ULTIMATE CONCERNS
A Conversation with Irvin D. Yalom

By Bruce Ramsay

When he realized Mars Hill Review was a Christian journal, Dr. Irvin Yalom told me he did not think we would be interested in an interview with an atheistic, existential psychiatrist. I responded that in spite of the disparities of belief in the existence of a divine designer and "ultimate rescuer," our readers would be intrigued by his thoughts and observations concerning our struggles to come to terms with the world around us. Though remaining skeptical, Dr. Yalom consented to the interview.

I have long admired the books of Dr. Yalom, and the courage and invention he demonstrates in writing about his work with psychiatric patients. His works-both fiction and nonfiction-are written in an economical, "no-nonsense" style, yet are filled with compassion for those struggling with the seemingly insurmountable and harsh realities dominating the circumstances of their lives. While his writing carries an immediacy and warmth borne out of an empathy with the foibles and tragedies of his clients, he never allows false sentiment to cloud his perceptions. Dr. Yalom stubbornly refuses to provide facile solutions to the philosophical dilemmas in which we are enmeshed, and it is this willingness to joust with existential windmills, coupled with his keen psychological insights, that give his writings their power. Dr. Yalom is, above all, a man of integrity and conviction.

Dr. Irvin Yalom is a professor of psychiatry at Stanford University Medical School. He is best known for his two textbooks, Existential Psychotherapy and The Theory and Practice of Group Psychotherapy. More recently he has focused on writing fiction, with his novels Love's Executioner and When Nietzsche Wept demonstrating his gifts as a storyteller. His most recent novel is entitled Lying on the Couch.

Mars Hill Review: Could you share what you consider to be the fundamental beliefs of an existential psychotherapist?

Irvin Yalom: Let me begin by responding to your assumption that I am an existential psychotherapist. True, I wrote a textbook called Existential Psychotherapy and in that book I attempted to clarify my beliefs concerning the philosophy of psychotherapy. However, I do not consider existential psychotherapy to be a free standing field and so therefore I do not consider myself as an existential psychotherapist. By that, what I mean to say is that existential psychotherapy is an approach that is built on standard thoughtful psychodynamic psychotherapy. "Dynamic" meaning that it is a depth psychology in that we are looking at patients' unconscious, but also taking into account that the therapist has an informed sensibility or an increased sensitivity to certain existential issues in life and in therapy. So, when you ask me if I am an existential psychotherapist, I would answer that I am a psychotherapist and I have particular sensibilities to existential issues. But it is not a separate school. Sometimes students call me, as one did today, wanting to know where he could go to get a degree in existential psychotherapy. There really aren't any training programs like that.

That said, I want to qualify your question just a bit. By an existential approach what I am referring to is that the therapist has an increased sensibility to sources of despair and distress that are intrinsically linked to and emanate out of one's confrontation with issues that are inherent in the human condition. Other approaches to psychotherapy differ from this. For example, let's use the Freudian approach. I don't want to oversimplify, but a Freudian approach, at least in its origins, might say that our anxiety emanates out of psychosexual issues. It is believed these are developmental issues, as well as drives and impulses in us coming into conflict with the environment, with the reality principle. And so a lot of anxiety emanates from that.

But I would point out there is also a great deal of anxiety that emanates from our confrontation with certain givens of our existence. I wrote my textbook, Existential Psychotherapy, around what I consider to be four important givens of existence. The phrase I use in that book is "ultimate concerns." I think that is a very good descriptive term which I got incidentally from Paul Tillich, the eminent New York theologian. So I am positing that our anxiety comes from awareness of our own finiteness, our own death. This is in conflict with our desire to persist to be. Every living thing wants to persist in its own being. So that would be one source of anxiety, facing our own mortality or finiteness.

Another ultimate concern comes out of the sense or our desire for meaning in life. We seem to be meaning-seeking creatures. Even our neural organization tends to want to cluster common stimuli into some sort of a pattern. We look for some kind of overall purpose to our existence. Many people come into therapy because of a lack of this sense of meaning.

