Born the same year as Irvin Yalom, I heard of his work and writings throughout my professional career, but somehow I never read any of his writings, heard him speak, or met the man. It was with great interest, therefore, that I approached the opportunity to read and review this anthology. Yalom tells us he was asked by his publisher of three decades to write a retrospective, presumably on the occasion of his retirement from his academic position at Stanford University. With the aid of his son Ben, who organized and edited this soft-cover volume, he embarked upon the task.

Yalom starts with a vignette that not only launched him into a psychiatric career but also demonstrates his writing ability and contributes to our understanding of why many consider him a master therapist. Yalom’s first patient as a third-year student on a psychiatric clerkship was a young depressed woman who was a lesbian in the days when homosexual acts were illegal and her sexual preference would be diagnosed as sexual deviance. He knew nothing about lesbians aside from one titillating passage in Proust where Swann spied on two women making love. He wondered what he could offer her and decided that he would allow her to be his guide in exploring her world. Over a period of several weeks she developed "a tender, even loving relationship" with the first of his sex to listen attentively and respectfully to her. She seemed to improve rapidly. At a weekly case conference on that clerkship, Yalom presented this patient before an audience that included luminaries of the Boston Psychoanalytic Institute. He tells us that no one took notes and that silence enveloped the conference room. After this presentation, to his astonishment, he was praised lavishly and told that nothing more needed to be said because this spoke for itself. This, he tells us, was an epiphany, a moment of insight. It also tells the reader that empathic listening and some understanding enabled him to capture the essence of the patient’s life, to communicate it to others, and to be therapeutic. This apparently is the talent that makes Yalom the person he is. The book focuses on Yalom’s three areas of interest and contribution: group therapy, existential psychotherapy, and writing.

Jerome Frank, a master of group psychotherapy, trained Yalom at Johns Hopkins. Being a good therapist, Yalom first deals with resistance, that is, resistance to the concept of group therapy, which prevails despite a formidable body of research showing that it is at least as effective as individual psychotherapy. There are economic and system concerns and resistances. Because group therapy potentially can allow the therapist to earn more money in a shorter period of time, therapists need to question their motivation in initiating this form of therapy and patients need to deal with their feelings about this factor. Doing group therapy is very challenging. It requires a lot of energy and a wide referral base, both of which are essential to its initiation and continuation. Yalom tells us that the uninformed and unprepared patient may find this form of treatment threatening and seek safety in individual therapy. There may be ingrained professional prejudice against a form of treatment that may be viewed as counter to the traditional one-to-one analytic model, which older therapists would be loath to abandon. Yalom also points to the resistance of some therapists to give up their position as a traditional authoritarian medical practitioner in favor of the more transparent and egalitarian head of a group.

Having dealt with resistance, Yalom then goes into the work of group therapy, largely based on his best-selling book (600,000 copies in print) The Theory and Practice of Group Psychotherapy(1). In discussing how group psychotherapy works, he deals with many factors. These include instillation of hope, the universality of impulses of problems and fantasies etc., imparting information, the role of altruism in patients helping each other, the corrective recapitulation of the primary family group, the developing of socializing techniques, imitative behavior, catharsis, existential factors, group cohesiveness, interpersonal learning, and the group as a social microcosm.

Yalom separates here-and-now therapy, an area in which he has made his most original contributions, from groups in which it plays little role, such as Alcoholics Anonymous, cognitive therapy, psychoeducational groups, and cancer support groups. He tells us that the here-and-now approach does not naturally develop on its own but needs to be learned. It consists of two parts: a nonhistoric immediate experience part that takes precedence over the current outside life and the distant past of group members and an essential second part that consists of recognizing, examining, and understanding the process. Yalom also discusses non-here-and-now groups, such as hospitalized patients, those suffering from addictive disorders, the terminally ill, and the bereaved.

I found the second part of this book, which deals with existential psychotherapy, the most interesting. It is based on Existential Psychotherapy(2), which Yalom tells us was 4 years in the writing and twice as long in the reading. Somehow I got through a first-rate psychiatric residency program and an academic career without knowing what the term "existential" really means. Perhaps this was because, as Yalom tells us, the term "defies succinct definition" and because "existential" has been used by colleagues as a false sophistication. Instead of plain ordinary anxiety and depression, for example, the pseudosophisticate refers to existential anxiety and existential depression, in many instances without knowing its meaning themselves, thereby enhancing resistance to the concept. Yalom comes as close as anybody can to explaining the term and its usefulness in the practice of psychotherapy, using meaningful clinical examples. He tells us that it is a dynamic approach to therapy that focuses on concerns rooted in the individual’s existence. It deals with four ultimate concerns—death, freedom, isolation, and meaninglessness. Yalom implies that the perceived amorphous nature of existentialism is based on the fact that its approach cuts across categories and clusters in a novel manner. He says that "the clinician will find the language psychologically alien" and that "the existential position cuts below the subject-object cleavage and regards the person not as a subject who can, under the proper circumstances, perceive external reality but as a consciousness who participates in the construction of reality." He explores life-death interdependence, death anxiety and the lack of attention paid to it in psychotherapy theory and practice, and fundamental defenses against death. He says that death awareness opens only one facet of existential therapy. It helps us understand anxiety. To arrive at a fully balanced therapeutic approach, however, one must examine the other concerns—freedom, isolation, and meaninglessness.

The third section of the book, On Writing, is the most personal. Essentially Yalom explores his interest in writing and his experience in it in making him a better communicator. He says that he often turns to a great writer for a phrase or literary device that brings home an insight with power and clarity. He starts with the interesting observation that, although Freud considered himself a scientist, not a single one of his insights came from science but from his own intuition, artistic imagination, and knowledge of literature and philosophy. Yalom discusses his and his wife Marilyn’s exploration into what has been called applied psychoanalysis—using psychological insights in a publication to understand the author.

In the still more personal remainder of this book, we learn of the historic underpinnings of Yalom’s interest in and use and love of fiction and storytelling. We learn of his ninth birthday, when he lay sick with the mumps in the back of his father’s roach-infested grocery store in a Washington, D.C., ghetto. His Aunt Leah gave him a book, Treasure Island (also my first book), which opened him up to the world of the written word and fiction. Yalom believes that his interest in and love of writing has contributed to his ability to communicate. No doubt this is correct, but most observers of artists, including writers, believe that inborn, perhaps inherited qualities play an important role. We are told that Yalom learned that his father "wrote wonderful poems" as a youth. Perhaps Irvin Yalom and his readers are also indebted to the man behind the grocery counter in Washington, D.C.

As Professor Emeritus of Psychiatry at Stanford University, looking at his work over the past decades with the help of his son Ben, Irvin Yalom gives us a volume that offers a wide array of knowledge and insights. It tells me what I missed in not reading Yalom sooner than this and offers a first-rate anthology of a first-rate communicator and psychiatrist. It is a book that should interest all behavioral professionals as well as the lay public.