Becoming Myself: A Psychiatrist's Memoir

by Irvin D. Yalom

  Marilyn’s interview with Norman Torrey, the formidable chairman of the Columbia French Department, remains part of our family lore. Professor Torrey glanced at her eight-month pregnant abdomen with wonderment: he had probably never before seen a pregnant applicant. And then he was even more astonished to learn that she also had a one-year-old child. In an apologetic tone, Professor Torrey pointed out that financial aid required the student to teach two courses and take four, suggesting the interview was at an end. But Marilyn instantly replied, “I can do that.”

  A couple of weeks later, his letter of acceptance arrived: “Materfamilias, We have a place for you.” Marilyn found some childcare and plunged into the hardest year of her life. I had the compensatory blessing of comradeship with my fellow interns, but Marilyn was entirely on her own. She took care of our two children, with some help from a housekeeper and almost no help from her husband, who was away every other night and every other weekend. Thereafter, Marilyn always considered this year the hardest one of her life.

  CHAPTER FIFTEEN

  THE JOHNS HOPKINS YEARS

  I’m on my Lambretta, Marilyn is sitting behind, her arms encircling me. I feel the wind in my face as I watch the speedometer. Sixty-five, sixty-eight, seventy-one. I am going to reach eighty. I can do it. Eight O. I know I can do it. Nothing else matters. The handlebars vibrate slightly, then more and more, and I begin to lose control. Marilyn is crying, “Stop, stop, Irv, slow down, I’m scared. Please stop. Please please.” She screams and pounds on my back.

  I wake up. My heart is racing. I sit up in bed and feel for my pulse—over a hundred. That damn dream! I know that dream too well—I’ve dreamt it many times. I know exactly what prompted the dream now. Last night in bed I was reading a passage in On the Move, a memoir by Oliver Sacks, in which he describes being a member of the “ton club,” a group of youthful motorcycle riders who had driven their motorcycles above one hundred miles per hour.

  The dream is not only a dream: it is a memory of a real event that I’ve replayed countless times, both as a daydream and as a nocturnal dream. I know that dream and I hate it! The real event took place after the end of my internship, when I had a week of vacation before starting my three-year psychiatric residency at Johns Hopkins Hospital in Baltimore. Marilyn’s mother had agreed to care for our two children for a long weekend, and we took off on the Lambretta for the Eastern Shore of Maryland; it was on this trip that the event accurately depicted in the dream occurred. I didn’t think too much of it at the time—perhaps I was actually amused by Marilyn’s panic. The road was empty and I just wanted to open the throttle. Like a teenager, I was exhilarated by speed and felt absolutely invulnerable. It was only much later that I realized the extent of my thoughtlessness and stupidity. How could I possibly have involved my wife in this stunt with two young children at home? Aiming for eighty miles per hour, unprotected, bareheaded—those were the days before helmets! I hate thinking about it and even now hate writing about it. I shuddered recently as Eve, my daughter, a physician, described visiting a ward full of paralyzed young men, all with broken necks from accidents on motorcycles or surfboards. They, too, must have once felt invulnerable.

  We didn’t crash. Eventually, I returned to sanity and slowed down, and for the rest of the time we rode safely through the charming little settlements on Maryland’s Eastern Shore. On the way home, when I went for a ride by myself while Marilyn napped after lunch, I hit an oil slick and took a nasty fall, scraping my knee badly. We stopped at an emergency room. The physician cleaned out the wound and gave me a tetanus antitoxin shot, and we returned to Baltimore without further mishap. Two days later, just as I was preparing to report for my first day of residency, I broke out in a rash, which soon developed into massive hives. I had had an allergic reaction to the horse serum in the tetanus shot and was immediately hospitalized at Hopkins for fear that my breathing would become compromised and a tracheotomy required. I was treated with steroids, which proved immediately effective, but I felt fine the next day and was taken off the steroids and discharged. I started my residency the next morning. In those early days of steroid use, physicians did not appreciate the need to taper steroids slowly, however, and I had an acute withdrawal syndrome with depression, along with such intractable anxiety and insomnia for the next couple of days that I had to load up with Thorazine and barbiturates to get to sleep. Fortunately, it was to be my only personal encounter with depression.