Other individuals may come into therapy because of a confrontation with deep isolation. Isolation is a complex issue-we not only deal with isolation from other people, which is not necessarily an existential issue, but we have to face the deeper sense of isolation that arises from the realization that no matter how close we get to another person we are still going to have to face death alone. We are born alone, thrown into the world alone, and we have to leave the world alone. That is a terrifying reality.

The last ultimate concern that I discuss in Existential Psychotherapy has to do with freedom. Not political freedom, that is a positive thing: we all strive for political freedom. What I mean by freedom is the philosophical idea that we are really the authors of our own life plan, our own life design. Although our eyes and our education may tell us that we are shaped by the structure of the universe, that is not the only reality. Rather, I agree with Sartre when he points out that we create our own lives, we are the authors of our own lives. Before him, Kant said that we really are responsible for the shape of time and matter. Our brains organize the stimuli we receive in such a way as to give them meaningful patterns. So, that is a long-winded response to your question, but to summarize, I am saying that an existential psychotherapist is one who has great sensitivity to the ultimate concerns of patients. Some patients have yet to really grapple with ultimate concerns, but when I work with patients who are facing death, these issues are going to be uppermost all the time.

MHR: When a lot of people think of existentialism or the existentialist movement, they think of European philosophers speaking in vague, theoretical, and often confusing ways. Do you feel the average person can find benefit from this approach, or is this something more appealing and relevant to tweed-coated academia?

IY: Well it depends on who that person is. You have to look at the deep subjective experience of each person. One man may come in and have some deep despair about a more finite issue such as marital stress, a relationship at work, or problems with his anger, and for him it may have no concern. While another man may come in who is forty-five and beginning to question his own life and what he has done. Is he satisfied? Or is he beginning to feel he is on the decline? He is in what we call mid-life crisis. He wants to view his whole life from the standpoint of meaning, and must ask what kind of regrets he has for how he has lived his life. Existential issues are going to be very important for this man.

MHR: These ultimate concerns you described-our struggle with meaning, the reality of our own death, our ultimate aloneness, and our anxiety with freedom-strike me as rather stark and perhaps even dismal realities to confront. How do you think it is beneficial for people to face and discuss these in therapy at a very frank level?

IY: Well, I don't know if I really agree they are actually dismal; they are the facts of life. I don't think they are any more dismal than looking at our anatomy and physiology. This is what we come into the world with. This is what is there. So, I feel these ultimate concerns are not dismal at all, but enlighten and enable us to be fully aware of ourselves and our position in life. The awareness of ultimate concerns helps us to more ably deal with reality, and if we aren't afraid to confront reality, then we don't have to struggle with having to avoid seeing what is true. Death is a dismal subject, but if we look deeply into it and try to master our feelings about it we are strengthened by it. I have many quotes in Existential Psychotherapy about facing reality. Thomas Hardy said, "If a way to the better there be, it exacts a full look at the worst." It is a matter of looking at the worst and looking through it. One gets strongest in the broken places. You overcome by enlightenment, by knowing as much as you can about yourself. I cannot agree with any psychological system that sponsors denial and hiding things from oneself.

MHR: Do you ever choose not to take a person down the path that would help them look at these existential realities?

IY: Of course. If these concerns aren't germane to a particular individual, then I may never bring them up. I never impose a system on anyone. In most therapy sessions, it would not occur to me to assume the role of teacher and expose a patient to all these issues. I will only bring up an ultimate concern if it seems to be important in that patient's therapy.

MHR: I recently heard someone state that the termination or diminished role of confession in the church did much to promote the advent of psychotherapy. The Protestant church has never had formal confession, and it appears to be dying out among Catholics. Any thoughts?

IY: I am very interested in the idea of confession and have been for a long time-I have always felt that confession can be a very powerful psychotherapeutic device. Once I was in an isolated Catholic cathedral in Shanghai, a few years ago when Christian worship was not permitted in China. The church was empty, so I got into the confessional box and sat there for a while. I am almost ashamed to admit it, but it was on the priest's side of the box-I wanted to see what it was like. I feel that priests have many powerful weapons at their disposal-the most powerful being their authority to say that someone is forgiven in ways that the therapist cannot. However, to me, there is something infantalizing about receiving absolution from a priest. The parishioner doesn't have to rely upon his own resources, his own growth, to struggle with the larger questions and trials of life. There is still a kind of parental figure saying, "You are forgiven, my child." I am not sure that is most conducive to human personal growth.

