Becoming Myself: A Psychiatrist's Memoir

by Irvin D. Yalom

  As my first year progressed, I began feeling overwhelmed by all the data, all the various clinical conditions I encountered, the idiosyncratic approaches of my supervisors, and I longed for some comprehensive explanatory system. Psychoanalytic theory seemed the most likely option, and most psychiatric training programs at that time in the United States were analytically oriented. Though today’s chairmen of psychiatry are generally neuroscientists, in the 1950s most of them were psychoanalytically trained. Johns Hopkins, aside from the consultation service, was a leading exception.

  So I met dutifully with Olive Smith, four times weekly, read Freud’s writings, and attended the analytically oriented conferences in the consultation wing of the department, but as time went by I grew increasingly skeptical of the psychoanalytic approach. My personal analyst’s comments seemed irrelevant and off the mark, and I grew to feel that, though she wanted to be helpful, she was too constrained by the edict of neutrality to reveal to me any of her real self. Moreover, I was coming to believe that the emphasis on early life, and primal sexual and aggressive drives, was severely limiting.

  The biopsychological approach at that time had little to offer aside from such somatic therapies as insulin coma therapy and electroconvulsive therapy (ECT). Though I personally administered these many times and sometimes saw extraordinary recoveries, these treatments were disparate approaches discovered by accident. For example, clinicians have for centuries observed that convulsions caused by various conditions, such as fever or malaria, had a salutary effect on psychoses or depression. So they searched for methods of inducing hypoglycemic coma and seizures both by chemical (Metrazol) and electrical (ECT) means.

  Toward the end of my first year, a newly published book titled Existence by the psychologist Rollo May came to my attention. It consisted of two long, excellent essays by May and a number of translated chapters by European therapists and philosophers, such as Ludwig Binswanger, Erwin Straus, and Eugène Minkowski. This book changed my life. Though many of the chapters were written in deep-sounding language that seemed designed to obfuscate rather than to illuminate, May’s essays were exceptionally lucid. He laid out the basic tenets of existential thought and introduced me to the relevant insights of Søren Kierkegaard, Friedrich Nietzsche, and other existential thinkers. As I look at my 1958 copy of Rollo May’s Existence, I see notations of approval or disagreement on almost every page. The book suggested to me that there was a third way, an alternative to psychoanalytic thought and the biological model—a way that drew from the wisdom of philosophers and writers from the past 2,500 years. As I browsed through my old copy while writing this memoir, I noted, with great surprise, that Rollo, around forty years later, had signed it and written, “For Irv, a colleague from whom I learn Existential psychotherapy.” This brought tears to my eyes.

  I attended a series of lectures on the history of psychiatry, stretching from Philippe Pinel (the eighteenth-century physician who introduced a humane treatment of the insane) to Freud. The lectures were interesting, but, to my mind, flawed in the assumption that our field began with Pinel in the eighteenth century. As I listened, I kept thinking of all the thinkers who had written on human behavior and human anguish long before—philosophers, for example, such as Epicurus, Marcus Aurelius, Montaigne, and John Locke. These thoughts, and Rollo May’s book, persuaded me that it was time to begin an education in philosophy, so during my second year of residency I enrolled in a year-long course in the history of Western philosophy at the Johns Hopkins University Homewood campus, where Marilyn studied. Our textbook was Bertrand Russell’s popular History of Western Philosophy, and, after so many years of physiological, medical, surgical, and obstetrical textbooks, these pages were ambrosia to me.

  Ever since that survey course, I’ve been an autodidact in philosophy, reading widely on my own and auditing courses both at Hopkins and, later, Stanford. I had no idea, at the time, how I would apply this wisdom to my field of psychotherapy, but, at some deep level, I knew I had found my life’s work.