  On my third day at Hopkins, we first-year residents had our initial meeting with the very formidable John Whitehorn, the chairman of psychiatry, who would become a major figure in my life. A stern, dignified man who rarely smiled, John Whitehorn had a bald pate ringed by short gray hair. He wore steel-rimmed spectacles and intimidated almost everyone. Later I was to learn that even chiefs of other departments treated him with deference and never referred to him by first name. I did my best to attend to his words, but was so exhausted by my lack of sleep and the sleeping drugs in my body that I could barely move in the morning, and during Dr. Whitehorn’s greeting to us I fell asleep in my chair. (Many decades later, Saul Spiro, a fellow resident, and I reminisced about our time together at Hopkins, and he told me he respected me enormously for having had the chutzpah to fall asleep at our first meeting with the boss!)

  Aside from some low-grade anxiety and mild depression, I recovered from my allergic reaction in about two weeks, but I was so unnerved by the experience that I decided to seek therapy. I asked the chief resident, Stanley Greben, for advice. In that era it was commonplace, even de rigueur, for psychiatric residents to have a personal analysis, and Dr. Greben recommended that I see his own analyst, Olive Smith, an elderly senior training analyst in the Washington-Baltimore Psychoanalytic Institute, and one with royal lineage: she had been analyzed by Frieda Fromm-Reichman, who, in turn, had been analyzed by Sigmund Freud. I had a great deal of respect for my chief resident, but, before making such a huge decision, I decided to solicit Dr. Whitehorn’s opinion about my symptoms following steroid withdrawal and about starting analysis. It appeared to me that he listened with little interest, and then, when I mentioned starting analysis, he slowly shook his head and commented simply, “I believe you will find that a little phenobarbital might be more effective.” Remember that these were the pre-Valium days, although a new tranquilizing drug called Equanil (meprobamate) was shortly to be introduced.

  Later I learned that other faculty members were highly amused to discover I had the audacity (or stupidity) to pose this question to Dr. Whitehorn, who was known to be extremely skeptical of psychoanalysis. He took an eclectic position, following the psychobiological approach of Adolf Meyer, the long-term previous chair of the Johns Hopkins Psychiatry Department, an empiricist who focused on the patient’s psychological, social, and biological makeup. Thereafter, I never spoke of my psychoanalytic experience to Dr. Whitehorn and he never asked.

  The Hopkins Psychiatry Department had a split personality: Whitehorn’s point of view prevailed in the four-story psychiatric hospital and outpatient department, while a strong orthodox psychoanalytic faction ran the consultation service. I generally dwelled in Whitehorn territory, but I also attended analytic conferences in the consultation department, especially the case conferences led by Lewis Hill and Otto Will, both astute analysts, and also world-class storytellers. I listened enthralled to their clinical case presentations. They were wise, flexible, and thoroughly engaged with their patients. I marveled at the way they described an interaction with a patient: so caring, so concerned, and so generous. They were among my first models for the practice (and narration) of psychotherapy.

  But most analysts worked very differently. Olive Smith, whom I was seeing four times a week for analysis, worked in an orthodox Freudian manner: she was a blank screen, revealing nothing of herself through words or facial expression. I rode from the hospital to her office in downtown Baltimore only ten minutes away on my Lambretta every day at 11 a.m. Often I could
not help taking a quick look at my mail just before leaving, which resulted in my arriving a minute or two late—evidence of resistance to the analysis that we often, and fruitlessly, discussed.

  EN ROUTE TO ANALYST, BALTIMORE, 1958.

  Olive Smith’s office was in a suite with four other analysts, all of whom had been analyzed by her. At that time I considered her elderly. She was at least seventy, white-haired, somewhat bent over, and unmarried. Once or twice I saw her in the hospital going to a consultation or an analytic meeting and there she appeared younger and spryer. I lay on the couch, with her chair positioned at the end, near my head, and I had to stretch my neck and look back to see her, sometimes to check that she was still awake. I was asked to free-associate and her responses were entirely limited to interpretations, very few of them helpful. Her occasional lapses from neutrality were the most important part of the treatment. Obviously many found her helpful—including all the analysands in her suite of offices and my chief resident. I have never understood why it worked for them and not for me. In retrospect, I think she was the wrong therapist for me—I simply needed someone more interactive. Many times I have had the unkind thought that the main thing I learned in my analysis was how not to do psychotherapy.

