Becoming Myself: A Psychiatrist's Memoir

by Irvin D. Yalom

  Almost always, my books have germinated slowly in my mind, with no single moment of conception. The Gift of Therapy is the single exception. By the time I left that Renaissance bestseller exhibition I knew exactly what my next book would be. I would write a book of tips for young therapists. A patient’s face came to mind, a writer I had seen years before. After abandoning two unfinished novels she had announced to me that she would never again start another unless some idea for a book came along and bit her on the ass. Well, that day at the Huntington, a book bit me on the ass, and I put everything else aside and the next day began to write.

  The process was straightforward. Since my early days at Stanford I had kept a file labeled “Thoughts for teaching,” into which I dropped ideas and vignettes from my clinical work. I simply raided my “Thoughts for teaching” file. I read my notes over and over until one caught my fancy and I fleshed it out in several paragraphs. The tips were written in no particular order, but, at the end, I surveyed what I had written and grouped them into five clusters:

  1. The nature of the therapist-patient relationship

  2. Methods of exploring existential concerns

  3. Issues arising in the everyday conduct of therapy

  4. The use of dreams

  5. The hazards and the privileges of being a therapist

  I had originally been hoping for a hundred tips, as in A Hundreth Good Pointes of Husbandry, but by the time I reached eighty-four, I had entirely eviscerated my file. (I started building it up again as I continued to see patients, and nine years later, in a second edition, I added eleven more tips.)

  From the very beginning I had a title in mind: I would modify Rilke’s title and call it Letters to a Young Therapist. But as I was nearing completion, an amazing coincidence occurred: Basic Books invited me to participate in a mentoring series titled “Letters to a Young . . . ” (Therapist, Mathematician, Contrarian, Catholic, Conservative, Chef, etc.). Loyal as I was to Basic Books, I preferred not to be part of the series. However, since they had co-opted Rilke’s title, I needed a new one. One Hundred Tips for Therapists wasn’t possible, and everyone vetoed 84 Tips for Therapists. Eventually my agent, Sandy Dijkstra, suggested The Gift of Therapy. I wasn’t wild about the title, but I never came up with a better one and it’s grown on me over the years.

  I wrote the book in opposition to the brief, manualized, problem-solving, cognitive behavioral approach to psychotherapy spawned by economic pressures. I was fighting, too, against psychiatry’s overreliance on medications. This battle continues today, despite overwhelming research evidence that good outcomes depend on the intensity, the warmth, the genuineness, and the empathy of the therapeutic relationship. I hoped The Gift of Therapy would help preserve a human and humane approach to psychological suffering.

  To that end, I intentionally use provocative language: I go out of my way to tell students exactly the opposite of what many have been taught in behaviorally oriented training programs. “Avoid Diagnosis,” “Create a New Therapy for Each Patient,” “Let the Patient Matter to You,” “Blank Screen? Forget It. Be Real,” “Check into the Here-and-Now Each Hour.”

  Several sections of The Gift of Therapy stress the importance of empathy and convey the Roman playwright Terence’s ancient sentiment that “I am human and nothing human is alien to me.” One section, “Empathy: Looking Out the Patient’s Window,” relates one of my favorite clinical stories. Throughout adolescence, one of my patients had been locked in a long, bitter struggle with her naysaying father. Yearning for reconciliation and a new beginning to their relationship, she had looked forward to her father driving her to college—a rare occasion when just the two of them would be together for several hours. But the long-anticipated trip proved a disaster: her father behaved true to form by grousing at length about the ugly, garbage-littered creek by the side of the road. She, on the other hand, saw no litter whatsoever in the beautiful, rustic, unspoiled stream. As a result, she gave up on her father and lapsed into silence, and the two of them spent the remainder of the trip (and of their lives) looking away from each other. A great many years later, she happened to make the same drive again and was astonished to note that there were two streams—one on each side of the road. “This time I was the driver,” she said sadly, “and the stream I saw through the window on the driver’s side was just as ugly and polluted as my father had described it.” But by the time she had looked out her father’s window, it was too late—her father was dead and buried. “So look out the patient’s window,” I urge therapists. “Try to see the world as the patient sees it.”

