Becoming Myself: A Psychiatrist's Memoir

by Irvin D. Yalom

  As a reader I had lived in novels all my life, but I was a rank amateur at writing one. I pondered how to insert my imagined plot into 1882 without changing historical events. I could think of only one solution: to locate the entire novel in an imagined thirteenth month of that year. Perhaps I was overly cautious: I dared leap into fiction but played it safe by keeping one foot in reality, using historical characters and events rather than inventing fictional ones, even to the point of taking some of Nietzsche’s dialogue from his letters. I felt as though I were learning to ride a bicycle by using training wheels.

  Ultimately I envisioned a thought experiment that served as a keystone for the writing that would follow: imagine what might have happened if Friedrich Nietzsche had been placed in a moment of history when he could have invented a psychotherapy, derived from his own published writings, that could have been used to cure himself.

  What a pity, I often mused, that it was not possible to have situated the story ten years later and imagined a therapeutic encounter between two towering geniuses: Nietzsche, the philosopher, and Freud, the psychoanalyst. But history did not cooperate. In 1882, Freud was still a young medical student, and he would not become a renowned practitioner for another decade. By that time Nietzsche had suffered a catastrophic brain disease (most likely tertiary syphilis) that resulted in severe dementia for the rest of his life.

  If not Freud, then who else in 1882 might Nietzsche consult for help? My historical search yielded no names of practicing therapists in Vienna, or, for that matter, anywhere else in the world: the field of psychotherapy had yet to be born. As I’ve mentioned earlier, we often regard Freud as the father of psychoanalysis, but he was far more than that: he was the father of psychotherapy per se.

  Ultimately I decided to have Nietzsche consult with Dr. Josef Breuer, Freud’s teacher and mentor. Breuer, an outstanding physician, was often called upon to treat eminent figures, including royalty suffering from arcane medical conditions. Moreover, in 1880 Breuer had developed a unique psychological therapy, the forerunner to psychoanalysis, in order to help a patient known as Anna O., who suffered from hysteria. Breuer told no one about his innovative treatment of Anna O. except his medical student Sigmund Freud, who was also a friend of the family, and possibly some of his other medical students, and he did not publish his account of Anna until twelve years later, in Studies in Hysteria, a book he coauthored with Freud.

  But how to link Breuer and Nietzsche? I chanced upon a convenient historical fact: in 1882, Lou Salomé’s brother was a first-year student in the medical school where Breuer taught. I imagined the following scenario: Lou Salomé, stricken with guilt over the psychological pain she had inflicted upon Nietzsche, speaks of her distress to her brother, who, having attended a class where his teacher, Breuer, had discussed his treatment of Anna O., urges his sister to consult Breuer. A more experienced novelist would have had no difficulty fictionalizing all these events, but I stayed close to my mantra, “Fiction is history that might have happened.”

  Eventually, the first part of the plot fell into place. Through Lou Salomé, Nietzsche comes to consult Breuer for help with his physical ailments. Breuer tries to find a way to address Nietzsche’s psychological disturbance, but Nietzsche is too proud and refuses to surrender power. Breuer tries every tactic he knows, but to no avail, and the treatment reaches a complete stalemate. At this point, in my attempt to be faithful to the character of both Nietzsche and Breuer, I had written myself into a corner, and I spent a couple of days struggling with how to proceed. I know that many writers produce a detailed outline first, but I turn the job over to my unconscious and allow the characters and events to evolve organically on the stage of my mind, while I simply record and fine-tune the work. In this case, that evolution had come to an impasse.

  Marilyn and I had heard of Silhouette, a lovely, rarely visited island near Mahé, and we took a ferry there for a weekend. Soon after our arrival, a tropical storm descended, with heavy winds and torrential rains, and so I had no choice but to stay inside and write. It was here that I had a bolt of inspiration that resolved the Nietzsche-Breuer problem.

  I was so excited about my solution that I ran out into the drenching rain to find Marilyn. I finally spotted her in the small hotel lounge, and right there read aloud the last few lines of the chapter, in which Breuer is walking home after Nietzsche had once again rebuffed his attempts to heal him.

  He listened to the wind, to his steps, to the bursting of the fragile, icy crust of snow underfoot. And suddenly he knew a way—the only way! All the way home he crunched the snow and, with every step, chanted to himself, “I know a way! I know a way!”

