The opening phase of dynamic psychotherapy helps the therapist to understand why the patient is seeking treatment; what kind of triggers to current problems are present; and house troubled the patient is in terms of both physical and psychological health (text p. 41). Yalom (1989) allows for several sessions of introductory therapy, also in keeping with the psychodynamic model. At this introductory phase, the therapist gets an idea of what treatment options to present and how to proceed. Yalom (1989) also determines the frequency of the treatment in the introductory phase (text p. 41). The core way that the relationship between Yalom (1989) and Carlos exemplifies psychodynamic therapy is in regards to the transference neurosis, which intensifies in therapy (text p. 53). However, transference is worked through as a core element of the therapeutic process. In the case with Carlos, neurotic transference is exemplified most clearly in the way Carlos goads the therapist related to his sexual desires. When he speaks about rape, he eggs on Yalom (1989) as if to get Yalom (1989) to admit that he also wants to rape women. As Yalom (1989) puts it, there is likely "some Oedipal competition going on between the two of us which was making communication more difficult," (70). Yalom (1989) refers to the fact that Carlos's graphic terms of what he would do, and his goading question about wouldn't he rape if he could, are signs Carlos projects rivalry onto him. This rivalry transforms itself during the therapeutic process into a relationship of mutual respect and healing.
Yalom (1989)'s willingness to explore Carlos's unconscious reveals the techniques rooted in psychoanalysis and psychodynamic therapy, both of which honor the role that the unconscious mind can play in the development of neuroses and coping mechanisms. The therapist repeatedly returns to Carlos's dreams, notably the dream of the green Honda. Similarly, Yalom (1989) refers to Carlos's fear of death and compensation thereof via belief in reincarcation. The green Honda dream allows a convergence between the role of the subconscious and the fear of death.
However, Yalom (1989) does not confine himself to a singular therapeutic model. Especially with Carlos, the patient's complex issues require a multifaceted approach. In addition to the dynamic psychoanalytic model, Yalom (1989) relies on Adlerian, Rogerian, and Ellis's Rational Emotive Behavior Therapy REBT. With regards to the latter, REBT, Yalom (1989) does rely heavily on its techniques. As the Corsini & Wedding (n.d.) textbook points out, REBT therapy "holds that people are biologically and culturally predisposed to choose, create, and enjoy, but that they are also strongly predisposed to overconform…hate, and foolishly block their enjoying," (p. 231). Throughout Yalom (1989)'s analysis and narrative, it is clear the therapist feels that Carlos has tremendous potential to "choose, create, and enjoy," which is why he engages Carlos in sessions with "ambitious" treatment goals. Moreover, this is the area in which Yalom (1989)'s therapy combines the REBT principles with those of Rogerian therapy, as Rogerian therapy advocates unconditional positive regard. Yalom (1989) exhibits nothing but unconditional positive regard for a patient that even the therapist admits would be hard to pawn off on another therapist due to his outburst in group.
Carlos is described as "isolated," especially from his family, and presents himself as being unapologetically misogynistic (62). His "obvious depression" serves as an opportunity for psychoanalysis and healing. However, there is nothing "endearing" about Carlos, raising issues of countertransference (62). He is cynical and uses humor to divert attention from his presenting condition. Carlos exhibits "socially objectionable behavior" in group therapy and is especially demeaning and practically abusive toward women (65). In particular, Carlos expresses pleasure when visualizing women getting raped. "If rape were legal, I'd do it -- once in a while," Carlos states, (67). Multiple therapeutic interventions offer the key to approaching Carlos's problems, showing that it is possible to engage in "ambitious" therapy with someone at the end of life.
After extensive radiation and chemotherapy, Carlos's sex life was "confined entirely to masturbating while watching rented sado-masochistic videotapes," (63). Nonsexual human intimacy seemed "alien" to Carlos (63). He had been using creative visualization and meditation as part of his cancer therapies. Carlos exhibits a sense of humor, used almost as a defense mechanism. Yalom (1989) notes that "many of his noxious traits and beliefs were soft and open to being modified," (64). Because Carlos is an end-of-life case, treatment is not viewed with long-term goals in the way that it might be with someone who was in perfect health. Yalom (1989) persists, partly because of his unconditional positive regard, but also because he sees potential in Carlos for embracing his mortality, making peace with himself and with his family, and facing death with dignity. In so doing, Yalom (1989) uses REBT to show Carlos where his most irrational thoughts and behaviors stem from, and gets him to unravel the problem from its very roots. The roots also entail delving into the patient's unconscious via dreams.
Carlos responds well to therapy because he enjoys the process. He discusses his dreams, revealing the role of the unconscious in psychotherapy in keeping with the principles of psychoanalysis and psychodynamic therapies. Likewise, Carlos loves talking about women and sex. Yalom (1989) postulates that Carlos's obsession with women helps him to divert attention from his cancer. Whether he can catch the eye of a lady, viewed as a conquest, helps Carlos to feel more in control of his life. Yalom (1989) posits that Carlos has some "scrap of self-consciousness or shame" that presents opportunities for therapeutic intervention. Interestingly, Yalom (1989) notes that when Carlos's cancer gets worse and he is forced to face mortality, he becomes less crude and "more thoughtful, compassionate, wiser," versus when his cancer is in remission and he grew "noticeably more coarse and shallow," (68-69).
One of the ways Yalom (1989) relies on REBT is by assisting Carlos to the breakthrough related his irrational feeling that he could have married a woman he met at church. Carlos has abused himself physically and verbally, berating himself for not walking a lady to her car. Carlos irrationally believes that had he walked Ruth to her car, he would have had a quantifiable chance of marrying her. Initially Carlos cannot see the problem with his reasoning, so Yalom (1989) must make an analogy where it hurts the most: by referring both to Carlos's children and to his fear of death. Likewise, Carlos's feelings about the "losers" in the group and how they are nothing like him presents an irrational cognitive process that is resolved in therapy using techniques of REBT (70). Yalom (1989) does to convince Carlos that his condition of cancer might mean that he is facing death immanently, but that it does not necessarily mean that Carlos cannot change his lifestyle to become a happier, better person. The metaphor of the green Honda becomes a motivating factor for Carlos to change his life. The green Honda represents everything that Carlos hates: it is a symbol for his body and his uncontrollable life. When he sees the car for what it is, as a symbol of his not living his life they way he should be, Carlos is able to rationally deal with the style of life issues and the defensive processes that are impeding his ability to form healthy and beneficial relationships.
Carlos ultimately achieves goals that he did not know he had before therapy: such as creating methods by which other people can bond together to overcome their psychological issues. Using REBT, Yalom (1989) points out the ways that Carlos has been irrationally demanding regarding especially Ruth at the church social, and how he berates himself with "head pounding and self-recrimination" part of the irrational belief system (73). Moreover, Yalom (1989) is aware of Carlos's "denial" about his…