Becoming Myself: A Psychiatrist's Memoir

by Irvin D. Yalom

  In response to these common questions, I explained that the group is a social microcosm, and that the issues raised in the therapy group would replicate or resemble the types of interpersonal issues that initially brought them into therapy. This step, I’d learned, was crucial. Later, I conducted and published research demonstrating that patients who were effectively prepared for group therapy fared much better in therapy than those who were not well prepared.

  I continued my association with the T-group movement for several years and was part of the faculty of NTL workshops at Lincoln, New Hampshire, as well as in a weeklong workshop for CEOs in Sandusky, Ohio. To this day I am grateful to T-group pioneers for showing me the way to lead and to research interpersonally based groups.

  Gradually over the years, I fashioned an intensive group therapy training program for psychiatry residents consisting of several components: a weekly lecture, observation and post-group discussion of my weekly therapy group, having the residents lead a therapy group with weekly supervision, and lastly, participating in a weekly personal process group that I led with a colleague.

  How did overworked first-year residents respond to spending this much time learning about group therapy? With a good bit of grousing! Some busy residents particularly resisted the two hours spent each week observing my group and often showed up late or skipped sessions entirely. But as the weeks passed, an unexpected phenomenon occurred: as the group members grew more involved with one another and took more risks, the students grew more and more interested in the drama unfolding before them and the attendance rate sharply increased. Soon they were referring to the group as “Yalom’s Peyton Place” (a takeoff on the name of a TV soap opera in the 1960s). I think of the effect as similar to being engrossed in a well-structured story or novel, and I consider it a propitious sign when therapists are eager to see what will happen next. Even now, after half a century of practice, I generally look forward to each new session, whether individual or group, with anticipation about what new developments will transpire. If that feeling is absent, if I approach a session with little anticipation, I imagine the patient may be experiencing a similar feeling and make an effort to confront and alter that.

  What effects did student observation have on the patients? That gigantic question worried me a great deal as I noticed how edgy group members were when students were behind the mirror. I tried reassuring patients that student psychiatrists operated under the same confidentiality rules that professional therapists followed, but that was of little help. Then I tried an experiment: I would attempt to turn the annoying presence of observers into something positive. I asked group members and students to switch places for twenty minutes at the end of the meeting. Thus the group members, in the observation room, observed my post-meeting discussion with the students. This step instantly enlivened both the therapy process and the teaching! The therapy group members listened with keen interest to the students’ observations about them, and the students felt like they were under so much scrutiny that they paid sharper attention to their observation of the group. Eventually I added yet another step: the group members had so many feelings about the observers’ commentary and about the observers themselves (whom they often adjudged to be more uptight than group members) that they wanted additional time to discuss their observations of the observers. So I tacked on an additional twenty minutes in which the students went back to the observation room, and the patients and I returned to the group room and discussed the observers’ comments. I realize this is far too time-consuming for everyday practice, but I believe that the format substantially increased the effectiveness of both the therapy group and the teaching.

  All this was very new. This was a time when I was grateful not to be a member of some traditional school of therapy. I gave myself free rein to create new approaches and had learned enough about outcome research to test my assumptions. Looking back, I surprise myself. Many veteran therapists would feel queasy about others observing their therapy, and yet I felt perfectly comfortable with observation. This confidence doesn’t match with my inner vision of myself—somewhere in there is the anxious, ill-at-ease, self-doubting adolescent and young man that I was. But in the matter of psychotherapy, and especially group therapy, I had come to feel entirely comfortable taking risks and acknowledging mistakes. I had some anxiety about these innovations, but anxiety was old stuff for me and I had learned to tolerate it.

  For my eightieth birthday I had a reunion party at my home and invited all my residents from those early years at Stanford. Many of them brought up their group therapy training experience and commented that, in their entire course of training, watching my group was the only time they ever observed firsthand a senior clinician doing therapy. Of course, this brought to mind my own training at Hopkins and that tiny-mirrored window through which we watched a therapy group. So, thank you, Jerry Frank.

  University faculty members are not promoted for teaching. That old chestnut, publish or perish, is no jest: it is a fact of life in academia. The twenty groups in the outpatient program provided an excellent opportunity for research and publication. I examined how therapists can best prepare patients for group therapy, how to compose groups, why some members dropped out of the groups early, and what the most effective therapeutic factors were.

  As I continued to teach group therapy, I realized that a comprehensive textbook was sorely needed, and all my experiences—lectures, research, and therapy innovations—could be incorporated in a textbook. A few years into my work at Stanford, I began outlining such a book.

  During this period, I also had a strong connection to the Mental Research Institute (MRI), a collective of innovative clinicians and researchers, such as Gregory Bateson, Don Jackson, Paul Watzlawick, Jay Haley, and Virginia Satir. For an entire year, I spent every Friday in an all-day conjoint family therapy course taught by Virginia Satir, and I grew to respect the effectiveness of family therapy—a format in which all members of the household meet together with a therapist. At that time, conjoint family therapy was far more visible than it is today, and I knew at least a dozen therapists in Palo Alto who did family therapy exclusively.

