DISCUSS THE THERAPEUTIC PROCESS AND THERAPEUTICALLIANCEAS CASE STUDIEDINN IRVIN YALOM’S LOVE’S EXECUTIONER. IS THE THERAPY WORKING? EXPLAIN.
Discuss the therapeutic process and therapeutic alliance as case studied in Irvin Yalom’s Love’s Executioner. Is the therapy working? Explain.
Let me start by giving, you the reader, a summary of Thelma who is the client in “Love’s Executioner”. Thelma, now 70 years old has presented for therapy while in crises (suicidal). As the reader you are not quite sure why Thelma, at this stage, has decided to do this. She has attended many therapists and in eight years has never mentioned, as far as she’s concerned, the real reason she needs counselling. Thelma has suffered chronic depression and has been in psychiatric treatment almost continuously for 20 years. Her story is rooted in eight years previous when she met a therapist called Matthew, a young Psychology Intern at a local County Mental Health clinic where she had been treated by a series of trainees. She met Matthew weekly for eight months and also saw him in his private practice for another year. When Matthew secured a new full-time position else-where he had to terminate therapy with all his private patients. In Thelma’s view, Matthew was by far the best therapist she had ever had and felt she was more open, honest, and forthcoming than with any other therapist in the past and, he in turn, had been open, honest, and very direct with her. It seems that Thelma had fallen in love with Matthew, which is a very important factor as you will see later, she felt he also reciprocated those feelings. Matthew was lost in psychosis, at the time he became romantically involved with Thelma so therefore you cannot re-create a state of shared romantic love, (two people being deeply in love because it was never there in the first place). (Yalom 2013).
After a year had passed, Thelma and Matthew met accidentally and had coffee and a chat, where they broke with their professional therapist/client relationship and this led to a romantic interlude which lasted, in full, 27 days. For those 27 days Thelma lived in a state of pure love, joy and ecstasy and everything was good in her world. However, Matthew broke all contact with Thelma telling her the relationship wasn’t right and she fell into a deep state of depression. Despite numerous attempts to contact him where she continually left messages on his answerphone, after initially answering her a couple of times Matthew severed all contact. Thelma, at this point was showing signs of sustained aggression towards Matthew – she was not taking No for an answer. Thelma then became obsessed by the” Why” as she felt she needed to know this and Matthew would not contact her. In a cry for help and to gain his attention she attempted a drug overdose which was successfully scuppered by her husband Harry. There is another story around her husband also which I will mention later. Now enter the therapist Irvin Yalom and so the story begins. It is important to remember Thelma was in crisis when she met Yalom.
I’m going to put forward an argument from the view point of both the client “Thelma” and the therapist “Yalom” that the therapeutic process and therapeutic alliance may or may not have worked. You, the reader can make up your own mind.
The therapeutic process for a client usually means meeting with a therapist to resolve problematic behaviours, beliefs, feelings, relationship issues and)/or somatic responses (sensations in the body). (Cully and Bond 2004).
The therapeutic alliance is essentially the professional relationship between the client and the therapist where the client will discover within himself/herself the capacity to use that relationship for growth and change and personal development will occur (Rogers 1967). There are several characteristics which are a sign of healthy relationship either professional or personal:
(g) Healthy conflict
(h) Healthy attachment
Let us start with “Yes” the therapy did work for Thelma. It must be remembered that Thelma was in crises when she first met Yalom and had already attempted suicide once and was still suicidal when she presented herself for therapy with Yalom. She bought into the idea of six months of therapy with Yalom and one has to remember Thelma is the most important person in this story. The fact that she turned up for her therapy sessions every week tells us she was having a need met. The suicidal thoughts seemed to have lessened during the length of time she was in therapy and again this is positive.
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It also seemed, as you progressed in the story, that Thelma wanted the attention of a man. She was married to Harry and their marriage seemed dysfunctional to the reader. However, we do not have the right to judge Thelma on this fact. Reading this story brought up judgemental thoughts in me and I realised that as the reader, I was judging Thelma’s marriage and her relationship with her husband. Was this because my own marriage failed over 11 years ago? It might seem dysfunctional but maybe it worked perfectly well for Thelma and Harry. We see in the story where Thelma divulges in some of her therapy sessions with Yalom that her husband Harry worked away from home a lot and they didn’t seem particularly close. However, when Thelma decided to end her therapy sessions with Yalom which would have been a huge step for her, her husband accompanied her to one of the last sessions and was happy she was ending therapy as he felt she was getting worse. “Give me back my wife, Doctor, the old Thelma – just the way she used to be” (Yalom 2013). Harry, it seems, preferred Thelma in a depressed state but was that because he was not present emotionally in the marriage or physically as he travelled a lot? There seemed to be no lack of love or attachment between Harry and Thelma and they both had expectations of each other. Did Harry also embrace illusion like Thelma? Whatever way you look at these facts, Thelma and Harry’s relationship filled a need in each other that neither of the were willing to give up. This idea brought up feelings of frustration in me personally because I couldn’t see any real support for each other between Thelma and Harry i.e. being there for each other at every turn. I felt this related back to my marriage break up 11 years ago. As the reader you should not judge Thelma and Harry on their relationship and certainly not as the Therapist.
