Becoming Myself: A Psychiatrist's Memoir

by Irvin D. Yalom

  THE AUTHOR WITH CRITIC ALFRED KAZIN AND STANFORD LAW PROFESSOR JOHN KAPLAN, CENTER FOR ADVANCED STUDY IN BEHAVIORAL SCIENCES, 1978.

  I made such good progress that I completed the book a year later. I began it with an incident from an Armenian cooking class taught by Efronia Katchadourian, the mother of Herant Katchadourian, a good friend and colleague. Efronia was a great cook, but she spoke little English and taught entirely by demonstration. As she prepared her dishes, I jotted down all the ingredients and all her steps, but, try as hard as I could, my dishes never tasted as good as hers. Surely, I thought, this was not an insoluble problem: I resolved to observe her even more closely, and at the next lesson I watched her every step as she prepared her dish and then handed it to her lifelong attendant, Lucy, to place into the oven. This time, I kept my eye on Lucy and saw something extraordinary: on the way to the oven, Lucy casually threw in handfuls of various spices that struck her fancy! I am absolutely persuaded that those extra throw-ins made all the difference.

  I used this introductory anecdote to reassure readers that existential psychotherapy was no new strange esoteric approach but had always been present in the form of valuable, but unspoken, throw-ins offered by most experienced therapists.

  In each of the book’s four sections—death, freedom, isolation, and meaning—I described my sources, my clinical observations, and the philosophers and writers whose work I drew upon.

  Of the four sections of the text, the one on death is the longest. Elsewhere in professional articles I had written a good bit about working with patients facing death, but in this text I focused on the role that death awareness can play in the therapy of a physically healthy patient. Though I think of death as the distant thunder at our picnic of life, I also believe that a genuine confrontation with mortality may change the way we live: it helps us trivialize the trivial and encourages us to live without building up regrets. So many philosophers, in one way or another, echo the lament of my patient dying of cancer: “What a pity I had to wait until now, until my body was riddled with cancer, to learn how to live.”

  Freedom is the ultimate concern most central to many existential thinkers. In my understanding, it refers to the idea that, since we all live in a universe without inherent design, we must be the authors of our own lives, choices, and actions. Such freedom generates so much anxiety that many of us embrace gods or dictators to remove the burden. If we are, in Sartre’s terms, “the uncontested author” of everything that we have experienced, then our most cherished ideas, our most noble truths, the very bedrock of our convictions, are all undermined by the awareness that everything in the universe is contingent.

  The third topic, isolation, does not refer to interpersonal isolation (i.e., loneliness), but to a more fundamental isolation: the idea that we are each thrown alone into the world and must depart alone. In the ancient Everyman tale, a man is visited by the angel of death, who informs him that his time has come to an end and he must take the journey to face judgment. The man pleads that he be allowed to take someone with him on his journey, and the angel of death responds, “Sure—if you can find someone willing to go.” The rest of the story depicts his unsuccessful attempts—his cousin, for example, says he cannot go because he has a cramp in the toe. Finally he finds someone to accompany him, but, in this Christian morality tale, it is not another being, but instead good deeds. The only comforting thing that can accompany us while dying is the knowledge that we have lived well.

  My discussion of isolation focuses a great deal on the therapist-patient relationship, on our wishes to fuse with another, on our fear of individuation. As death approaches, many are aware that when they perish their whole unique separate world will perish as well—that world of sights and sounds and experiences unknown to anyone else, not even life partners. As I reach my mid-eighties, I experience that form of isolation more and more keenly. I think about the world of my childhood—the Sunday-night gatherings at Aunt Luba’s home, the odors wafting from the kitchen, the roast brisket, the tsimmes, the cholent, the games of Monopoly, my chess games with my father, the odor of my mother’s Persian lamb coat—and then I shudder as I realize all of this exists now only in memory.