  Later in my residency I had a three-month clerkship at the nearby Patuxent Institute, a prison housing mentally ill offenders. I saw patients in individual therapy and led a daily therapy group of sexual offenders—one of the most difficult groups I’ve ever led. The members spent far more energy trying to persuade me they were well adjusted than they did working on their problems. Since they had an indeterminate sentence—that is, they were incarcerated until psychiatrists declared them recovered—their reluctance to reveal a great deal was entirely understandable. I found my experience at Patuxent fascinating, and by the end of the year decided I had sufficient material to write two articles: one on group therapy for sexual deviants, and another on voyeurism.

  The voyeurism article was one of the first psychiatric publications on that topic. I made the point that voyeurs did not simply want to view naked women: if voyeurs were to experience great pleasure, it was necessary that the viewing be forbidden and surreptitious. None of the voyeurs I had studied had sought out strip joints or prostitutes or pornography. Second, though voyeurism had always been considered an annoying, quirky, and harmless offense, I found that not to be true. Many inmates I worked with had started with voyeurism and then progressed to more serious offenses, such as breaking and entering and sexual assault.

  As I was writing the article, my medical-school case presentation of Muriel came to mind, and just as I had evoked the audience’s interest by beginning that presentation with a story, I began my voyeurism article with the tale of the original Peeping Tom. My wife, while working on her doctorate, helped me retrieve early accounts of the legend of Lady Godiva, the eleventh-century noblewoman who had volunteered to ride naked through the street to save her townspeople from the excessive taxation imposed by her husband. All the townspeople, save Tom, showed their gratitude by refusing to look at her nakedness. But poor Tom could not resist a peek at naked royalty and, for his transgression, was struck blind on the spot. The article was immediately accepted for publication in the Archives of General Psychiatry.

  Shortly afterward, my article on the techniques of leading therapy groups for sexual offenders was published in the Journal of Nervous and Mental Disease. Unrelated to my Patuxent work, I also published an article on the diagnosis of senile dementia. Because it was unusual for residents to author publications, the Hopkins faculty responded very positively. Their plaudits were gratifying but also a bit puzzling to me because writing came so easily.

  John Whitehorn always dressed in a white shirt, necktie, and brown suit. We residents speculated he had two or three identical suits, since we never saw him wear anything else. The entire resident class was expected to attend his annual cocktail party at the beginning of every academic year, and we all dreaded it: we had to stand for hours dressed in our suits and ties and were served a small glass of sherry and no other food or drink.

  During our third year, the five other third-year residents and I spent the entire day every Friday with Dr. Whitehorn. We sat in the large corner conference room adjacent to his office as he interviewed each of his hospitalized patients. Dr. Whitehorn and the patient sat in upholstered chairs, while we eight residents sat a few feet away in wooden chairs. Some interviews lasted only ten or fifteen minutes, others lasted an hour, and sometimes two or three hours.

  His publication “Guide to Interviewing and Clinical Personality Study” was used in most psychiatric training programs in the United States at the time and offered the neophyte a systematic approach to the clinical interview, but his own interviewing style was anything but systematic. He rarely inquired about symptoms or areas of distress, but instead followed a plan of “Let the patient teach you.” Now, over half a century later, a few examples still remain in mind: one patient was writing his PhD thesis on the Spanish Armada, another was an expert on Joan of Arc, and another was a wealthy coffee planter from Brazil. In each of these instances, Dr. Whitehorn interviewed the patient at great length, at least ni
nety minutes, focusing on the patient’s interests. We learned a great deal about the historical background of the Spanish Armada, the conspiracy against Joan of Arc, the accuracy of Persian archers, the curriculum of professional welding schools, and everything we wanted to know (and more) about the relationship between the quality of the coffee bean and the altitude at which it was grown. At times I was bored and tuned out, however, only to discover, ten or fifteen minutes later, that a hostile, guarded, paranoid patient was now speaking more frankly and personally about his or her inner life. “You and the patient both win,” John Whitehorn said. “The patient’s self-esteem is raised by your interest and your willingness to be taught by him, and you are edified and will eventually learn all you need to know about his illness.”

