their control (other people's actions, bad genes, social class injustices etc), therapy can work by either teaching equanimity or helping them change the environment.

If however we want lasting/ deeper change, the client needs to be encouraged to acknowledge their role in the problems- even if its only 1 %; one can also ask if they play victim, what is it in there for them to be repeatedly victimized? Whats the payoff in this situation? #GoT

In a group therapy format, participants soon assume typical roles. By observing each other they realize that 1) their behavior leads to feelings in others and how others view them 2) others opinions shape their self perceptions. Their own role in the here-and-now can be addressed

'Responsibility assumption is an essential first step in the therapeutic process. Once individuals recognize their role in creating their own life predicament, they also realize that they, and only they, have the power to change that situation'. Tools, like regret-in-future, work

Chap 48: never(almost never)make decisions 4 the patient
Many clients present decision dilemmas 2 therapists & covertly/overtly seek their advice; however therapist has information made available that is filtered by the client; hence its never a good idea 2 decide on clients part

Of special relevance is marital conflicts where client may paint a bad picture of spouse; however, if there is evidence of physical abuse Yalom makes an exception to this rule and does all he can to discourage the client from returning to spouse where he/she may be abused further

Chap 48: Decisions: a Via Regia into existential bedrock
There are technical reasons 4 not making decisions 4 clients- they may feel controlled, inadequate etc & leave therapy; but a deeper reason is that resistance to making decisions is a royal road 2 anxiety evoked by freedom

Because decision dilemmas evoke freedom-anxiety, clients may go to great lengths to avoid making decisions- they need to be educated that not making a decision is also a decision for which they are responsible. It should be explored if they are happy making that choice. #GoT

Chap 49: focus on resistance to decisions
'“Alternatives exclude”—that concept lies at the heart of so many decisional difficulties. For every “yes” there must be a “no.”' 'Choosing one woman, or one career, or one school, means relinquishing the possibilities of others.' #GoT

Thus making decisions, which cuts us off from other possibilities, exposes us to our limits, making us aware that we are not special / have unlimited potential / choices, that our life course is not infinitely branching and that we are perishable and not immune to biological laws

That is why making decisions is hard and why its so important to address the underlying anxiety and roots of the process. {Just as 'life will be lived all the better if it has no meaning', life will be lived better if we know our limitations and freedom within constraints} #GoT

Chap 50: facilitating awareness by advice giving
While decision dilemmas are best left to explore themes of freedom-anxiety etc, sometimes the therapist may need to prescribe behaviors so as to shake the existing behavioral patterns of the client & make decisions on their behalf

Chap 51: facilitating decisions: other devices
Clients may blame parents etc years later for their problems and show resistance. They need to be exposed to the absurdity of their situation as past cannot be changed. The decision to let go of past as an excuse has 2 be facilitated

Sometimes people are not able to know what they really want; sometimes when say a thought experiment is done (what emotion would you feel if your partner broke away with you?), then reflection can lead to insight on what proactive steps they need to take leading to a decision

Sometimes making the client see ones situation from a 3rd person perspective helps (describing a pseudo client who is similar to the client and seeking her advice) {a similar ploy I use is 'what would you say to a friend?' } This inevitably leads to some perspective. #GoT

Chap 52: Conduct therapy as a continuous session
Yalom advises recording the session and sharing the recording with clients so that they can reflect about it when say commuting to next one. His weekly summaries in group sessions served similar purposes of connecting sessions #GoT

Although like Melanie Klein, he typically waits for the client to start the session with her 'points of urgency'; at time he likes to start the session inviting client to reflect in feelings associated with last session, if it was particularly tumultuous; this maintain continuity

Chap 53: take notes of each session
Yalom, before starting a session, likes to go over the notes from the past sessions- major issues discussed, his feelings/any unfinished business etc; even if there is nothing to note that's an indicator of little progress/stagnation in therapy

Chap 54: encourage self-monitoring
Yalom highlights the importance of self monitoring (how they act & are perceived by others) by the client; eg. a shy client invited to a social gathering should self monitor; class reunions, visiting parents etc are good occasions too to reflect

Chap 55: when your patient weeps
Like a friend our first instinct my be to comfort, but as a therapist we need to encourage plunging deeper. (“If your tears had a voice, what would they be saying?”) Therapy is emotion expression followed by/ alternating with emotion analysis. #GoT

Chap 56: give yourself time between patients
Budget at least 15 minutes b/w sessions to take notes for the last session, and reading notes and thinking/ preparing for the next session. You have a tree to cut, so sharpen your ax in the break time b/w sessions. Don't shortchange!