  I was treating a patient with ulcerative colitis and asked Don Jackson to be my co-therapist for several family sessions. Together we published a paper about our findings. During my next year I saw several families in therapy, but ultimately I found individual and group therapy more intriguing. I haven’t done any family therapy since then, though I often refer patients to family therapists. Another member of the MRI was Gregory Bateson, the famed anthropologist and one of the theorists behind the “double-bind” theory of schizophrenia. Bateson was a memorable raconteur and held open conversations at his home every Tuesday evening, which I often attended and greatly relished.

  Another area that interested me during my first years at Stanford was the field of “sexual disorders,” to which I had been introduced during my residency when I worked with sexual offenders at the Patuxent Institute. At Stanford, I regularly consulted on weekends with sexual offenders incarcerated at Atascadero State Hospital, and for the next several years I saw a number of patients in my practice who were voyeurs, exhibitionists, or had some other form of disturbing sexual compulsion or obsession. I often treated gay men, who, in retrospect, suffered primarily from society’s views of them. I gave a grand rounds presentation at Stanford about some of my work with these patients, and, immediately afterward, a plastic surgeon, Don Laub, in the Stanford Department of Surgery, asked if I would serve as a consultant for a new program he was launching with a series of transsexual patients requesting surgical gender change. (The term “transgender” did not yet exist.) At that time, such surgery was not performed in the United States—patients seeking gender change had their surgery in either Tijuana or Casablanca.

  Over the next few weeks the Surgery Department referred about ten patients to me for presurgical evaluation. None of these patients had serious mental disorders, and I was stru
ck by the power and depth of their motivation for sex change. Most of them were poor and had worked for years to save money for the surgery. All were anatomical males who wished to become females: the surgeons were not yet offering the more challenging female-to-male surgery. The Surgery Department enlisted a social worker to lead a presurgical group offering training in feminine mannerisms. I attended one class exercise in which the patients sat at a bar and the instructor rolled coins into their laps and taught them to spread their knees to catch the coins in their skirt, instead of reflexively pressing their knees together as males tend to do.

  The project was far ahead of its time but ran into problems after a few months: one of the postsurgical patients became a bottomless nightclub dancer advertising herself widely as a Stanford Hospital creation, and another attempted to sue the hospital for battery after his male genitalia had been removed. The project was closed down, and it was a great many years before Stanford again offered such surgery.

  My family’s first five years in Palo Alto, 1962 to 1967, coincided with the beginning of the civil rights, antiwar, hippie, and beatnik movements—all of them radiating from the San Francisco Bay Area. Students inaugurated the Free Speech Movement in Berkeley, and teenage runaways swarmed to Haight-Ashbury in San Francisco. But at Stanford, thirty miles away, things remained relatively calm. Joan Baez was living in the area, and Marilyn once marched in an antiwar demonstration with her. My most vivid memory of this period is attending a huge Bob Dylan concert in San Jose, where Joan Baez unexpectedly came onstage for a few numbers. I became a lifelong Joan Baez fan, and was thrilled, years later, when I had the chance to dance with her after one of her café performances.

  Like everyone else, we were devastated by the news of John F. Kennedy’s assassination in 1963. It shattered the image that our peaceful lives in Palo Alto would be unaffected by the ills of the outside world, and we bought our first television set to witness the events surrounding Kennedy’s death and memorial services. I eschewed all religious belief and practice, but in this instance, Marilyn, feeling the need for community and ritual, took our two older children—Eve, aged eight, and Reid, aged seven—to a religious service at the Stanford Memorial Church. Having not entirely escaped the pull of ceremony, we always held a Passover Seder at our home with family and friends. Never having learned Hebrew, I always asked a friend to read the ceremonial prayers.

  FAMILY PORTRAIT, CA. 1975.

  Despite my unpleasant memories of childhood, I continued to favor the type of food I was raised on: Eastern European Jewish cuisine and no pork. Not Marilyn. Whenever I was out of town, the children knew she would serve them pork chops. I clung to some ceremonial rites. I had my sons circumcised, followed by a ceremonial repast with friends and family. Reid, the eldest of my three sons, chose to have a Bar Mitzvah. In addition to these few Jewish traditions, we had a Christmas tree, filled stockings for the children, and laid out a big Christmas Day feast.

  I’ve often been asked whether my lack of religious belief has been a problem in my life or my psychiatric practice. My answer is always no. First, I should say that I am “nonreligious” rather than “antireligious.” My stance was by no means unusual: for the overwhelming majority of my Stanford community and my medical and psychiatric colleagues, religion played little or no role in their lives. When I’ve spent time with my few devout friends (for example, Dagfinn Føllesdal, my Catholic Norwegian philosopher friend), I always feel tremendous respect for the depth of their faith, and I’m inclined to say that my secular views almost never influence my therapy practice. But I have to admit that in all my years of practice, only a handful of committed religious individuals have sought me out. My most frequent contact with devout individuals has come in my work with dying patients, and in every instance I welcome and support any religious comfort they can find.