  After the morning interviews, we had a two-hour lunch served in his large, comfortable office on good bone china in leisurely southern style: a large salad, sandwiches, codfish cakes, and, my favorite dish until this very day, Chesapeake Bay crab cakes. The conversation stretched from salad and sandwiches to dessert and coffee and ranged over many topics. Unless we steered him in a particular direction, Whitehorn was prone to discuss his new ideas on the periodic table. He would walk to the blackboard and pull down the periodic table chart that was always hanging in his office. Though he had taken psychiatric training at Harvard and had been chairman of psychiatry at Washington University in St. Louis before coming to Hopkins, he had originally been a biochemist, and had done substantial research on the chemistry of the brain. I remember posing questions about the origins of paranoid thinking, to which he responded at great length. Once, when I was passing through a phase of highly deterministic thinking about human behavior, I suggested to him that total knowledge of all the stimuli imposing upon the individual would allow us to predict with precision his or her reaction, both in thought and action. I compared it to hitting a pool ball—if we knew the force, angle, and spin, we’d know the reaction of the ball being struck. My position prompted him to take the opposite view, a humanistic perspective that was foreign and uncomfortable for him. After a lively discussion, Dr. Whitehorn said to the others, “It is not out of the question that Dr. Yalom is having a bit of fun at my expense.” As I think back on it, he was probably right: I do recall feeling a bit amused that I had maneuvered him into the very humanistic point of view I usually espoused.

  My only disappointment with him came when I lent him a copy of Kafka’s The Trial, which I had loved in part for its metaphorical presentation of neuroticism and free-floating guilt. Dr. Whitehorn returned the book a couple of days later, shaking his head. He told me he just didn’t get it and that he’d rather talk to real people. By that time, I had been in psychiatry for three years, and I had yet to encounter any clinician who was interested in the insights of philosophers or novelists.

  After lunch we returned to observing Dr. Whitehorn’s interviews. By four or five o’clock I began getting antsy, eager to get out and play tennis with my regular partner, one of the medical students. The house staff tennis court was only two hundred feet away in an alcove between the departments of psychiatry and pediatrics, and on many Friday evenings I kept my hopes alive until the last rays of sunshine had vanished, then sighed and turned my full attention back to the interview.

  My final contact during my training with John Whitehorn came in my last month of residency. He summoned me to his office one afternoon, and when I had closed the door behind me and sat before him, I noticed his face seemed less severe. Was I mistaken, or did I discern friendliness, even a trace of a smile? After a typical Whitehornian pause, he leaned toward me and asked, “What do you plan to do with your future?” When I said that my next step was my upcoming mandatory two years of service in the army, he grimaced and said, “How fortunate you are that we are at peace. My son was killed in World War II in the Battle of the Bulge—a God-damned meat grinder.” I stammered that I was sorry, but he closed his eyes and shook his head to indicate that he didn’t wish to speak further of his son. He asked about my plans after the army. I told him I was uncertain about the future and had responsibilities to my wife and three children. Perhaps, I told him, I might enter practice in Washington or Baltimore.

  He shook his head and pointed to my published papers lying in a neat pile on his desk and said, “Publications like these say something else. They represent the steps of the academic ladder one must ascend. My gut tells me that if you continue thinking and writing in this manner, there might be a bright future for you in a university teaching department—one, for example, such as Johns Hopkins.” His final words rang in my ears for many years: “It would be flying in the face of fortune for you not to pursue an academic career.” He ended the session by giving me a framed photograph of himself with the inscription, “To Dr. Irvin Yalom, with affection and admiration.” It hangs today in my office. As I write, I see it now, resting uncomfortably alongside a picture of Jolting Joe DiMaggio. “With affection and admiration”—as I think of those words now I am astonished: I never recognized those sentiments in him at the time. Only now, as I write this, do I register that he, and Jerome Frank, as well, had indeed served as mentors to me—great mentors! I know it’s time to discard my notion that I am entirely self-created.