  Her fee was twenty-five dollars per session. One hundred a week. Five thousand a year. Twice my annual salary as a resident. I paid for my analysis by doing physical exams, at ten dollars each, for the Sun Life Insurance Company of Canada every Saturday, zipping around the back streets of Baltimore on my Lambretta, wearing my hospital whites.

  As soon as I decided to take my residency at Johns Hopkins Hospital, Marilyn applied to the Johns Hopkins University PhD program in comparative literature. She was accepted and worked under the guidance of René Girard, one of the most eminent French academics of his time. She chose to write her PhD thesis on the myth of the trial in the works of Franz Kafka and Albert Camus and, with her encouragement, I began to read Kafka and Camus as well, before moving on to Jean-Paul Sartre, Maurice Merleau-Ponty, and other existential writers. For the first time, my work and Marilyn’s began to converge. I fell in love with Kafka, whose Metamorphosis stunned me as no piece of literature had ever done. And I was also jolted by Camus’s The Stranger and Sartre’s Nausea. Through narrative, these writers had plumbed depths of existence in a way that psychiatric writing never seemed to have achieved.

  Our family thrived during our three years at Hopkins. Our oldest, Eve, attended nursery school right in the courtyard of the square compound where we lived with the other house staff. Reid, a lively, playful child, had no trouble adjusting to the care of a housekeeper when Marilyn was pursuing her PhD studies at the Hopkins campus fifteen minutes away. During our final year in Baltimore, Victor, our third child, was born in the Johns Hopkins Hospital, which was just one block up the hill from our home. We were fortunate to have healthy, lovable children, and I looked forward to seeing and playing with them every evening and on weekends. I never felt that my family life was an impediment to my professional life, though I am sure this was not the same for Marilyn.

  I loved my three years of residency. From the very beginning, each resident had the clinical responsibility of running an inpatient ward as well as meeting with a roster of outpatients. The Hopkins surroundings and staff had a genteel, southern quality that now feels like a thing of the past. The psychiatry building, the Phipps Clinic, containing six inpatient wards and an outpatient department, had opened in 1912, when it was overseen by Adolf Meyer, who was succeeded by John Whitehorn in 1940. The four-story red brick building was sturdy and dignified; the elevator operator, a fixture for four decades, was courteous and friendly. And the nursing staff, young and old alike, sprang to their feet when any physician entered the nurses’ station—ah, those were the days!

  Though hundreds of patients have passed from my memory, I remember many of my first patients at Hopkins with eerie clarity. There was Sarah B., the wife of a Texas oil tycoon, who had been in the hospital for several months with catatonic schizophrenia. She was mute and often frozen into one position for hours at a time. My work with her was wholly intuitive: supervisors were of little help, because no one knew how to treat such patients—they were considered beyond reach.

  I took care to meet with her every day for not less than fifteen minutes in my small office in the long hallway just outside the ward. She had been entirely mute for months, and since she never responded by word or gesture to any question, I did all the talking. I told her about my day, the newspaper headlines, my thoughts about the group meetings on the ward, issues I was exploring in my own analysis, and the books I was reading. Sometimes her lips moved but no words were uttered; her facial expression never changed, and her large, plaintive blue eyes remained fixed upon my face. And then, one day, as I was babbling along about the weather, she suddenly stood up, walked over to me, and kissed me hard on the lips. I was flabbergasted, didn’t know what to say, but kept my composure, and, after musing aloud about possible reasons for the kiss, I escorted her back to the ward and tore over to my supervisor’s office to discuss the incident. The one part I didn’t acknowledge to my supervisor was that I had rather enjoyed the kiss—she was an attractive woman and her kiss had aroused me, but I never for a moment forgot that my role was to heal her. After that, things continued as before for weeks longer until I decided to try a course of treatment with Pacatal, a major new tranquilizer (now long discarded) that had just come on the market. To everyone’s great surprise, Sarah was a changed person within a week, talking often and generally quite coherently. In my office we engaged in long discussions about the stresses in her life preceding her illness, and at some point I commented on my feelings about meeting with her silently for so long and my many doubts that I had offered her anything in those sessions. She replied immediately, “Oh no, Dr. Yalom. You are wrong. Don’t feel that way. All through that time you were my bread and butter.”