Chap 57: Express your dilemmas openly
Therapists face several dilemmas: which feelings evoked by an act of client to disclose to her; when to dodge questions & instead focus on why the question is being asked in the first place etc. Yalom advises to be open about it with clients.

Chap 58: do home visits
Yalom likes 2 visit clients in their home occasionally-this gives insights about the client like their organizational abilities, sensitivities, hoarding instincts etc that can be useful in therapy;but most useful is the fact that client feels that he cares

Chap 59: Dont take explanation too seriously
'Therapists place a far higher value than patients on interpretation and insight.' Freud believed that therapist was an archeologist digging up past and putting a jigsaw puzzle together to arrive at insight(s) so that client can change

However, Yalom believes that change/growth happens first & insight later; the process and the hunt for explanation (a natural human drive) brings the client & therapist together to deepen the therapeutic relationship. Also remember its *an* explanation and not *the* explanation!

Chap 60: Therapy accelerating devices
Group therapies use many accelerating/ unfreezing devices like 'trust fall' (where members fall backwards to be caught by other members), 'top secret' where members read anonymized top secrets of each other; the aim is to build trust/ open up

Such exercises should not be an end in themselves-they should be followed by proper debrief: what does it reveal about participants beliefs about trust, empathy, self-disclosure; other techniques include informal role playing, 'empty chairs' etc all providing rich data 4 analysis

A powerful exercise 2 discuss issues related 2 identity is 'Who am I'; Participants write on 8 slips of paper their answers & arrange from central to peripheral; they then meditate what it would mean 2 get stripped of/let go of that identity in reverse order(peripheral 2 central)

Chap 61: Therapy as a dress rehearsal for life
The therapeutic relationship is a means to an end and not an end in itself; therapy is not a substitute, but a dress rehearsal 2 make actual changes in real world settings. The intimacy achieved, social skills learned should transfer

Chap 62: use the initial complaint as leverage
Sometimes when the therapeutic relationship becomes complex (say a women therapist is feeling manipulated by a male client) returning to why the client initiated therapy (trouble in relationships with females) may be very useful #GoT

Chap 63: don't be afraid of touching your patients
Training typically requires that therapist maintain a distance from their clients, not touching them, rejecting hugs etc (4 legal reasons); however Yalom believes it leads 2 artificial distinctions b/w therapist/client, sick/well

He likes to shake/hold hands, touch shoulders etc at least once in each session and if a client wants to hold hands longer or wants a hug, he treats that as grist for therapy mill (to be discussed in next session), but usually complies unless there is a sexual motive. Be human!

If the sexual feelings are involved, discuss openly and do not act on them; nothing is more important than creating a safe space for client. Do not press contact (like parting handshake) if client is angry and wants to leave (seek permission if necessary). Use as grist 4 the mill

Chap 64: Never be sexual with patients
Sexual transgressions are a problem where power differentials exist like in priesthood, workplace etc; it becomes acute in therapy as therapeutic intimacy (not to be confused with sexual intimacy) is actively encouraged by the therapist #GoT

As clients get such attention/ care from the therapist, feelings of love and at times with sexual overtones develop naturally in some of them; such here-and-now feelings are grist for the mill of therapy & should be examined & not brushed aside; however do not gratify the client

Sometimes the source of sexual feelings may be within the therapist- if its due to clients behavior its grist for the mill; however if it due to sexual deprivation of therapist, Yalom advises 2 go 2 a prostitute, but spare your client as that's both morally & professionally wrong

'If, in the final analysis, the therapist can find no solution to unruly sexual impulses & is unable or unwilling to get help from personal therapy, then I believe he should not be practicing therapy.' Its destructive 2 clients & destructive 2 therapists when better sense returns

