Becoming Myself: A Psychiatrist's Memoir

by Irvin D. Yalom

  Paula surprised me by beginning the first session with an old Hasidic tale:

  A rabbi had a conversation with the Lord about Heaven and Hell. “I will show you Hell,” said the Lord, and he led the rabbi into a room containing a large round table. The people sitting around the table were famished and desperate. In the middle of the table was an enormous pot of stew that smelled so delicious that the rabbi’s mouth watered. Each person around the table held a spoon with a very long handle. Although the long spoons just reached the pot, their handles were longer than the would-be diners’ arms: thus, unable to bring food to their lips, no one could eat. The rabbi saw that their suffering was terrible indeed.

  “Now I will show you Heaven,” said the Lord, and they went into another room, exactly the same as the first. There was the same large round table, the same pot of stew. The people were equipped with the same long-handled spoons—but here everyone was well nourished and plump, laughing and talking. The rabbi could not understand. “It is simple, but it requires a certain skill,” said the Lord. “In this room, you see, they have learned to feed each other.”

  Though I’ve led groups for many decades, I have never experienced such an inspired opening. The group cohered quickly, and when members died, I brought in new members, and continued leading the group for ten years. Later, I invited psychiatry residents to co-lead the group for a year, and then a new psychiatry faculty member, David Spiegel, joined me for a number of years.

  Not only did the group provide much comfort to a great many patients, but it offered me a profound education. To take but one of a myriad of examples, I think of a woman who came week after week with such a weary, despondent look in her eyes that we all struggled, in vain, to offer her solace. Then suddenly one day she showed up with a spark in her eyes and wearing a bright-colored dress. “What happened?” we asked. She thanked us and said that the group discussion the prior week had helped her make a pivotal decision: she had decided she could model to her children how to face death with grace and courage. I’ve never encountered a better example of how a sense of meaning in life generates a sense of well-being. It is also a striking example of the concept of “rippling” that helps many attenuate the terror of death. Rippling refers to passing parts of our self on to others, even to others whom we do not know, much as the ripples caused by a pebble in a pond go on and on until they are no longer visible but continue at a nano level.

  From the very beginning I invited interested Stanford residents, medical students, and occasionally undergraduates to view the group through the two-way mirror. In contrast to the traditional therapy groups at Stanford, which tolerated observation uneasily, the cancer patients responded in a strikingly different manner: they wanted and welcomed students. Their confrontation with death had taught them much about living, and they were eager to pass that on to others.

  Paula was highly critical of Kübler-Ross’s stages of grief. Instead, she placed great emphasis on learning and growing from the confrontation with death and often spoke of the “Golden Period” she had inhabited for the past three years. Several other group members shared that experience. As one of them put it: “What a pity I had to wait until now, until my body was riddled with cancer, to learn how to live.” That phrase took up permanent residence in my mind and helped shape my practice of existential therapy. I often put it this way: though the reality of death may destroy us, the idea of death may save us. It brings home the realization that since we have only one chance at life, we should live it fully and end it with the fewest regrets possible.

  My work with the terminally ill led gradually to confronting healthy patients with their mortality in order to help them change the way they lived. Often this entails simply listening and reinforcing patients’ awareness of their finite life span. On many occasions I have employed an explicit exercise: I ask the patient to draw a line on a sheet of paper, and then I say, “Let one end represent your birth and the other end your death. Now please place a mark on the line to denote where you are now and meditate on that diagram.” This exercise rarely fails to incite deeper awareness of life’s precious transiency.

  CHAPTER TWENTY-FOUR

  CONFRONTING DEATH WITH ROLLO MAY

  Of the fifty men and women who passed through our group for cancer patients, all died of their illness except for one: Paula. She survived cancer only to die later of lupus. I knew from the outset that if I were to write honestly and usefully about the role that death plays in life, I had to be taught by those facing imminent death, but I paid a price for this lesson. Often I was severely anxious after the group sessions: I brooded about my own death, had difficulty sleeping, and was often hounded by nightmares.