Thelma did divulge the issue of Matthew to Yalom but yet at times Thelma was disclosing plenty of information but he felt they were not making contact. “We might as well have been in separate rooms” (Yalom 2013). Therapists are not there to “fix” a client or “rescue” them but rather to empower them. Therapy gives the client an opportunity to create something new in terms of relationship but, as well, it highlights the compulsion to repeat patterns which have occurred in the past. The existential approach is unlike most therapies as it is not based on technique but rather the therapist employs philosophical views about the essential nature of human existence. (Corey, 2008). I believe this is the style Yalom used with Thelma and she was talking about her experiences.
Now for the argument that the therapeutic process and therapeutic alliance did not work.
When Yalom first met Thelma, he disregarded 20 years of experience/evidence at the outset that Thelma was a poor candidate for psychotherapy. He may have ignored his “hunch” not to treat Thelma because she did present to him in crises and he wanted to help her as she was so vulnerable. It’s important to note that all clients are vulnerable when they embark on therapy. This hunch Yalom had does seem like a negative at the onset.
Yalom striped away defences with Thelma without building anything to replace them (Yalom 2013). He showed Thelma that her obsession was not real and it was stopping her from being “present” in her life right now. Thelma while in therapy with Yalom was defending against reality – reality, is seemed, felt very cold and uncomfortable without the obsession. Yalom perhaps, on some level, “felt honoured” that Thelma had chosen him to talk about a major issue in her life which she had not shared with other therapists in 8 years of counselling. For Thelma not to have divulged the issue in counselling for 8 years, this takes a special type of person i.e. someone who tolerates considerable deceitfulness, someone who embraces intimacy in fantasy but may avoid it in life. Was Yalom fulfilling his role? It seemed that he was not and got quite frustrated with Thelma at times. This would suggest that the therapeutic alliance was not working that well. She behaved in a very primitive way by leaving all the messages for Matthew (sustained aggression) – she was forcing her way in – yet with Yalom and Harry, she refused to connect or engage, these two things sit in contrast with each other yet Yalom did not explore this further- why? Something was awakened in Thelma in this rage but we don’t find out what? This it seems leads to the breakdown of the therapeutic alliance and process.
Yet while Thelma was in therapy, as Yalom stated at times, Thelma’s “love” for Matthew was, in reality, something else, perhaps an escape, and a shield against isolation. While in the 27 days of Thelma and Matthew’s relationship they only had sexual intercourse once and this didn’t seem important to Thelma. The obsession with the love affair was stronger than other feelings Thelma had it seems. Replaying an obsession over and over makes you “absent” i.e. missing out on what’s happening in front of your eyes for the fantasy in your head. Thelma was very manipulative and she divulged information to Yalom to let him know she was in control (or felt she was) but she also withheld a lot of information which was important e.g. It wasn’t until after the three-way meeting Yalom discovered that Matthew was vulnerable when Thelma met him and also there was an age difference. Thelma left Yalom “holding” a lot during the end sessions of the therapy especially. While she had attended the different therapists over the eight years, not mentioning Matthew, she had left messages for Matthew to let him know she was talking to other therapists. One can imagine that Matthew would have thought that he was the topic of some of those therapeutic sessions and what he had done, getting involved with Thelma was ethically wrong. Thelma could have been trying to punish Matthew, yet she told Yalom all that mattered to her was that Matthew would think well of her. There seems to be incongruence on the part of Thelma that Yalom didn’t pick up on. Why did Thelma elevate Matthew and give him so much power? Rogers’s theory assumes that clients can understand what is causing them unhappiness in their lives. He also believed that that clients have the capacity for self-direction and constructive change in their personal lives. (Corey 2008). It seems in Thelma’s case, she may not have understood what was making her unhappy. Thelma had a lot of psychological pressure, e.g. she was so upset about Matthew not staying in touch that she disconnected from how she was really feeling. It seems that Thelma felt the euphoria she felt with Matthew for the twenty-seven days, stopped the hurt she was feeling and that which was pulling her down.
Yalom felt that Thelma’s fear of aging and death fuelled her obsession with Matthew. He was hoping to build a relationship/alliance with her to reduce the obsession with Matthew. However, Thelma distanced herself from personal questions and when Yalom broached the subject of age, she immediately threw the question back at him “do you like working with older patients?” Thelma had trouble expressing herself and she admitted that only twice she felt” herself” i.e. when she danced and when she was with Matthew. Perhaps Yalom could have challenged this statement? Yalom found it hard to form an alliance with Thelma because she found it difficult to be intimate or close to anyone e.g. (a) she can’t be intimate with Harry because she can’t share her thoughts about Matthew with him, (b) she can’t get close to her friends in case she hurts them when she commits suicide and she can’t with Yalom cause a therapist hurt her 8 years ago. Yalom himself felt there was no strong therapeutic alliance formed by month 5 of therapy.
