For decades, Irvin Yalom has been one of the most prominent authors speaking about the nuances of psychotherapy. Like many of my colleagues, I first became acquainted with Yalom’s work in graduate school. I was assigned to read several of his books to “get a feel” for what it would ultimately look like to be a therapist. Since then, I have read each of his books- I continue to reread and reference them as I continue growing in this work.
At his core, Yalom is most known for embodying the ephemeral notion of being a human-first clinician. His writing transcends the logistics of conducting treatment- while showcasing his work, he also candidly shares his own experiences, struggles, and emotional states.
For the time, this approach was quite groundbreaking. Until Yalom, most psychologists eloquently spoke about their brilliant work without a hint of struggle or uncertainty. Their treatment success stories often resulted in new therapists feeling two ways: inspired about the field AND discouraged when their own work didn’t seem to hold up to those impossible standards.
Love’s Executioner contains ten vignettes exploring key themes of what it means to be human- as both a patient and therapist). Here are some of the main takeaways from this book:
Chapter 1: Love’s Executioner
“I do not like to work with patients who are in love. Perhaps it is because of envy—I, too, crave enchantment. Perhaps it is because love and psychotherapy are fundamentally incompatible. The good therapist fights darkness and seeks illumination, while romantic love is sustained by mystery and crumbles upon inspection. I hate to be love’s executioner.”
This quote, which begins the book, aptly captures one of the rawest truths we therapists experience in our work. We sit with people experiencing love and joy and romantic idealization, but we also sit with them in grief and pain and bitter truth. Sometimes these dual realities exist simultaneously.
In this chapter, Yalom shares about his treatment with Thelma, a patient who came to therapy after engaging in a sexual relationship with her former therapist. He spends the majority of the time trying to deconstruct Thelma’s self-proclaimed obsession with this man. He also describes a session where he met with both Thelma and the former therapist together to clarify what happened during the whirlwind affair.
Yalom dives into the existential concept of how therapists sometimes become executioners, in the sense that we must untangle the pain underlying disillusionment or enchantment. In many ways, this speaks to the existential nuances clinicians face throughout treatment. We want to help others, but sometimes “help” comes in the form of painful confrontations.
Chapter 2: “If Rape Were Legal…”
“In general, it’s best not to undermine a defense unless it is creating more problems than solutions, and unless one has something better to offer in its stead.”
In this vignette, Yalom speaks about his work with Carlos, a patient with advanced cancer who brazenly commented about his aim in life being “to screw as many different women as he could.”
Yalom describes being his main human connection and feeling mixed uncertainty about how to best support him. When Carlos’s cancer treatment was more acute, he became more compassionate and thoughtful. But when things felt more “stable,” Yalom regarded him as more shallow and coarse.
In time, through their work together, Carlos learns to harness his terminal illness into a deeper sense of compassion for himself and others. This leads him to become more generous- with all parts of himself- and Yalom can graciously reflect on the gift of what it means to find meaning at the very end of life.
Chapter 3: “The Wrong One Died”
“Is it a crime to keep on hoping? What mother wants to believe her child has to die?”
All therapists sit with grief, even if it’s not our designated specialty. Grief impacts all of our patients, and we can never quite predict when it might occur.
In his treatment with Penny, Yalom reflects on his first experience working with a patient grieving the loss of a child. He eloquently describes her pain, sharing how it eroded her marriage and consumed the majority of her time and well-being.
While grief work requires deep validation and witnessing, Yalom takes a bolder approach in helping Penny understand the role of her guilt and the potential harm it may be causing her. He emphasizes how she is punishing herself by refusing to let her daughter go.
This chapter sheds light on so many heavy topics: grief and its rippling effect on the entire family, shame and survivor’s guilt, and what it means to really sit with a patient in their raw pain in a short amount of time.
Chapter 4: Fat Lady
“I have always been repelled by fat women. I find them repulsive…how dare they impose that body on the rest of us?”
Yalom is a controversial author, and the Fat Lady chapter has been widely criticized for its sexist, fatphobic nature. In this vignette, Yalom explicitly describes his disgust toward his larger client, Betty, by emphasizing his discomfort with her physical appearance.
While Yalom is being honest about his own judgments, he continues to highlight his negative feelings and discomfort. This highlights a critical issue within the therapy profession- what should providers do when they can’t set their biases aside? Moreover, what active role should we all be playing in addressing our potential prejudices and projections?
Over the course of treatment, Betty lost significant weight, and Yalom acknowledged his ability to recognize her beauty. However, this doesn’t mean he changed his disposition on weight. Instead, it may reinforce that he only found her “worthy” after she changed her physical appearance.
In the book’s afterword, this is the one story Yalom indicates feeling regretful about writing. He states he would not have been so insensitive had he written the book today. However, this does not necessarily indicate a change in thoughts or a shift in countertransference.