  The discussion of the fourth ultimate concern, meaninglessness, touches on such questions as “Why were we put here? If nothing endures, what sense does life have? What is the point of life?” I’ve always been moved by Allen Wheelis’s account of throwing a stick for his dog, Monty, to retrieve.

  If then I bend over and pick up a stick, he is instantly before me. The great thing has now happened. He has a mission. . . . It never occurs to him to evaluate the mission. His dedication is solely to its fulfillment. He runs or swims any distance, over or through any obstacle, to get that stick.

  And, having got it, he brings it back: for his mission is not simply to get it but to return it. Yet, as he approaches me, he moves more slowly. He wants to give it to me and give closure to his task, yet he hates to have done with his mission, to again be in the position of waiting . . .

  He is lucky to have me to throw his stick. I am waiting for God to throw mine. Have been waiting a long time. Who knows when, if ever, he will again turn his attention to me, and allow me, as I allow Monty, my mood of mission?

  It is reassuring to believe that God has a purpose for us. Secular people find it discomfiting to know they must throw their own sticks. How reassuring it would be to know that somewhere out there exists a genuine, palpable purpose-in-life, rather than only the sense of purpose-in-life? Ovid’s comment comes to mind: “It’s useful that there should be gods, so let’s believe there are.”

  Though I’ve often thought of my book Existential Psychotherapy as a textbook for a course that did not exist, I never intended to create a new field of therapy. My intent was to increase all therapists’ awareness of existential issues in their patients’ lives. In recent years there have appeared professional organizations of existential therapists and, in 2015, I spoke via videoconference at the large first international congress of existential therapists in London. Though I welcome the increased emphasis on existential issues in therapy, I have some difficulty with the concept of a separate school of therapy. The organizers of the international congress had enormous difficulties establishing a comprehensive definition of the school. After all, there will always be patients whose therapy work primarily involves interpersonal issues, or self-esteem, or sexuality, or addiction, and for these patients existential questions may not be immediately pertinent. This has implications for training. Rarely does a week pass without some student asking me where they can be trained as an existential psychotherapist. I always suggest they first become trained as a general therapist, learn an array of therapy approaches, and then, in postgraduate programs or supervision, familiarize themselves with the specialized material of existential psychotherapy.

  CHAPTER TWENTY-SIX

  INPATIENT GROUPS AND PARIS

  In 1979, I was asked to serve, on a temporary basis, as medical director of the Stanford psychiatric inpatient unit. At that time psychiatric hospitalization nationwide was in turmoil: insurance companies had cut coverage for psychiatric hospitalization, insisting patients be transferred as quickly as possible to less expensive board and care facilities. With the majority of patients remaining in the hospital only a week or less, the composition of each group was rarely the same for two consecutive sessions, and the meetings became chaotic and ineffective. Largely because of this turmoil, staff morale was at an all-time low.

  I hadn’t planned to undertake another group therapy project, but I was restless and looking for a challenge. My desk was clear, my existential therapy book was finished, and I was ready for a new project. Given my deep belief in the efficacy of the group approach and the enticing challenge of creating a new way to lead inpatient groups, I agreed to take the position for two years. I recruited a psychiatrist who had graduated from the Stanford program to handle medications on the w
ard (psychopharmacology was never one of my strengths or interests), then concentrated primarily on designing a new group therapy approach for the changing inpatient wards. I began by visiting group meetings on inpatient wards at leading psychiatric hospitals around the country. I found confusion everywhere: not even the best-known academic hospitals had an effective inpatient group program. With such rapid turnover, group leaders felt compelled to introduce the one or two new members at the start of each session and invite them to describe why they were in the hospital. Almost invariably these accounts—followed by therapists coaxing responses from other group members—filled the entire meeting. No one seemed to be getting much benefit from these groups, and attrition was high. An entirely different strategy was needed.