  Though I was deeply immersed in my work in the 1960s and largely apolitical, I couldn’t help but notice cultural changes. My medical students and psychiatric residents began to wear sandals instead of “proper” shoes, and year by year their hair got longer and wilder. A couple of students brought me gifts of their home-baked bread. Marijuana infiltrated even faculty parties, and sexual mores were radically changing.

  I already felt part of the old guard when these changes occurred and felt shocked the first time I saw a resident wearing red plaid trousers or other outrageous garb. But this was California, and there was no stopping such change. Gradually I loosened up, stopped wearing neckties, and enjoyed marijuana at some faculty parties, where I, too, wore bell-bottomed trousers.

  In the 1960s, our three children—our fourth, Benjamin, was not born until 1969—were caught up in their own daily dramas. They attended the local public schools within walking distance of our home, made friends, took piano and guitar lessons, played tennis and baseball, learned to horseback ride, joined the Blue Birds and 4-H, and built a corral for two young goats in our backyard. Their friends from smaller homes often came over to our home to play. Our house was an old Spanish-style stucco with a front door surrounded by bright violet bougainvillea and a patio containing a small pond and fountain. The formal path leading down to the road was dominated by a majestic magnolia, around which the small children rode their tricycles. There was a neighborhood tennis court half a block from my home, where twice a week I played doubles with my neighbors, or, as they got older, with my three sons.

  FAMILY ON WHEELS, PALO ALTO, 1960S.

  In June 1964, we visited my family in Washington, DC. We were at my sister’s home with our three children when my mother and father drove over. I sat on a sofa with my daughter, Eve, and my son Reid on my lap. My son Victor and his cousin Harvey were playing on the floor nearby. My father, sitting in an adjoining upholstered chair, told me he had a headache, and two minutes later, suddenly and wordlessly, he lost consciousness and slumped over. I could feel no pulse. My brother-in-law, a cardiologist, had a syringe and Adrenalin in his physician’s bag and I injected Adrenalin into my father’s heart—but to no avail. Only later did I remember that just before he passed out I had seen his eyes fixated to his left, suggesting a stroke in the left side of his brain, not a cardiac arrest. My mother rushed into the room and clung to him. To this moment I can hear her crying, over and over, “Myneh Tierehle, Barel” (“My darling, Ben”). My tears flowed. I was astonished and deeply moved: it was the first time I had ever witnessed such tenderness from my mother, the first time I realized how much they loved one another. When the emergency unit came, I remember my mother still crying but saying to my sister and me, “Take his wallet.” My sister and I ignored her pleas, and both of us felt critical of her for focusing on money at such a time. But she was right, of course: his wallet, cards, and money disappeared in the ambulance and were never seen again.

  I had seen dead bodies before—my cadaver in the first year of medical school, bodies in pathology courses at the morgue—but this was the first dead body of someone I loved. It would not happen again for many years, until the death of Rollo May. My father’s funeral was held at a cemetery in Anacostia, Maryland, and after the service each of the family members ceremoniously threw a shovelful of soil on the coffin. As I did so, I felt lightheaded, and my brother-in-law caught my arm and steadied me, lest I fall into the grave. My father died as he had lived, quietly and unobtrusively. Even to this day I regret not having known him better. When I’ve returned to the cemetery and walked up and down the rows of tombstones where my father and mother and their entire community from the small shtetl of Cielz lay, my heart has ached for the gulf between me and my parents and all that remained unsaid.

  Sometimes when Marilyn describes her tender memories of walks in the park holding hands with her father, I feel bereft and cheated. Where were my walks and my father’s attention? My father worked hard his entire life. His store was open until 10 p.m. five days a week and until midnight on Saturdays: he was free only on Sundays. My only tender memory of time spent with my father revo
lves around our Sunday chess games. I recall he was always pleased with my play, even when I began to beat him at about the age of ten or eleven. Unlike me, he never, not once, was annoyed by losing games. Perhaps this is the reason for my lifelong engagement with chess. Perhaps the game offers some shreds of contact with my hardworking, gentle father who never got to see me as a more mature adult.

  When my father died, I was just beginning my life at Stanford. At the time I don’t think I fully appreciated my extraordinary good fortune. I had a position at a great university, worked with total independence, and lived in a blessed enclave with perhaps the world’s best weather. I never saw snow again (except at ski resorts). My friends, mostly colleagues at Stanford, were easygoing and enlightened. And never once did I ever again hear an anti-Semitic statement. Though we were not wealthy, Marilyn and I had the feeling of being able to do anything we wished. Our favorite getaway was Baja, California, at a colorful if modest location called Mulegé. We took our children there one Christmas, and they fully enjoyed the Mexican atmosphere replete with tortillas and piñatas. My children and I reveled in the snorkeling and spearfishing, which provided several delicious meals.