Chap 65: look for anniversary and life stage issues
Spousal or parental death anniversaries can trigger (unconsciously)extreme reactions including psychiatric hospitalizations. Birthdays (when say outliving parents), wedding/ divorce / retirement anniversaries all affect clients

Chap 66: Never ignore 'therapy anxiety'
When the client experiences anxiety either during the session/before coming 2 session, this needs to be explored in the therapy hour. Mostly the anxiety is not related 2 content discussed, but about process of therapy (therapeutic alliance)

When the anxiety appears during the session, Yalom becomes a detective along with the client, figuring out why the anxiety arose: this process of joint investigation enables client to appreciate that anxiety has identifiable roots, and can thus be prevented/ addressed. #GoT

Chap 67: Doctor, take away my anxiety
Sometimes when clients are quite anxious and looking for relief, Yalom asks them 'What is the perfect thing I can say to make you feel better'. This enables them to find magical relief when therapists says say 'you are most beautiful person'

The technique is aimed at addressing the child part (and not the rational mind) within the client who is looking for reassurances; and after reassuring plan is to look at other feelings associated with the incident (possible embarrassment at the reassurance requested etc) #GoT

Chap 68: On being love's executioner
Ordinarily, love is glorious, but sometimes the variety of love known as infatuation causes more distress than good. While therapy aims to illuminate, infatuated love thrives on magic and mystery and thus Yalom believes they are incompatible.

While passionate love is ecstatic, blissful, dissolving of lonely 'I' into enchanted 'We'; its also obsessive, idealizes beloved & hopeful of spending the rest of life basking in the presence of beloved. We need to appreciate the rapture as also make client prepare for its end!

Yalom believes the one true property of romantic love is that it is evanescent, it disappears; to prepare client deal with that, ask him what his life was before that? what about past loves? what happened to those feelings? Introduce a long term perspective/discourage impulsivity

The dissolution of obsession is not easy & may be triggered by chance/ planned encounters with the beloved; an analogy with drug addiction is appropriate. Oftentimes, obsession with love object is a distraction from some other painful thoughts. One should explore that in therapy.

Chap 69: Taking a history
One may take a systematic history of client (presenting complaint, previous therapy, physical health etc) in 1st couple of sessions or in brief therapy; but typically experienced therapists gather data intuitively/automatically throughout the sessions.

Chap 70: A history of the patients daily schedule
Despite his reliance in intuitive methods, Yalom always asks the client her daily schedule including eating, sleeping, watching TV, use of alcohol/drugs etc; in particular he is interested in how the client's life is peopled?

This is important as it leads 2 data/insights therapist might never have discovered (say the client spends 2 hrs playing solitaire on comp. daily) otherwise, but also as talking about these minute details of client's life leads 2 better bonding early on in the therapeutic process

Chap 71: How is the patient's life peopled
While daily schedule gives insight on who r the important people in clients life, Yalom also asks explicitly about best friends, past/present. Its also good for the client to draw a solar system with them in center/other imp. around them

Chap 72: Interview the significant other
Yalom feels its important to get a perspective from significant others by meeting them; else therapists image of SOs is highly skewed by what the client has presented. Also SOs become more fleshed in & its easier to enter in clients world

Chap 73: Explore previous therapy
Yalom always inquires about past therapists(if any) & if the client was not satisfied its usually because the therapist was distant, aloof etc; the point being not 2 repeat the mistakes. If experience was good, then also learn/continue good stuff

Chap 74: Sharing the shade of the shadow
All of us have a shadow side & some clients flagellate themselves over real/imaginary transgressions/ baser impulses. When a therapist attempts to normalize the feelings by referring to 'we' as having shadow, that becomes soothing/healing

Chap 75: Freud was not always wrong
Freud bashing is fashionable, but field of therapy owes its existence to him. Freud made many contribs: the value of insight/ deep self-exploration; the existence of resistance, transference, repressed trauma; the use of dreams & fantasies etc

Chap 76: CBT is not what its cracked to be
Its a perception that only empirically validated therapies are good therapies; Yalom points that other therapies are not invalid, they are just not-validated yet. He also points brief therapies are not brief/ long term outcome is unknown