  My student observers also grew troubled, and it was not uncommon for one of them to burst, sobbing, from the observation room before the session was over. To this day I regret I did not properly prepare those students for the experience or provide therapy for them.

  As my own death anxiety increased, I began thinking of all the psychotherapy I had had in the past—that long analysis during my residency, my year of therapy in London, a year of Gestalt therapy with Pat Baumgartner, as well as several sessions of behavior therapy and a short course of bioenergetics. As I looked back on all those therapy hours, I could not recall a single open discussion about death anxiety. Could this be true? That death, the primal source of anxiety, was never mentioned—not in any of my therapies?

  If I were to continue to work with patients facing death, I decided I had to get back into therapy, this time with someone willing to accompany me into that darkness. I had recently heard that Rollo May, the author of Existence, had moved to California from New York and was seeing patients in Tiburon, about eighty minutes from Stanford. I phoned him for an appointment, and a week later we met in his lovely house on Sugarloaf Road overlooking San Francisco Bay.

  Rollo was a tall, stately, handsome man in his late sixties. He generally wore a beige or white turtleneck sweater and a light leather jacket. His office was his study, just off the living room. He was a fine artist, and several paintings that he had done as a youth hung on the wall. I especially admired one of the high-spired church at Mont Saint-Michel in France. (After his death, Georgia, his widow, gave me that painting, which I now see daily in my office.) After only a few sessions, it occurred to me that I could make good use of my eighty-minute commute by listening to a tape of our prior session. I suggested this to him, and he agreed quite readily and seemed entirely at ease at my recording our meetings. Beginning each hour with him shortly after I had listened in my car to our previous session greatly increased my focus and, I believe, accelerated our work. Since then, when I have had patients with a long commute to my office, I have suggested this format to them.

  How I wish I could listen to those taped sessions now as I write these pages, but alas, that is not possible. I stored all the tapes in a drawer of an old desk in my tree-house office that was badly in need of repair. When my family and I took off for Oxford in 1974, I contracted to have the office rebuilt by an elderly, affable, midwestern jack-of-all-trades named Cecil, who had appeared at our front doorstep years before asking for work. We had plenty for him to do, as I have no skills in the art of house maintenance. Before long, Cecil and his chubby, affable, apple-pie-baking wife, Martha, who looked as though she had just popped out of a Mary Poppins film, moved their small trailer into a hidden corner of our property, where they lived and attended to all our upkeep matters for several years. When I returned from my sabbatical I found that Cecil had done a great job rebuilding my studio, but all the old rickety furniture, including the weathered desk and its drawers crammed with the tapes of my sessions with Rollo, had disappeared in the process. I never found those tapes and occasionally have alarming fantasies that their entire contents will appear somewhere on the Internet.

  Now, forty years later, I have great difficulty recalling details of our sessions, but I know I focused very much on my
thoughts about death and that Rollo, though uncomfortable, never shied away from discussing my most morbid thoughts. At that time my work with dying patients ignited powerful nightmares that vanished immediately upon awakening. At one point, I suggested to Rollo that I spend the night in a nearby motel in order to see him first thing the following morning. He agreed, and those sessions, held while my dreams were fresher, were particularly charged with energy. I told him of my fear that I would die at sixty-nine, my father’s age at death. He said it was odd, given my posture toward rationality, that I clung to such a superstitious belief. When I spoke of my work with dying patients and how they evoked death anxiety, he told me I was courageous to undertake such work and it was hardly surprising that I should feel anxiety.

  I recall telling Rollo how stunned I had always been by the passage in Macbeth where the title character says, “Life’s but a walking shadow, a poor player that struts and frets his hour upon the stage and then is heard no more,” and how, as an adolescent, I had applied it to every big person who had populated my life—Franklin Roosevelt, Harry Truman, Richard Nixon, Thomas Wolfe, Mickey Vernon, Charles de Gaulle, Winston Churchill, Adolf Hitler, George Patton, Mickey Mantle, Joe DiMaggio, Marilyn Monroe, Laurence Olivier, Bernard Malamud—all those who had strutted and fretted and made history in my world, and who were now gone, all turned to dust. Nothing left of them. Everything, really everything, passes. We all have only a precious, blessed instant in the sun. I have dwelled on that thought many, many times and still it never fails to shake me.