  I was her bread and butter. I have never forgotten that utterance and that moment. It returns to my mind often when I’m with a patient, clueless about what is going on, unable to make helpful or coherent remarks. It is then that I think of dear Sarah B. and remind myself that a therapist’s presence, inquiries, attention may be nourishing in ways we cannot imagine.

  I began attending weekly seminars with Jerome Frank, MD, PhD, the other Hopkins full professor, who, like Dr. Whitehorn, was an empiricist and persuaded only by logic and evidence. He taught me two important things: the basics of research methodology, and the fundamentals of group therapy. At that time, group therapy was in its infancy, and Dr. Frank had written one of the few good books on the topic. Every week, the residents—our eight heads crammed together—observed his outpatient therapy group through one of the first two-way observational mirrors to be used in this context, a hole in the wall that was only about one square foot large. After the group meeting, we met with Dr. Frank for a discussion of the session. I found group observation to be such a valuable didactic format that, years later, I would use it in my own group therapy teaching.

  I continued to observe the group every week long after the other residents had finished the course. By the end of the year, Dr. Frank had asked me to lead the group when he was away. From the very beginning I loved leading groups: it seemed obvious that the therapy group offered a rich opportunity for members to give and receive feedback about their social selves. It seemed to me a unique, rich setting for growth, allowing members to explore and express parts of their interpersonal selves and to have their behavior reflected back to them by their peers. Where else could individuals offer and obtain such honest and constructive feedback from a set of trusted equals? The outpatient therapy group had only a few basic rules: in addition to total confidentiality, the members were committed to show up for the next meeting, to keep communicating openly, and not to meet with each other outside the group. I recall envying the patients and wishing I could have participated as a member in such a group.


  Unlike Dr. Whitehorn, Dr. Frank was warm and approachable—by the end of my first year, he suggested I call him “Jerry.” He was a great teacher and a fine man, modeling integrity, clinical competence, and the necessity for research inquiry. We stayed in touch long after I left Hopkins, and we met whenever he visited California. On one memorable occasion, our families spent a week together in Jamaica. In old age, he developed severe memory problems, and I visited him in a residential center whenever I was on the East Coast. The last time I saw him, he told me that he spent his days looking at interesting things outside his window, and that each morning he awoke with a clean slate. He rubbed his hand over his forehead and said, “Whoosh—all the memories of the preceding day are wiped out. Entirely gone.” Then he smiled, looked up at me, and gave his student one final gift: “You know, Irv,” he said, reassuringly, “it’s not so bad. It’s not so bad.” What a sweet, lovely man. I smile whenever I think of him. Decades later, I felt greatly honored by being invited to give the first Jerome Frank Psychotherapy Lecture at Johns Hopkins.

  Jerry Frank’s group therapy method fit neatly into the interpersonal approach then au courant in American psychodynamic theory. The interpersonal (or “Neo-Freudian”) approach was a modification of the older, orthodox Freudian position; it stressed the importance of interpersonal relations in the individual’s development throughout the life cycle, whereas the older approach placed most of its emphasis on the very early years of life. This approach was American in origin and heavily based on the work of psychiatrist Harry Stack Sullivan, as well as on European theorists who had immigrated to the United States, especially Karen Horney and Erich Fromm. I read a great deal of the interpersonal theoretical literature and found it eminently sensible. Karen Horney’s Neurosis and Human Growth was by far the most heavily underlined book of my residency days. Though Sullivan had a great deal to teach, he was, unfortunately, such an abysmal writer that his ideas never had the impact they deserved. In general, though, his work helped me understand that most of our patients fall into despair because of their inability to establish and maintain nurturing interpersonal relationships. And, to my mind, it followed that group therapy provided the ideal arena in which to explore and to change maladaptive modes of relating to others. I was fascinated by the group process and, throughout my residency, led many groups in both inpatient and outpatient settings.