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by Irvin D. Yalom
HarperCollins , 1989
Review by James Sage on May 15th 2002
What do you want?
This simple question
generates some of the most intimate answers, even between perfect
I want my to see my
dead mother again. I want to be
loved. I want to live forever. I want to know, Dad, that you are proud of
me. I want to be young again. I want the childhood I never had...
And between patient
and psychotherapist, answers reflect a deeper anxiety, a fear, a restless
longing, that Yalom terms "existence anxiety" or "existence
pain". Existence pain is the kind
of pain that is "always there, whirring continuously just beneath the
membrane of life. Pain that is all too easily accessible" (p. 3). Existence pain is the organizing principle
behind Yalom's approach to existential psychotherapy, and typifies what he
calls the "givens" of existence. Yalom identifies these four
"givens" as follows.
First, there is the
anxiety that is generated by the inevitability of death (for each of us as well
as for those we love). The reality of
death haunts many; most of us avoid the topic altogether (we do so by inventing
convenient myths and comforting euphemisms).
Existential psychotherapy aims to penetrate, identify, and re-assess
these layers of concealment and these multiple defenses that attempt to shut
out the reality and finality of death that are so often destructive and
pain occurs when we realize the ultimate freedom with which we live our lives. The realization that we are free to choose
how our lives will unfold leads many to deny this responsibility. Ultimately, accepting responsibility for our
lives and our ways of relating to others will empower us and put us in control.
Third, great effort
is often spent to avoid the pain of being alone. The fear of failing to achieve close and personal relationships
often sabotages the very attempt to connect with others. Coupled with the nagging sense that each of
us will face death alone, aloneness generates so much grief that many people,
paradoxically, fail generate significant relationships. Identifying these
self-defeating tendencies is the first step at removing the obstacles that
hinder the generation of significant relationships.
pain occurs when we come to realize that life is devoid of any obvious
meaning. Our attempt to cling to
artificial meaning structures (leading to behaviors such as collecting dolls
and stamps in ritualistic fashion), ultimately unravels our ability to cope
with a world of existence and death.
Each of these sources
of existence pain (death, freedom, aloneness, meaninglessness) have a
synergistic effect with each other: often we employ arguably unhealthy
strategies to avoid one source of pain, which then exacerbates the pain and
anxiety experienced in other areas.
For example, people
often fear the finality of death that ultimately awaits a loved one. This leads us to place distance between
ourselves and others (as a kind of defense mechanism to avoid the pain of
loss). But in so doing, we place
barriers between ourselves and others, thereby undermining our ability to
relate to each other authentically.
This, in turn, reinforces the anxiety that, ultimately, each of us is
alone and will die alone. Avoiding the
pain of death places us directly in the path of existence pain that results
from being alone. And the diversity of
examples are as endless as there are people in the world.
For a more detailed and scholarly examination
of this existential approach to psychotherapy, see Yalom's Existential
Psychotherapy, New York: Basic Books, 1980.
is the story of ten patients who turned to psychotherapy to deal with existence
There is the woman who yearns for her dead
daughter, visiting her grave daily, while at the same time neglecting her two
There is the 60-year-old woman who clings to
a fantasy relationship with a man 35 years younger, all in the attempt to avoid
the uncomfortable reality of aging and death.
There is the man who
has the mentality of a sexual predator, even though lymphatic cancer is slowly
eating away his body.
Still another man
who, in an attempt to deny his own mortality, cannot throw away love letters
three decades old.
And then there's the "Fat Lady" who
manages to lose 100 pounds, despite longing to understand her father's
All in all, Yalom
presents an excellent account of how psychotherapy might unfold for both
patient and clinician. Yalom provides
an uncharacteristically personal account of the therapist's own challenges and illuminates
some of the fundamental challenges associated with providing therapy. After all, the therapist, too, is dealing
with existence pain just as much as the patient. This proves to make therapy sessions particularly intriguing, and
Yalom pulls no punches when providing introspective accounts of his own
Yalom's prose is both
accessible and penetrating as he leads the reader into the depths of the human
condition in ten unique accounts of existentialist psychotherapy. I highly recommend this book (as well as
others by Yalom) to anyone, on either side of the couch, who is remotely
interested in psychotherapy. Yalom is a
delight to read, and offers penetrating insights that apply to each of us who
is caught, inescapably and firmly, in the grips of the human condition.
© 2002 James Sage
James Sage is a Ph.D. candidate in
philosophy at the University of Utah. His interests include the evolution of
mind and rationality, philosophy of science, and naturalized theories of