MHR: In one of your texts you describe Søren Kierkegaard musing upon how his many successful friends had contributed to society by making life easier. He in turn decided, "I must do something, but inasmuch as with my limited capacities it will be impossible to make anything easier than it has become, I must, with the same humanitarian enthusiasm as the others, undertake to make something harder." In some ways it sounds like you are saying that is a good direction to take people.

IY: That is an amusing incident, but I don't feel I want to make life more difficult for people. I want to make life richer for people. I want to make life more meaningful for people. But you have to remember that I am not operating as a pastoral educator or a minister, where my intention is education, enlightenment, or conversion of a patient to a certain way of thinking. I never do that. I am a therapist. I try to work where the pain is and do what I can to be helpful to those people.

MHR: You state, "Though the physicality of death destroys us, the idea of death saves us." Why do you think this makes life better?

IY: The idea of death, facing death, can definitely enrich our life.

MHR: Do you believe then that those who face a lot of tragedy and suffering are more apt to experience richer lives?

IY: It depends on how they face it. Just because they experience a lot of tragedy and suffering, it doesn't necessarily follow that their lives will be richer. Their response to hardships could be just the opposite-they could be too frightened or beaten by tragedy to really come to terms with the reality of suffering. But I have worked for over ten years with patients who were dying of cancer. For some of these patients, facing death was a kind of liberating experience. These patients had the courage to come to terms with the great truth that life is finite, and realized they didn't have time to waste on trivialities. They made conscious decisions to spend the remainder of their time with the important things, with the people they loved most, with their families.

MHR: When I think and ponder about death, I still find myself wondering how someone can comfortably overcome that overwhelming reality of permanent annihilation.

IY: Tell me what you mean by that word "overcome."

MHR: Even in our attempts to make the best of life, to live without regret, death still haunts us. I would find myself still moving toward despair, no matter how rich a life I live. I still know death, permanent annihilation, awaits me.

IY: This is part of our condition. We could respond to annihilation by building illusions. All of the world's religions have tended to confront it by saying that it is too terrible to face so let's create a system denying it, whereby there is not annihilation, but some type of continued afterlife or existence. I think that denial of annihilation is the building block of religions which attempt to assuage human fears. But in fact, this is not the way that it is. We have a certain period of time so let's get the most out of our lives. Let's live as richly as we can. Let's live in such a way that when we get to the end of our lives we don't have the overwhelming regret that we have never really lived this one and only life which we have. The people that I have seen who have the most despair about death are the people who feel they haven't lived their lives very well. I feel that really facing an end to life can propel us into living our lives in a better, richer way.

MHR: You talk about anxiety as a primary psychiatric concern, and that it is a goal of the therapist to uproot and dismantle the sources of anxiety. How would a therapist address the significant levels of anxiety the client experiences when facing death?

IY: It depends on how he experiences the anxiety. A client may come in to see you who is terrified of death. He may be terrified to leave the house because he feels death is everywhere around him-the fear of death has leaked into his mind, a sense of horror and monsters, awful things going back to his childhood. But maybe if you ask people to examine their fears about death, you may begin to get to certain areas, certain beliefs they have about death that add to their anxiety. If death is somehow associated with the idea of burning in hell forever for some tiny sin they had committed in their life, well, that is conditional anxiety, and can be dealt with. It is not really connected to death per se.

MHR: It sounds like you believe that belief in a providential God, like that of an evangelical Christian like myself, tends to be an escape from the realities associated with life here on earth, the realities of existence or ultimate concerns like freedom, death, lack of meaning, and aloneness which we have previously discussed.