  The Stanford acute unit had twenty patients, and I separated them into a higher- and a lower-functioning group, each with six to eight members (the remaining patients, mostly the acute new admissions, were too disorganized to attend any group in their first couple of days). After some experimentation I developed a workable format. Because of the rapid turnover, I entirely gave up on the idea of continuity from one meeting to the next and developed a new paradigm: the life of each group would be a single session, and the leader’s task would be to make that single meeting as efficient and effective as possible. I developed a schema for higher-functioning patients that would have four stages:

  1. Each patient in turn would formulate an agenda of some interpersonal issue to work on in that meeting. (This task consumed at least a third of the meeting.)

  2. The rest of the group meeting was spent filling the agenda of each patient.

  3. Then, when the group meeting ended, the observers (medical, psychology, or counseling students, residents, and nurses who had observed the meeting through a one-way mirror) entered the room and discussed the meeting while the patients observed from an outer circle.

  4. Finally, for the last ten minutes, the group members responded to the observers’ post-group discussion.

  The first step, the formulation of an agenda, was the most difficult task for the patients and therapists. As I defined it, the agenda was not about why patients entered the hospital—not, for example, about the frightening voices they might hear, or the side effects of antipsychotic medications, or some traumatic event in their life. Instead, the agenda was to be about some problem in their relationships with others—for example, “I’m lonely. I need friends but no one wants to be with me,” or, “Whenever I open up, people will ridicule me,” or, “I sense that people consider me repulsive and a nuisance and I need to find out if that’s true.”

  The therapist’s next step would be to transform that into a here-and-now agenda. When a members says, “I’m lonely . . . ” the therapist might say, “Can you talk about the ways in which you feel lonely here in this group?” or, “Who might you want to be close to in this group?” or, “Let’s explore, as we proceed, what role you play in being lonely in this group today.”

  The therapist must be very active, but when it works well, the members of the group help each other improve their interpersonal behavior, and the results are significantly better than when focusing on why the patient has been hospitalized.

  I strove to give the observers—nurses, psychiatry residents, and medical students—an active role in the group, and that resulted in the observers making a significant contribution to the therapy group session. On a survey, the patients rated the last twenty minutes of the meeting (the discussion with the observers) as the most worthwhile part of the meeting! In fact, some patients habitually peeked into the observation room before the group started, and if there were no observers that day, they were less inclined to attend. These reactions were similar to the reactions of my outpatient groups. If members can lay eyes on the observers and get feedback from them, the therapy work is facilitated.

  For the daily group of lower-functioning patients, I formulated a model that included a series of safe, structured exercises of self-disclosure, empathy, social skills training, and identification of desired personal changes.

  And, finally, to address the diminished staff morale, I set up a weekly process group—that is, a group in which the staff (including the medical director and the head nurse) discussed their relationships with one another. Such a group is hard to lead but ultimately becomes invaluable in ameliorating staff tensions.

  After leading inpatient groups daily for two years, I decided to take a sabbatical (faculty members at Stanford are entitled to a six-month sabbatical every six years at full salary, or twelve months at half salary) to write a book on my approach to inpatient group therapy. My initial plan was to go to London again, where the writing vibes had been so salubrious, but Marilyn insisted on Paris. So, in the summer of 1981, we set off for France, taking our twelve-year-old son, Ben, with us. (By then, our daughter, Eve, was in medical school, Reid had completed college at Stanford, and Victor was at Oberlin College.)

  We began our trip by visiting our good friends Stina and Herant Katchadourian, at their home on an island off the coast of Finland. Herant had been a member of the Stanford Psychiatry Department for a few years but had such excellent executive skills that he had been appointed to the role of university ombudsman and dean of students. He was a gifted lecturer, and his course on human sexuality became legendary, by far the most heavily attended course in the history of Stanford University. Stina, his wife, who was a journalist, translator, and author, shared interests with Marilyn, and their daughter Nina became lifelong friends with our son Ben.

