Staring at the sun

You've been a professor of psychiatry at Stanford University for decades, you're a writer of both fiction and non-fiction and an individual psychotherapist and group therapist. Underlying these varied activities is your commitment to the therapeutic endeavour. What drew you to therapeutic work?
When I was about 13 my father had a severe coronary – he looked as though he were going to die. We waited until the physician, a man named Dr Manchester, drove up at night. I could hear his car crunching the leaves and then he came in the house and everything changed. He assuaged my anxiety, let me listen to my father's heart to reinforce the idea it was going regularly. He was an angel of mercy that night, and I think at that point I made the decision that I'd like to be able to try to pass that kind of relief on to others.

Why psychiatry, as opposed to another branch of medicine?  
Psychiatry was a link to the wisdom that I found in the novels I had been reading, to the odd vagaries of human behaviour that I would read about in Tolstoy and Hemingway. I don't know the origins of it, but I think it had to do with my extreme commitment to reading at that point.

Could you tell us about existential psychotherapy, the approach you're most closely associated with?
If we divorce ourselves from the busyness and distractions and meditate upon our lives, I think certain concerns become evident to us. There's the concern of death. Every one of us wants to persist in our own being but has to face inevitable death. There's the concern of life meaning.  We seem to be built to require some type of meaning in life and we're unfortunate enough to be thrown into a universe that doesn't have intrinsic meaning, so we have to construct a meaning that's strong enough to support a life. Then there's the idea that we're born alone and leave the world alone, so there's a certain kind of deep isolation. The last one is the concern of freedom: I mean being free, being the author of one's own life design. Anxiety and despair come not only from our biological substrate, problems with repressed instinctual drives, shards of half-forgotten traumas and current crises, but also from confrontation with these existential ultimate concerns. Existential psychotherapy is one of many approaches but it's an approach I think is necessary to a well-balanced therapist. I have never thought of existential psychotherapy as some sort of free-standing therapeutic school. A therapist should be well-grounded in all the other schools but in addition have a sensibility to existential issues.

In your recent book Staring at the Sun you say the therapeutic professions tend to avoid exploring anxieties about death and dying. Do you think this is a particularly difficult issue for us?
I think it's a very difficult issue. Staring at the Sun comes from a maxim by La Rochefoucauld, who said there are two things that we can't stare directly at – the sun or death. I'm suggesting that we can stare at death, it's not going to blind us. In fact we're better off for staring at it than pretending it's not there.

There was a time I became interested in the existential approach and I thought I'd begin to work with the population who couldn't evade existential issues, a population imminently facing death. As I started working with people who were dying of cancer I saw mounting anxiety swell up in me and everyone who was involved. The patients themselves were very willing, they wanted to be teachers. As a result of their confrontation with death they felt they had learnt something about how to live. They welcomed observers to the group, but my students who were watching it were extremely distressed by the experience, many of them having to leave the observation room because they broke down in tears. I eventually went back into therapy to deal with my own anxiety.

So the answer is yes, it's very difficult for us. We need to have personal therapy where we look at these issues, because if we can't face them in ourselves then we're going to avoid them in our patients. If you work with existential issues it's going to radically alter the nature of the therapeutic relationship in a direction of a greater authenticity, a genuineness with patients: no pretending that you're not dealing with the same issues they are dealing with, no attempts to keep distance from them by wearing uniforms, appealing to authority or having your office covered with advanced diplomas.  

I want to ask about your notion of the universality of the four ultimate concerns. What about the argument that fear of freedom and a sense of meaninglessness have a strong relationship with affluence – that they're not the concern of the majority of the world's people, who live in poverty and have limited social mobility?
I think that's true. This goes back to Maslow's hierarchy of needs; you'd need to have the other need taken care of before you deal with higher, existential needs. But even given that, I think there is a margin of autonomy. If nothing else is open to us we still have the option of deciding how we're going to respond to restrictions on our life. A patient of mine had little margin of autonomy: she didn't have a great deal of money, she was raising children alone, she felt absolutely trapped into her job, her life situation. One day she mentioned she had seen a job posting in another city but she just threw that in her wastepaper basket. Sometimes I talk about Nietzsche's concept of eternal return with patients. Here's the concept: suppose you were given an opportunity, that you were with this life again and again through all eternity and everything in it will remain exactly the same, every action you've made, even this conversation with you and me, even these trees waving in the breeze. Will this idea please you or terrify you? And here's the issue of therapy: if it terrifies you then maybe you're not living your life right. Is there a way for you to live this next year without building more regrets in your life? What happened was that the patient decided to explore that job and finally decided it wasn't the job for her. She felt better for leaving herself open to that and several months later did take another job.  