IY: Well, I do think almost all religions have arisen as an attempt to assuage existential anxieties. And if the religious system is one which tends to makes you feel that you are not alone, that there is a personal god who is looking after you, watching you, will always recognize you at the edge of the abyss, and who will meet you after death, you can live forever with that type of god. It seems to me that this is a basic evolution based on humankind's fear of existential annihilation. I know it is not going to be very popular with your readers, but that is what I believe.

MHR: It seems to me several of the existential philosophers, like Kierkegaard and Marcel for example, believed in such a personal god and even more specifically that God revealed through the Bible. Others such as Sartre and yourself do not believe in any such thing as a personal god and are, for all practical purposes, atheistic in orientation. Have you ever pondered why some have concluded the former and some the latter? The same data is available to both and it appears to me both sides view life with a tremendous amount of honesty and integrity.

IY: Well, I don't know, it seems to me the idea of a purely existential belief system really isn't compatible with a strong religious sense. I know that there are a couple of people who consider themselves existentialists. That may be so, among them obviously Kierkegaard and perhaps Gabriel Marcel. But nonetheless, the important thinkers who I feel have looked most closely into these issues are philosophers such as Sartre, Camus, Heidegger, and Nietzsche. These aren't people who will adopt a religious system. I think existentialism and religion are really quite inherently contradictory.

MHR: I am particularly attracted to your writing because of your honesty-you observe our condition in this life with courage and integrity. Couldn't it be that I also choose to look at life with open eyes and that I wrestle with the same existential realities, the same givens of existence as you? Yet given the same data as you, I have concluded that there is a personal and providential God, there is eternal life, there is a grand design to this universe. My belief is not an escape from the present reality.

IY: Well it is a belief; everyone has his or her own belief system. There is no proof or disproof of it. In my clinical work I wouldn't dream of tampering with a belief system which seems to be very useful for the patient. It goes far beyond what I can conclude. It doesn't seem to be self-evident in the data I pick up from life, nor does it personally seem necessary or helpful.

MHR: I would argue that my belief system is something more than "useful." Where do you find meaning in life? You concluded in your writing that one of the central elements to finding meaning involves engagement with other human beings. Could you elaborate on that?

IY: Certainly. What is it that supplies us with meaning? What are the more satisfying forms of meaning? Some people may find their meaning in the accumulation of material goods and wealth. But it seems to me that often is an empty kind of meaning. But there is a certain form of meaning that seems to reach deeper in us. The idea of a kind of union with another person, the idea of loving another person, trying to make our species better, trying to make the world better, giving to others, creating and getting in touch with our own creative impulses-all of these give us a sense of meaning in life. Some of these seem to be more enduring and powerful forms of achieving meaning. Some people, of course, do it through some type of union with a god. It gives them a sense of meaning through a spiritual union.

MHR: There is something peculiar to me about the individual seeking to find meaning from within themselves while operating in the context of a world which, they have concluded, has no meaning. This would seem to be the framework out of which Sartre and yourself are operating-the world has no meaning, makes no sense, is absurd. Now I suppose one could conclude that finding meaning for life from within in the context of this world-which you feel has no meaning, no grand design-is really an inappropriate defense against the reality of the world, against the ultimate concern of meaninglessness.

IY: To backtrack a little, I would substitute "inventing meaning" for the phrase "finding meaning." There is no intrinsic meaning in the universe. We are thrown into a universe which is consistently indifferent to us. We are mere specks, mere grains of sand on the beach in the universe. We have to create something that feels meaningful to us-a kind of meaning that makes us feel right at all levels of our being, like loving another, loving the human race, and doing as much as we can to make our life here better for ourself and everyone else. The need for meaning does seem to run very deep. So it is a question of the kind of meaning-what it feels like to us-rather than an objectively measured meaning. There is no such objectively measured meaning.

MHR: Have you wrestled much with the question of why in the world we were put here and why this whole creation is as it is?

IY: Well I don't think we were put here and I don't think there was any grand plan. I am very much persuaded by the overwhelming amount of evidence for Darwinian theory, that life has evolved according to Darwinian principles. I don't see any necessity from my personal psychic standpoint to think that there was an inherent meaning in the way that we were "put" here. It is true that we are very elaborate, complex human beings. All forms of animal life are extraordinarily complex. But there have been millions and millions of years in which these organisms have evolved in the way that they are.