  Marilyn’s aroused curiosity about what would happen next was an excellent sign, and I continued reading the denouement. Breuer’s inventive idea was to treat his fiercely resistant patient by turning the tables and asking Nietzsche to become his therapist. That reversal is the core idea around which all the later action revolves.

  Years later, when writing an essay on the novel for a collection titled The Yalom Reader, I wondered about the source of that core idea. Perhaps it came from Hermann Hesse’s novel Magister Ludi, which contains a story about two healers, one young, one old, who live on different ends of a continent. The young healer falls ill, sinks into despair, and sets out on a long journey to seek help from his rival, Dion.

  During his journey, one evening at an oasis the young man falls into a conversation with another traveler, an older man, who turns out to be Dion himself, the very man he had been seeking! Dion invites the young man back to his home, where they live and work together for many years, first as student and teacher, then as colleagues. Years later, when Dion falls ill, he calls his younger colleague to him and says, “I have a great secret to tell you. Do you remember that night when we met and you told me you were on your way to see me?”

  “Yes, yes. I will never forget that night and my first meeting with you.”

  “Well,” says Dion, “I, too, was in despair at that time and I was on my way to seek help from you!”

  An analogous role-switching appears in Emergency, a little-known fragment of a play by the psychiatrist Helmut Kaiser that was published in a psychiatric journal in 1962. In the play, a woman visits a therapist and begs him to help her husband, also a therapist, who is so depressed he is likely to kill himself.

  The therapist agrees. “Yes, of course I’ll see him. Ask him to call for an appointment.”

  The woman replies, “That is the problem. My husband denies that he is depressed and refuses to seek therapy.”

  “Then,” says the therapist, “I’m sorry but I see no way I can be of help.”

  The woman replies, “You could see him pretending to be a patient and then find a way to help him.”

  Alas, we never learn whether the strategy worked, since the rest of the play was never written.

  It occurred to me later on that I had witnessed something analogous in my own life. I once saw Don Jackson, an inventive psychiatrist, interviewing a chronic delusional schizophrenic patient who wore purple trousers and a flowing, magenta-colored robe. He spent his days on the ward perched imperiously on an elevated chair, silently regarding staff and patients alike as though they were his supplicants. Dr. Jackson observed the patient’s regal demeanor for several minutes, then dropped to his knees, bowing his head to the ground, and with outstretched arms he offered the man the keys to the ward, saying, “Your majesty, it is you, not I, who should have these.”

  The patient, bewildered, stared at the keys and at the genuflecting psychiatrist and uttered his first words in many days. “Mistah, one of us here is very, very crazy.”

  Toward the end of our stay in the Seychelles I began to experience diminished vision coupled with a very painful reaction to morning light. A local physician gave me some ointment that lessened the pain, but the photophobia continued, and soon I had to remain in the dark until about noon, when
the light would become bearable. The only room without windows was the bathroom, and so each morning until noon I wrote in the bathroom, using only the light of my computer. These were the first symptoms of Fuchs’ dystrophy, a disorder of my cornea that was to cause me discomfort and visual problems for decades. In this disorder, there is a diminishment in the number of epithelial cells in the cornea that process the fluid accumulated during the night when the lids are closed. The cornea becomes thickened and swollen, which compromises vision. When the eyes open in the morning, the fluid in the cornea slowly evaporates, and vision improves gradually during the day.

  The novel was flowing so well that I would have stayed in the Seychelles longer while Marilyn went on to Paris, but it was essential that I see an ophthalmologist. In Paris I learned that my only recourse was a corneal replacement, a procedure I delayed until our return to Stanford.

  We rented an apartment near the Luxembourg Gardens with excellent blinds that permitted me to write in the dark for the next two months until the book was finished. I mailed the manuscript to my agent, Knox Burger, who had represented Love’s Executioner. He rejected it immediately, saying, “There is no way I can sell this novel: nothing happens in it.” He then suggested I learn how to write a plot by reading the manuscript of Red Square, a new novel by one of his other writers, Martin Cruz Smith. In search of another agent, I sent the manuscript to Owen Laster at the William Morris Literary Agency, who accepted it immediately and sold it to Basic Books, a publishing house of nonfiction works that had only once in its history published a novel (The Doctor of Desire by Allen Wheelis).