  I never asked, but I am certain that many such sessions made Rollo personally uncomfortable, as he was twenty-two years older than me and closer to death. But he never flinched or failed to accompany me into my darkest inquiries about mortality. I recall no major “aha” moment of insight, but gradually I began to change and feel more comfortable working with dying patients. He had read a good bit of my work, including the final draft of Existential Psychotherapy, and was always generous in his posture toward me. I remain deeply grateful to him.

  I remember the first time Rollo saw Marilyn. It was years after my therapy with him had ended, and we had just arrived for a dinner party he was giving for the British psychiatrist R. D. Laing (with whom I had consulted while in London). Rollo opened his front door, greeted me, and then held out both hands toward Marilyn. She said, “I didn’t think you’d be so warm.” Without missing a beat, Rollo replied, “And I didn’t think you’d be so pretty.”

  It is uncommon and often highly problematic for patients and therapists to strike up a social relationship after therapy ends, but in this case it worked well for all parties. We became very good friends and our friendship continued until his death. From time to time, I lunched with him at the Capri, his favorite restaurant in Tiburon, and on several occasions we reviewed my therapy with him. We both knew he had been helpful, but the mechanism of help remained a mystery to us. He said, more than once, “I knew you wanted something from me in therapy, but I didn’t know what it was or how to give it to you.” As I look back on it now, I believe that Rollo offered me presence—he unhesitatingly accompanied me into dark territory and gave me some good, much-needed re-fathering. He was an older man who understood and accepted me. When he read the manuscript of Existential Psychotherapy, he told me it was a fine book and wrote a strong blurb for the cover. The quote he gave for the cover of a later book, Love’s Executioner (“Yalom writes like an angel about the devils that besiege us”), is the highest praise I have ever received.

  Around this time, Marilyn and I began to have significant problems in our marriage. She had resigned her tenured professorship at California State University at Hayward to accept a position at Stanford directing the newly created Center for Research on Women (CROW), where she built a whole new career for herself in the fledgling field of women’s studies. She nurtured young students and formed close relationships with the leading women scholars at Stanford. Her work had center stage in her mind, and I felt she was seriously neglecting our marriage. She had an entirely new social circle: I saw less and less of her and sensed we were truly drifting away from one another. I recall with great clarity a portentous evening in San Francisco when, during our dinner at Little City Antipasto, I said to her, “Your new life—your new position and your involvement in women’s issues—is great for you, but it’s not great for me. You’re so consumed with it that I’m no longer getting much from our relationship and maybe we should think of separ . . . ” I never finished that sentence because Marilyn broke out into a loud wail, so loud that three waiters rushed to our table and every face in the restaurant turned in our direction.

  This was the low point of our relationship and it happened at the time when Marilyn and I were often meeting with Rollo and Georgia. One evening, Rollo, ever willing to experiment, invited us over to try out some high-grade Ecstasy he had received as a gift. Georgia abstained and acted as chaperone for the evening. Neither Marilyn nor I had ever taken ecstasy before, but we both felt safe with Rollo and Georgia, and it turned out to be an extraordinarily mellow and healing evening. After taking the ecstasy, we talked, we dined, we listened to music, and to this very day we both believe that somehow, our marital problems simply dissolved. We changed: we let go of negative feelings and cherished each other more deeply than ever. Moreover, the change proved to be permanent! Neither of us quite understands it, and, inexplicably, we never tried the drug again.

  THE AUTHOR WITH ROLLO MAY, CA. 1980.