  As I ended my three years of residency, Dr. Whitehorn was ending his long career at Johns Hopkins, and I, along with the other residents and the entire faculty of the medical school, attended his retirement party. I remember well how he began his farewell address. After a lively introduction by Professor Leon Eisenberg, my supervisor in child psychiatry, who would soon assume the chair of the Harvard Department of Psychiatry, Dr. Whitehorn stood up, walked to the microphone, and began, in his measured, formal voice: “It has been said that a man’s character may be judged by the character of his friends. If that is so . . . ,” he paused and very slowly and deliberately scanned the large audience from left to right, “then I must be a very fine fellow indeed.”

  I had only two contacts with John Whitehorn after that. Several years later while I was teaching at Stanford, a close member of his family contacted me saying that John Whitehorn had referred him to me for psychotherapy, and I was pleased to be able to offer him help in a few months of therapy. And then, in 1974, fifteen years after my last face-to-face contact with him, I received a phone call from John Whitehorn’s daughter, whom I had never met. She told me that her father had had a massive stroke, was near death, and had very specifically asked for me to visit him. I was entirely dumbfounded. Why me? What could I offer him? But of course I did not hesitate, and the following morning I flew across the country to Washington, where, as always, I stayed with my sister, Jean, and her husband, Morton. I borrowed their car, picked up my mother, who always enjoyed a car ride, and drove to a convalescent hospital just outside of Baltimore. I arranged comfortable seating for my mother in the lobby and took the elevator to Dr. Whitehorn’s room.

  He appeared much smaller than I recalled. He was paralyzed on one side of his body and had expressive aphasia, which greatly impaired his ability to speak. How shocking it was to see the most gloriously articulate person I had ever known now drooling saliva and grubbing for words. After a few false starts, he finally managed to utter, “I’m . . . I’m . . . I’m scared, so damned scared.” And I was scared, too, scared by the sight of a great statue felled and lying in ruins.

  Dr. Whitehorn had trained two generations of psychiatrists, a great many of whom were now chairmen at leading universities. I asked myself, “Why me? What could I possibly do for him?”

  I ended up not doing much. I behaved like any nervous visitor, searching desperately for words of comfort. I reminded him of my days with him at Hopkins and told him how much I had treasured our Fridays together, how much he had taught me about interviewing patients, how I had taken his advice and had become a university professor, how I tried to emulate him in my work by treating patients with dignity and interest, how, following his advice, I let patients teach me. He ma
de sounds but could not formulate words, and finally, after thirty minutes, he fell into a deep sleep. I left shaken and still puzzled about why he had called for me. Later I learned from his daughter that he died two days after my visit.

  The question “Why me?” ran through my mind for years. Why call for an agitated, self-doubting son of a poor immigrant grocer? Perhaps I was a stand-in for the son he had lost in World War II. Dr. Whitehorn died such a lonely death. If only I could have given him more. Many times I wished for a second chance. I should have said more about how I treasured my time with him, and told him how often I thought of him when I interviewed patients. I should have tried to express the terror he must have been feeling. Or I should have touched him, or held his hand, or kissed his cheek, but I desisted—I had known him too long as a formal, distant man, and besides, he was so helpless that he might have experienced my tender gestures as an assault.

  Some twenty years later, in a casual lunch conversation, David Hamburg, the chairman of psychiatry who brought me to Stanford after I left the army, told me he was doing some housecleaning and found a letter of support for my appointment from John Whitehorn. He showed me the letter and I was stunned by its final sentence: “I believe that Dr. Yalom will become a leader of American Psychiatry.” Now, as I reconsider my relationship with John Whitehorn, I think I understand why I was summoned to his deathbed. He must have viewed me as someone who would carry on his work. I’ve just now turned to look at his picture hanging over my desk and try to catch his gaze. I hope he was comforted by the thought that, partly through me, he would continue to ripple into the future.