  Upon publication, a short, dismissive review in the New York Times described When Nietzsche Wept as a “soporific little novel.” That was the low point. After that came a series of highly positive reviews in other newspapers and magazines, and, a few months later, When Nietzsche Wept was awarded the gold medal for best fiction of the year by the Commonwealth Club of California. Second prize? Red Square by Martin Cruz Smith! Marilyn did not hesitate to send notice of this award both to the New York Times reviewer and to my former agent, Knox Burger.

  THE AUTHOR BESIDE A TOWER OF FREE COPIES OF WHEN NIETZSCHE WEPT, VIENNA, 2009.

  Sales of When Nietzsche Wept were good in the United States, but dwarfed by its popularity in other countries. It was eventually translated into twenty-seven languages, with the largest audience in Germany and the largest readership per capita in Greece. In 2009, the mayor of Vienna selected it as the book of the year. Each year the mayor chooses a book, prints 100,000 copies, and distributes them free to the citizens of Vienna, leaving stacks of books at pharmacies, bakeries, schools, and the annual book fair. Marilyn and I flew to Vienna for several days of public presentations, one of them at the Freud Museum. There, in what was once Freud’s living room, I had an open discussion of the novel with an Austrian philosopher.

  THE AUTHOR WITH HIS WIFE, MARILYN, AND PORTRAIT AT DINNER, VIENNA STADTHAUS, 2009.

  The week culminated in a huge evening gala event for several hundred people at the town hall presided over by the mayor. After my address to the audience, dinner was served, and the evening ended in a lively Viennese waltz. Since I am a poor dancer, Marilyn waltzed with our good friend Hans Steiner, a Stanford psychiatrist of Viennese birth, who flew to Vienna with his wife, Judith, for the occasion. It was an over-the-top experience for all of us.

  Two years after the book’s publication, when I was on a speaking tour in Munich and Berlin, a German filmmaker approached me with the idea of making a documentary based on my visits to various sites in Germany where Nietzsche had lived. Together we visited Nietzsche’s birthplace and childhood home in Röcken and the church where his father had preached. Next to the church is Nietzsche’s burial plot, along with those of his sister and parents. Rumor has it that Nietzsche’s sister, Elisabeth, had his body moved so that she could be placed between their mother and father. At Nietzsche’s school in Pforta, an old schoolmaster informed me that even though Nietzsche excelled in classics, he was not first in his class. At Elisabeth’s house in Weimar, which has been turned into a museum, I saw the official admission document for Nietzsche’s hospitalization at Jena, shortly before he died; the diagnosis clearly stated “Paretic syphilis.” Hanging on the wall of the museum was a photograph of Hitler offering Elisabeth a bouquet of white roses. A few days later, at the Nietzsche archives in Weimar, I had the great pleasure of holding an early draft of Thus Spake Zarathustra, written in Nietzsche’s own hand.

  Years later, filmmaker Pinchas Perry made a film of When Nietzsche Wept. Though it was a low-budget film, it features a remarkable portrayal of Nietzsche by Armand Assante, an actor well-known to film buffs. In a conversation with Assante I learned that, of all his sixty films, he is most proud of his performance as Nietzsche.

  One of the great surprises of my life occurred eleven years after publication, when I received a letter from a researcher in the Weimar archives, whom I had met there on my earlier trip to Germany. She informed me that she had just discovered an 1880 letter to Nietzsche from a friend urging him to consult with Dr. Josef Breuer for his medical problems! Nietzsche’s sister, Elisabeth, scotched the plan, ostensibly because he had already consulted several other noted physicians. Nietzsche referred to his sister as an “anti-Semitic goose,” and it’s possible that she rejected the plan because Breuer was Jewish. The letter to Nietzsche suggesting he visit Breuer and two follow-up letters can be heard on the English audiobook version of the novel. This startling confirmation reassured me that I had remained true to Gide’s aphorism: Fiction is history that might have happened.

  CHAPTER THIRTY

  LYING ON THE COUCH

  After living in the clouds with When Nietzsche Wept, I was tugged back to earth by my textbook The Theory and Practice of Group Psychotherapy, which was squealing for attention. Now ten years old, it needed an update and a facelift if it was to continue competing with other textbooks. For the next year and a half I felt yoked to the plough as I spent day after day in the medical school library at Stanford reviewing the group research of the past decade, adding relevant new research, and, the most painful part, shaving off older material.