In my experience therapists are more comfortable and more fully themselves working either with individuals or groups. Is this the case for you?
I felt equally comfortable. I haven't been doing groups for a number of years, except I am in a group: for at least 15 years I have been in a leaderless support group of other psychiatrists. It's been quite a wonderful thing. I don't know what the group situation is in Britain but in this country fewer and fewer groups are interpersonally based – the kind I describe in my textbooks. There's just a handful of people who are doing them, and I wonder why. I feel it's a sad thing because I'm so convinced the group is a highly effective modality. My suggestion is that all you clinical psychologists get yourself into a support group of other therapists. You can talk about the things that are troubling you in your life, including patients. I think if everybody would do this they would start to lose some of their fear about being in groups and see how valuable they are.

You have called yourself an atheist with religious concerns. How does this influence you as a therapist?
Let me just say that it's not right to think of me as being an anti-religious therapist. If it seems to me the patient is drawing a great deal from religion, I wouldn't think of questioning that. In fact I'd do just the opposite. Do we have time for a three-minute story? It's a story of a man who called me and said, 'I'd like to see you one time in consultation'. He was a very odd looking person, he came in with a big pile of drawings and told me that he had been visited every night by God and sent these visions to draw. So he showed me these drawings. Some of them were acrylics and there were paintings. They were just unbelievable, he was such a creative person. So I thought the answer to his riddle was that these drawings and these ideas are wonderful. He knows it, but he doesn't have enough faith in himself. So he gives them away and in this instance he's giving them away to God. They're his creations, although his talent may well be God-given. He left fairly satisfied. I'm not questioning his belief in God. I don't do that in my therapy. But my own belief is a secular belief.

One of the striking things reading your work is the constancy of your values and ideas.
Another not so nice way of looking at that is that my writing is repetitious!

Or that they were good ideas in the first place. How have you developed over the course of your career, particularly from the point of view of patients?
Our field is different from a lot of fields in that we get better as we get older because of a couple of things. One of them is the greater knowledge and awareness of yourself, provided you keep working on yourself like being in a group or getting back into therapy when you go through the anxiety of various life stages. But secondly I believe that you grow wise and I feel I'm wiser when I work with patients, in addition to having accumulated much more experience. I tend to be less uptight about revealing myself, I don't have strong rules about what you can say and what you can't. Younger people need to have a set of rules just to dampen their anxiety a little bit. I tend to be more open, I reveal more of myself to patients. I'll talk about dilemmas, I'll work with the patient more out loud.

Over the many years I've been in practice, I would say 90 per cent of patients have been in therapy before and come because they've been unhappy with the therapy they've experienced in the past. Almost invariably it has to do with the therapist being too disinterested, too uninvolved with the patient, too hidden.  

Who is your favourite writer and why?
It keeps changing every month or two. I like a British writer named David Mitchell. I think he is the best writer alive. Tremendous creativity. He doesn't baulk at flying around the supernatural. His language is quite wonderful. He somehow has not won the Booker Prize, and I don't understand why. The Booker Prize winner two years ago was John Banville, and I like his work very well. Philip Roth has got a new book out called Exit Ghost, which I find touching. He's ageing and pursuing the question of what ageing does to a writer's skills. I'm dealing with that myself so that book speaks for me a great deal. I always go back and read the classics every few years; Dickens, Tolstoy, Dostoevsky are my favourites.

What are your future projects?
When I finished this book I thought 'I'll see whether I can live without writing a book' because I've been writing one after the other for decades. But now another project has been touched off by a visit to Amsterdam and Copenhagen just recently. I spent a day travelling and looking at the Spinoza homes and the Spinoza museum and suddenly I have an idea that maybe there is a novel, I might be able to try and write about Spinoza. But he's so complex, so controversial, so difficult to understand – I'm sure this will be a project that will take the rest of my life.

Resources
Full audio version, plus Q+A session, available as an MP3 at www.thepsychologist.org.uk
www.yalom.com
Yalom, I.D. (2008). Staring at the sun: Overcoming the terror of death. Piatkus Books.
Yalom, I.D. (2005). The Schopenhauer cure. HarperCollins.
May, R. (1983). The discovery of being: Writings in existential psychology. W.W. Norton (1994 reprint)
www.youtube.com: Randy Pausch's 'last lecture'