MHR: But doesn't design imply a designer?

IY: No, not to me. You see beautiful ripples of sand on the beach but that doesn't mean someone designed them. I think you are going to find that at the bottom I am really a secular materialist in that way. I used to always get into arguments with Rollo May. He would argue from the standpoint of Kierkegaard and I from Nietzsche. He would always refer to me as a religious person. I never quite understood that. Many people have said that and that has always astounded me to hear that said of me. They say I am religious because I am asking and discussing religious questions. Maybe that is so; perhaps one of the issues of organized religion is that it is the only real forum that exists for us to talk about these kinds of issues, ethical and moral issues. There is no way of teaching them in the schools. There is still a difference between religious meaning and theological theist kinds of meaning. There are a lot of religious individuals who are still not theists.

MHR: To move in a different direction, what do you think promotes change in individuals?

IY: I think the very first step of change is, people have to get to the point where they say, "I am not really satisfied." They must get to a point where they say, "I am uncomfortable. Something is bothering me. I am anxious. I am in despair." From there, I help them to take a look at what their responsibility is in creating this kind of despair and discomfort. Then, one of the questions that can be posed, not to all people, but to some people is: Are you satisfied with the kind of life you have chosen to live? Maybe your despair has to do with the whole way you are living your life. Maybe it is not just your conflict with your wife.

MHR: There still seems to be a significant gap between what one can create in this life and what we most desire. That still must be wrestled with. Do you still find people who seek change and begin to find a good life yet still feel it is not enough?

IY: Well, yes, indeed. Are you thinking of some specific scenario?

MHR: One example comes to mind. In your recent book, Lying on the Couch, there was the woman, Eva, a terminal cancer patient of the psychotherapist Dr. Ernest Lash. At the end of her life it seemed like a great struggle for Ernest to not allow her to die alone, or at least completely alone. But ultimately he had to wrestle with the fact she was going to die alone.

IY: Right, but he tried to ease her pain as much as he could by extending himself to her and extending his love to her. In a sense, one has to face this kind of existential aloneness, but sometimes it helps to know there are others who are sharing this with you. I think I used the metaphor in one of my books-I think it was Existential Psychotherapy-that even though you are in your own little ship it is awfully nice if you see the lights of the other ships all around you. I thought that was a nice way of putting it.

MHR: In your therapy you put a strong emphasis on dealing in the present, what is going on in the here-and-now. You consider this crucial in facilitating change. I agree with that but I would like to hear you elaborate on that a bit. It seems so common in therapy today for the past to be central, to be the focus in the healing process.

IY: When you say "the present," let me just append that a little bit to say it is the present and the future becoming present. What I mean by that is, you extend yourself into looking at how you view yourself into the future, what you want to make of yourself in the future, the things that are waiting in the future. So I am very interested in future tense and I am also very interested in the present in therapy because I look at the very moment we are living in and how that patient is relating to me. I think the way that patient is relating to me in the therapy situation replicates how that patient is operating or behaving with other important figures in his life. We are not very good observers of ourselves. If I hear my patient spend a lot of time telling me how other people regard her or what she does with other people, that information may be very full of error because it is seen through the patient's eyes. But if I see how that patient is treating me and relating to me-being frightened of me or being confusing to me-it tells me a whole lot more. That is why I work in the present, in the here-and-now, because what is right in front of me is much more accurate than a mere recollection of events. I certainly don't discount that there are trends in the client's life which need to be examined and, of course you cannot really know someone unless you know something about his background, where he has come from, parents, and that type of thing. But to place a major emphasis on uncovering the past with an idea that you are going to figure out why that person is like he or she is today is totally erroneous. Therapists and analysts now are beginning to see that there is no accurate data in history. You are only hearing it through the patient's error-filled eyes and ears. So you can't actually ever reconstruct the past. The best we can do is hear the patient's narrative of the past. You can never really get the facts of the past, because there really are no facts, only the patient's interpretation of the facts. This is because we are active participants in how we observe. There is no such thing as science and history. There is only interpretation.