  All the while, in the back of my mind, another novel was percolating. On my bicycle rides and during quiet moments before falling asleep, I experimented with plotlines and characters, and I soon began working on a tale I would title Lying on the Couch. I was amused by the double entendre: my book would deal with a lot of lying and a lot of psychotherapy on the couch.

  Having completed my apprenticeship as a novelist, I discarded my training wheels and no longer fretted with fitting the characters and events into a certain historically accurate time and place. On this new project I was going to have the pleasure of composing an entirely fictional plotline peopled only by made-up characters, and unless the world is loonier than I imagined, this was going to be fiction that could never have happened. Yet underlying the surreal events of a comic novel, I intended to explore serious and substantial questions. Should we, as the early psychoanalysts insisted, withhold our real selves and offer only interpretations and a blank screen? Or should we instead be open and genuine and disclose our own feelings and experiences to our patients? And if so, what pitfalls might lie in store?

  I have written much in the professional psychiatric literature about the overarching importance of the therapy relationship. The mutative force in therapy is not intellectual insight, not interpretation, not catharsis, but is, instead, a deep, authentic meeting between two people. Contemporary psychoanalytic thinking has also gradually arrived at the conclusion that interpretation is not enough. As I write these words, one of the most widely cited psychoanalytic articles in recent years is titled “Non-Interpretive Mechanisms in Psychoanalytic Therapy: The ‘Something More’ Than Interpretation.” That “something more,” referred to as “now moments” or “moments of meeting,” is not too different from what is presented in the articl
e my fictional character Ernest is attempting to write in Lying on the Couch, titled “On In-Betweenness: The Case for Authenticity in Psychotherapy.”

  In my own practice I strive continuously for an authentic meeting with my patients, both in group and individual therapy. I tend to be active, personally engaged, and often focus on the here-and-now: rarely does a session pass without my inquiring about our relationship. But how much of his/her own self should the therapist reveal? The vital issue of therapist transparency, hotly debated in the field, is analyzed, dissected, and stretched to its limits in this comic novel.

  I have just reread Lying on the Couch for the first time in years and am struck by many things I had long forgotten. First, though the plot is entirely fictional, it contains a great many real events from my life. This is not rare: I once heard Saul Bellow say, “When a novelist is born the family is doomed.” It is well-known that the characters of Bellow’s early life populate the pages of his fiction. I’ve followed suit. About a year prior to writing this novel, a friend of a friend attempted to swindle me by selling me shares of a company that, as I learned later, did not exist. My wife and I gave him $50,000 to invest. Though we soon received very official-appearing certificates of deposit from a Swiss bank, still there was something about him that aroused my suspicion. I took the certificates to a US branch of the Swiss bank and learned that the signatures were forged. Then I called the FBI and informed the swindler that I had done so. Just before my meeting with the FBI, he appeared at my door with $50,000 in cash. This event and this swindler were the inspiration for Peter Macondo in my novel, a con man who preys on therapists.

  But it was not just the con man: a great many other acquaintances, events, and parts of myself found their way into the novel. Details of my poker game are there (including caricatures of myself and other players). Because of my poor vision, I’ve stopped playing poker, but to this day when I have lunch with my old poker chums, they refer to one another by the names I had given them in the novel. Also, there is a patient (heavily disguised) who was particularly seductive to me in real life, as well as a sophisticated but arrogant psychiatrist who once supervised me. I also included a friend from my Hopkins days, Saul, who is Paul in the novel. Much of the furniture and art is real, including a glass sculpture Saul made and dedicated to me of a man looking over the edge of a bowl, titled “Sisyphus Enjoying the View.” The list is very long: pet peeves, books, clothes, gestures, my earliest memories, my parents’ history as immigrants, my games of chess and pinochle with my father and uncles—they’re all scattered throughout the novel, including my attempt to kick the grocery-store sawdust from my shoes. I tell a story about the father of a character named Marshal Streider, who is the owner of a small grocery store on Fifth and R Streets in Washington, DC. When a customer enters his store asking for a pair of work gloves, he says they are in the back storeroom, but then he goes out the back door and gallops down the block to the market to buy a pair of gloves for ten cents, and sells them to the customer for thirteen cents. That is a true story told to me by my father, who had owned a store at that address just before I was born.