Chap 77: Dreams- use them, use them , use them
Many young therapists resist dreamwork, as they find it as complex, imagery subtle/incomprehensible & also the newer biological research sometimes makes dream sound as random patterns; besides there are many schools of interpretation

Yalom laments this inattention to dreams as 'Dreams represent an incisive restating of the patient’s deeper problems, only in a different language - a language
of visual imagery...Freud considered them “the royal road
to the unconscious."' Thus his insistence on using dreams #GoT

Chap 78: Full interpretation of a dream: forget it!
Yalom believes a full interpretation of a dream is not possible and paralyzes new therapists; its also not desirable/ necessarily is the best use of therapy hour. So just use the parts of dream that are relevant to therapy! #GoT

Chap 79: Use dream pragmatically: Pillage & loot
'The fundamental principle underlying my work with
dreams is 2 extract from them everything that expedites/accelerates therapy. Pillage/loot the dream, take
out of it whatever seems valuable,& don’t fret about the discarded shell'

'focus on those parts of dream that pertain to current stage of therapy—for eg, the lack of engagement and the restricted affect—and make no attempt to understand the dream in its entirety.' Thus, a dream presented early in therapy maybe in context of anxiety of entering therapy

Chap 80: Master some dream navigation skills
Inquire about dreams of clients, esp repetitive dream, nightmares etc; write down dream details or you'll forget them; asking clients to repeat dream in present tense plunges them back in dream and you can inquire about dream affect

encourage clients to select parts of dream and free associate (do not censor, even if silly, irrelevant, taboo) ; inquire about relevant events of day preceding the dream; encourage client to see all people/ objects in dream as aspects of oneself etc; all these r important skills

Chap 81: Learn about the patients life form the dreams
Dreams r not just about the unconscious conflicts: 'a dream is an extraordinarily rich tapestry threaded through with poignant significant memories of the past. Simply culling those memories may often be a valuable endeavor.'

The people appearing in the dreams are often not single people, but composites - of people long forgotten like past best friends, uncles etc ; by inquiring about the dreams and the free associations to faces in dreams, one can uncover past people/incidents of significance #GoT

Chap 82: Pay attention to the first dream
The first dream (in therapy) is often quiet instructive; it shows the fear/ anxiety of the client and her misgivings/ misconceptions about entering therapy. Hence use these first dreams to know more about clients' underlying issues #GoT

Chap 83: Attend carefully to dreams about the therapist
One of the most important dreams is where the therapist enters the dream either as a person or a symbol; as these dreams point to therapeutic dynamics these need to be carefully harvested and interpreted. #GoT

Chap 84: Beware the occupational hazards
Therapists at times feel isolation: their one sided intimate relationship with clients leaves them with little energy for outside mutually enriching relationships. Sometime the adoration they receive from clients serve as proxy relations

They are also idealized/devalued by others, and internalize it as feeling of grandiosity/ self-doubts. Also if one practices narrowly (say with terminal cancer patients) then one gets demoralized/ burnt out sooner; antidote is to work with broad groups & undergo personal therapy

Another occupational hazard is attempted/ completed suicide by client and threat of or actual lawsuits; both of these again demotivate /change therapist behavior. Yalom advises participating in therapy /support groups for continuing personal therapy and addressing the issues

Chap 85: cherish the occupational privileges
Therapy is a life of service and meaning, not only ensuring growth of clients, but by ripple effects helping create a gentler, better world. The never-ending scrutiny and inner work, also leads to growth and maturity of therapist #GoT

Therapists are also cradlers of secrets: clients share their inner aspects enabling therapist to get a view of humanity that is raw & unadulterated. Knowing that we all have painful secrets draws us closer. We are able to transcend our ltd vision & apprehend true human condition

Therapists act as guides enabling clients to discover newer aspect of themselves and as healers who can heal old wounds.

What an extraordinary privilege indeed, just like religious healers/ shamans and the lot over the course of history.

Blessed are the therapists! #GoT

This completes my capturing of tips from the #GiftOfTherapy by Irvin Yalom; the thread ends here, but the learning stays forever.
What an extraordinary privilege it has been to share the thoughts of Yalom via this thread; hope it was useful and informs your practice. #GoT #thanks