  In the early 1990s, around the time he turned eighty, Rollo suffered from transient ischemic attacks (TIAs) and felt confused and anxious for hours at a time, sometimes as long as a day or two. Sometimes Georgia would phone me when the incidents were extreme, and I would visit and spend time with Rollo, talking and walking in the hills behind his home. Only now, at the age of eighty-five, do I fully appreciate his anxiety. I have fleeting moments of confusion and momentarily forget where I am or what I’m doing. That was what Rollo experienced, not for moments, but for hours and days at a time. Yet somehow he continued to work until the very end. Late in his life I attended one of his public talks. His delivery was as strong as ever, his voice sonorous and soothing, but, toward the end, he repeated the same story he had told just a few minutes before. I cringed when I heard that, I cringed for him, and often I remind my friends to be honest with me and tell me when it’s time for me to stop.

  One evening Georgia phoned to say that Rollo might be near death and asked us to come immediately. The three of us spent that night taking turns sitting next to Rollo, who had lost consciousness and was in advanced pulmonary edema, breathing laboriously, sometimes with deep, long breaths followed by shorter, shallower ones. Ultimately, on my watch, as I was sitting by him and touching his shoulder, he took one last convulsive breath and died. Georgia asked me to help her wash his body to prepare him for the mortician, who, the following morning, would take him to the crematorium.

  That night, shaken by Rollo’s death and his impending cremation, I had a powerful and unforgettable dream:

  I’m walking with my parents and sister in a mall and then we decide to go upstairs. I find myself on an elevator but I’m alone—my family has disappeared. It’s a long ascending elevator ride. When I get off I’m on a tropical beach. But I can’t find my family though I keep looking and looking for them. Though it is a lovely setting—tropical beaches are paradise for me—I begin to feel pervasive dread.

  Next I put on a nightshirt that bears a cute, smiling face of Smokey the Bear. That face on the shirt then becomes brighter, then brilliant. Soon the face becomes the entire focus of the dream, as though all the energy of the dream is transferred onto that cute grinning little Smokey Bear face.

  The dream woke me, not so much from terror, but from the brilliance of the blazing emblem on the nightshirt. It was as though floodlights suddenly turned on in my bedroom.

  What lay behind the blazing image of Smokey? I’m certain it was connected
to Rollo’s cremation. His death confronted me with my own, which the dream portrays through my isolation from my family and that endless elevator ride upstairs. I’m shocked by the gullibility of my unconscious. How embarrassing it is that some part of me has bought into the Hollywood version of immortality as a celestial paradise, complete with tropical beach.

  I had gone to sleep that night shaken by the horror of Rollo’s death and his pending cremation, and my dream attempted to de-terrify that experience, to soften it, to make it bearable. Death is disguised benignly as an elevator trip upstairs to a tropical beach. The fiery cremation is transformed into a nightshirt, ready for the slumber of death, bearing an adorable image of a cuddly bear. But the terror cannot be contained, and Smokey Bear’s image blazes me awake.

  CHAPTER TWENTY-FIVE

  DEATH, FREEDOM, ISOLATION, AND MEANING

  For years in the 1970s my existential psychotherapy textbook was always simmering in my mind, but it seemed so diffuse and overwhelming that I was unable to start writing it until one day when Alex Comfort visited us. I recall the two of us sitting in my rebuilt tree-house studio talking. He listened intently as I told him about my reading and my ideas for the book. After about an hour and a half, Alex stopped me and solemnly proclaimed, “Irv, I’ve listened, I’ve heard you out, and, with total confidence, I pronounce that the time has come for you to stop reading and start writing.”

  Exactly what I needed! I could have flailed about for several more years. Alex knew about books—he had published over fifty of them—and somehow his compelling tone and faith in me allowed me to clear my docket and start writing. The timing was perfect, since I had just been invited to spend a scholarly year at the Stanford Center for Advanced Study in the Behavioral Sciences. Though I continued to meet with a few patients, I wrote almost full-time for the entire 1977–1978 academic year. Unfortunately, I did not take full advantage of the chance to get to know some of the thirty other distinguished scholars, including the future Supreme Court justice Ruth Bader Ginsburg. But I did form a friendship with sociologist Cynthia Epstein, who has remained in our life to this day.