Chapter 5: “I Never Thought It Would Happen to Me”
*“Those hours were hard for me. I had spent too many hours in my youth silently hating my mother’s tongue. I remember the games of imagination I played as a child trying to invent the existence of someone she did not hate.”*
In his work with Elva, Yalom depicts his discomfort with this patient’s rage. Countertransference is a persistent theme in this book- as it is in all of Yalom’s books- and this one truly captures the frustration or insecurity we can sometimes feel working with certain individuals.
Over time, Yalom grows to enjoy Elva. At a pivotal point in treatment, she gets robbed, and it deeply fractures her sense of safety. The main impact, however, was that the robbery made her aware of her husband’s death. This awareness becomes an integral part of therapy, and it speaks to key themes about how we support our patients in cultivating and accepting new insights.
Chapter 6: “Do Not Go Gentle”
“But there is timing and judgment. Never take away anything if you have nothing better to offer. Beware of stripping a patient who can’t bear the chill of reality.”
Yalom’s work with Dave alludes to familiar aches with long-lost love and sexual desire. Dave comes to treatment feeling burdened by old letters from a former lover. He is interested in Yalom holding these letters for him. Yalom agrees to store these letters under the agreement that Dave attends a therapy group and discloses the nature of their deal.
This speaks to the unorthodox approach Yalom takes with some of his patients. At his heart, he embraces experiential work, often blurring lines between “standard” ethics and attunement to what he believes a patient needs. This approach does not work well for everyone- and may not be advised for each therapist- but it certainly offers a unique angle for how we may intervene in our treatment.
Chapter 7: “Two Smiles”
“Marie was a forbidding presence and most people felt daunted and distanced by her beauty and hauteur. I, on the other hand, was strongly drawn toward her. I was moved by her, I wanted to comfort her, I imagined embracing her and feeling her body unfreeze in my arms.”
Yalom talks about his patient, Marie, with admiration and deep care. She initially came to care for support with bereavement and depression. Throughout the early stages of treatment, Yalom flounders between feeling optimistic about helping her and completely stuck with what to do.
In this chapter, Yalom dives into his own efforts in peer consultation. This is an important subject for all therapists- we cannot and should not work in isolation, and good consultation is one of the most important ways we can support our growth. Yalom normalizing this need offers important modeling for us all.
Chapter 8: Three Unopened Letters
“I ended the session by establishing a contract. I agreed to help in any way I could, to see him through the crisis, to visit him at home for as long as necessary. I asked, in return, that he agree not to make any irreversible decisions.”
Chapter 8 also highlights Yalom’s unorthodox work by describing a home visit he takes with his patient, Saul. This chapter overviews a rupture in therapy, and Yalom demonstrates his attempts to repair the mistake he made. He seeks to be vulnerable with his patient to better support his care.
However, this chapter is also controversial. As demonstrated in the above quote, these types of contracts can reinforce an unequal power differential and create undue pressure on patients. Sometimes they speak to a therapist’s desire to fix or change at a pace that may not be suited to the patient’s needs. It may work well for Yalom, but there’s no guarantee this intervention would work well (or even be feasible) for all clinicians.
Chapter 9: Therapeutic Monogamy
My first impulse was to get the hell away, far away–and not see her again. Use an excuse, any excuse: my time all filled, leaving the country for a few years, embarking on a full-time research career. But soon I heard my voice offering her another appointment.”
In his work with Marge, Yalom describes his own existential struggle about working with a patient in severe distress and his feeling some shame over choosing the “easy life” in working with “easy patients.”
This chapter overviews other salient themes that all therapists can identify with: the difficulty associated with working with chronic mental health issues (like severe depression), intense feelings of helplessness, and how simple questions can be groundbreaking for some patients. In this case, it was Yalom merely asking about what had helped in the past that set insight into motion for his patient.
Chapter 10: In Search of the Dreamer
“He cried in my office that day. He cried for all that he had missed, for all the years of deadness in his life. How sad it was, he said, that he had waited until now to try to come alive. For the first time I felt very close to Marvin. I clasped his shoulder as he sobbed.”
This final chapter encapsulates Yalom’s work with Marvin, a patient who presents as very “logical” but has a rich inner world that is showcased through his dreams. In treatment, Yalom must straddle both needs- attuning to Marvin’s desire for concrete and predictable goals along with validating the existential distress that often plagues him.
This, too, captures such an important part of therapy. We often must balance different needs and presenting concerns that patients experience. It can be hard to categorize the order of significance, and getting that hierarchy wrong sometimes comes with catastrophic consequences.
A Final Note
Like any psychotherapy book, it’s important to be mindful of the context and timing in which it was written. There are valid reasons why Yalom is so well-known and revered. Furthermore, Love’s Executioner unquestionably provides intriguing insights into this field.
However, some of the ideas are problematic and would be considered outdated or offensive if suggested today. Laws, ethics, and best practices certainly change as the years progress. Nevertheless, I recommend that all therapists read this book at least once during their career. It truly magnifies some of the raw and tender parts of the work we do.