  The island was a fairy-tale retreat of pines and blueberries surrounded by a forbidding ocean, and during our visit, Herant convinced me to make the jolting leap from the sauna into the frigid North Sea, which I did—but only once. From Finland we took the overnight ferry to Copenhagen. I ordinarily get seasick even looking at a picture of a boat, but with the aid of a small dose of marijuana I floated serenely to Copenhagen, and there I gave a day’s workshop for Danish therapists. We also did some sightseeing, visiting the graves of Søren Kierkegaard and Hans Christian Andersen, buried close to one another in Assistens Cemetery.

  Once we arrived in Paris, we settled into a fifth-floor flat, sans elevator, on the rue Saint-André-des-Arts, three blocks from the Seine in the Fifth Arrondissement. With Marilyn’s help I obtained an office two blocks from the rue Mouffetard that had been set aside by the French government for foreign scholars.

  It was a wonderful sojourn. Ben climbed up and down the five flights to buy our morning croissants and the International Herald Tribune before taking the Paris Métro to the École Internationale Bilingue. Marilyn worked on a new book, Maternity, Mortality, and the Literature of Madness, a work of psychological literary criticism. I met many of her French friends and we were invited to numerous dinners, but communication was difficult: few of them spoke English, and though I worked hard with a French teacher, I made little progress. At social gatherings I generally felt like the village idiot.

  I had taken German in high school and college, and, perhaps because of German’s similarity to the Yiddish my parents spoke, I did well enough. But something about the lilt and cadence of French confounded me. Perhaps it is related to my inability to keep a melody in my mind or reproduce it. The bad-language gene must have come from my mother, who had considerable problems with the English language. But the French food! I especially looked forward to our morning croissants and our 5 p.m. snacks. Our street was a lively pedestrian mall with outdoor stands hawking otherworldly sweet strawberries, and gourmet shops selling slices of chicken liver pâté, and rabbit terrine. At the boulangeries and patisseries, Marilyn and I went for the tarte aux fraises des bois and Ben for the pain au chocolat.

  Though I couldn’t understand enough French to go with Marilyn to the theater, I accompanied her to a few concerts—a memorable countertenor in the Sainte-Chapelle and a rousing Offenbach at the Châtelet—but most of all I enjoyed the museums. How could I
not appreciate Claude Monet’s water lily paintings, especially after Ben, Marilyn, and I traveled by train to Monet’s rural home in Giverny and saw the storied Japanese-style bridge spanning the floating garden of water lilies. I wandered through the Louvre, lingering especially in the rooms containing the ancient Egyptian and Persian artifacts and the majestic Susa glazed-brick Frieze of Lions.

  During this wonderful Parisian stay, I wrote Inpatient Group Psychotherapy in six months, far, far more quickly than any other book I’ve produced. It is also the only book I dictated. Stanford was generous enough to send my secretary, Bea Mitchell, with us to Paris, and every morning I dictated two or three first-draft pages that she transcribed; during the afternoons, I edited, reedited, and prepared for the next day’s writing. Bea Mitchell and I were good friends, and every day we strolled the two blocks to the rue Mouffetard and had lunch at one of the street’s many Greek restaurants.

  Inpatient Group Psychotherapy was published by Basic Books in 1983 and subsequently influenced the practice of group therapy on many inpatient wards. Moreover, a number of empirical studies have supported the efficacy of this approach. But I never returned to inpatient work; instead, I shifted back to extending my knowledge of existential thought.

  I decided to continue my philosophical education by learning more about Eastern thought, an area in which I was abysmally ignorant and had completely left out of Existential Psychotherapy. In the last few months before leaving for Paris, I had begun reading in that area and speaking to scholars at Stanford, including one of my residents, James Tenzel, who had attended retreats with a renowned Buddhist teacher, S. N. Goenka, at his ashram, Dhamma Giri, in Igatpuri, India. All the experts I consulted persuaded me that reading was insufficient and that it was important for me to engage in a personal meditative practice. So, in December, toward the end of our stay in Paris, I said goodbye to Paris and to Marilyn and Ben, who remained a month longer, and took off alone to visit Goenka in India.