Yalom’s idea to have a three-way meeting with Thelma, Matthew and himself produced negative vibes for Thelma and she felt an “amputation” had taken place (Yalom 2013). Up until that meeting, she felt there was a chance, however small, that she would get back together with Matthew. From listening to Matthew’s story and comparing it to Thelma’s, Yalom’s understanding was that their experiences were very different. Thelma’s anger towards Matthew after the meeting was a sign that the old defences were no longer viable, she was in a fluid state. She felt her losses were too great. She lost (a) hope for the future, i.e. her small chance of getting back with Matthew, (b) she lost the best 27 days of her life (Yalom had shown her those days weren’t real) (c) she had lost the sustaining memory of her life’s highest point so far and (d) she had lost eight long years of sacrifice – she had been protecting an illusion i.e. Matthew’s love for her. Were there childhood issues of loss – should this have been explored by Yalom?
Thelma it seems punished Matthew by attempting to commit suicide and she punished Yalom by ending therapy. At times you feel Yalom’s despair because Thelma’s husband wants his wife back the way she was before she started therapy with Yalom. At the point when Thelma recognised her obsession for what it was, it seemed grief started to appear for her but at the same time this led to her despair that therapy was a waste of time. As Yalom stated in “If Rape were Legal” – it is better not to undermine defences unless they are making more problems than solutions and unless one has something better to offer in its place. (Yalom 2003).
The Research Report Yalom mentioned at the end of therapy with Thelma paints a positive picture where it depicts Thelma as being “improved significantly”. It states she is less depressed and no longer seen as a suicide risk. Her self-esteem has improved and also her anxiety, hypochondriacal tendencies and her tendency for obsession and psychotic behaviour. It also states that Thelma was very secretive about the therapeutic process. It could be said that Thelma is well capable of duping the Research Group. That leads the reader to wonder was it the therapeutic process/alliance that improved Thelma’s state of mind or was it the fact that she was meeting Matthew once monthly for a coffee and a chat, after she finished therapy i.e. just two people having coffee and chatting, no other agenda. Is this all she wanted and possibly used Yalom to facilitate the three-way meeting with Matthew so she could perhaps arrange these regular meetings at a different time? Regardless of what the Research Report stated at the end of the 6 months therapy sessions, Thelma it seemed still had trouble connecting to “reality”, but how can we the reader, judge what her reality is? She was still with her husband Harry as far as the reader knows, but yet yearning for a relationship with Matthew, but this marriage filled a need in both Thelma and Harry as they stayed together. People deserve understanding and acceptance because they are human (Cully and Bond 2004). When, during the therapy process, Thelma became aware of her obsession with Matthew being a problem and the illusion was striped away, she did feel anger but then used that as an excuse to end therapy as her losses were too great. She did commit to the therapy process for the six months which also indicates to the reader that the therapeutic process was working for Thelma. In the Beginning Stage of therapy, we saw a working relationship being established, problems defined and clarified, an assessment made by Yalom (i.e. willing to work with Thelma) and a contract was negotiated. In the Middle Stage we saw Thelma being assisted in reassessing her problems and concerns, which helped to shift the process from problems to solutions and the End Stage typically in concerned with planning for and taking effective action and focuses on ending the Counselling relationship. (Cully and Bond 2004). Thelma ended the therapy herself.
Yalom himself felt guilty at the end of the treatment and he felt his belief that “he could treat anyone” let him down and embarrassed himself professionally. However, Thelma did not throw any blame on Yalom and remained secretive with the Research Group about the details of her therapy which certainly did not point the finger of failure at Yalom as a therapist, which leads the reader to believe that Thelma did not think the therapeutic process or therapeutic alliance was a failure. Thelma is a very interesting case though and there are several factors in the story which leaves you wondering if Thelma was just a person vulnerable to being fixated (she cannot accept the loss of Matthew) but this may not be a conscious thing. Her age is also important as she’s thinking of “the meaning of her life” and what’s it all about. As the reader I wanted to “fix” Thelma and this made me realise that it also brought out an exaggerated sense of responsibility in me – this is possibly from bringing up my kids as a single parent. Thelma was having a need met by attending therapy and at the end of the six months, there was no mention of suicide in the Research Report, she was happily meeting Matthew for coffee every month or so and her psychological issues and depression had improved. It certainly seems like the therapeutic process and therapeutic alliance did work.
- Gerald Corey, 2008 Theory and Practice of Counselling and Psychotherapy, 5th Edition, U.S.A., Brooks/Cole Publishing Company.
- Sue Cully and Tim Bond 2004, Integrative Counselling Skills in Action, London, Sage Publications Ltd.
- Carl R. Rogers, 1967, On Becoming a Person, a therapist’s view of psychotherapy, U.K., Constable & Robinson Ltd.
- Irvin D. Yalom, 2013, Love’s Executioner and Other Tales of Psychotherapy, London, Penguin Group.
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