  Rereading The Gift of Therapy now makes me feel quite exposed: all my favorite ploys and responses are out there for all to see. Only recently, a patient wept in my office and I said to her, “If those tears could speak what would they say?” When I reread the book and saw these exact words in one of the tips, I felt as if I were plagiarizing myself (and hoped she hadn’t read the book).

  Some of the tips encourage therapists to be honest by acknowledging errors. It’s not the commission of errors that is important: it’s what you do with them. Several tips encourage student therapists to use the here-and-now, that is, to stay focused on what is happening in the therapist-patient relationship.

  The final tip in The Gift of Therapy, “Cherish the Occupational Privileges,” particularly moves me: I am very often asked why, at the age of eighty-five, I continue to practice. Tip number eighty-five (sheer coincidence that I am now eighty-five years old) begins with a simple declaration: my work with patients enriches my life in that it provides meaning in life. Rarely do I hear therapists complain of a lack of meaning. We live lives of service in which we fix our gaze on the needs of others. We take pleasure not only in helping our patients change, but also in hoping their changes will ripple beyond them toward others.

  We are also privileged by our role as cradlers of secrets. Every day patients grace us with their secrets, often never before shared. The secrets provide a backstage view of the human condition without social frills, role-playing, bravado, or stage posturing. Being entrusted with such secrets is a privilege given to very few. Sometimes the secrets scorch me and I go home and hold my wife and count my blessings.

  Moreover, our work provides the opportunity to transcend ourselves and to envision the true and tragic knowledge of the human condition. But we are offered even more. We become explorers immersed in the grandest of pursuits—the development and maintenance of the human mind. Hand in hand with patients, we savor the pleasure of discovery—the “aha” experience when disparate ideational fragments suddenly slide smoothly together into a coherent whole. Sometimes I feel like a guide escorting others through the rooms of their own house. What a treat it is to watch them open doors to rooms never before entered, discover unopened wings of their house containing beautiful and creative pieces of identity.

  Recently I attended a Christmas service at the Stanford Chapel to hear a sermon by Rev. Jane Shaw that underscored the vital importance of love and compassion. I was moved by her call to put such sentiments into practice whenever we can. Acts of caring and generosity can enrich any environment in which we find ourselves.

  Her words motivated me to reconsider the role of love in my own profession. I became aware that I have never, not once, used the word love or compassion in my discussions of the practice of psychotherapy. It is a huge omission, which I wish now to correct, for I know that I regularly experience love and compassion in my work as a therapist and do all I can to help patients liberate their love and generosity toward others. If I do not experience these feelings for a particular patient, then it is unlikely I will be of much help. Hence I try to remain alert to my loving feelings or absence of such feelings for my patients.

  Very recently, I began working with Joyce, a depressed, angry young woman recovering from extensive surgery for a life-threatening cancer. As soon as she entered my office, I sensed her terror, and my heart went
out to her. Yet in our first sessions, I did not feel close to her. Though she was obviously tormented, she also emanated the message that she had it all under control. And I felt confused by her vacillating complaints: one week she spoke bitterly of the irritating habits of her neighbors and friends, and the next week she bemoaned her isolation. Something was off, and each week as I thought about our next session, I could feel myself wince. I sometimes considered referring her to another therapist. But I nixed that idea because she had read many of my books, and she had emphasized from the very start that she had seen many therapists and I was her last resort.

  During our third session, something odd happened: it suddenly dawned on me that she had a remarkable physical resemblance to Aline, a good friend’s wife, and on several occasions I had the fleeting, uncanny experience of thinking I was speaking to Aline, not Joyce. Each time that happened, I had to jerk myself back to reality. Though I was now on good terms with Aline, I had, at first, found her smug and off-putting. Had she not been the wife of a good friend, I would have avoided her. Was it possible, I began to wonder, if, in some strange fashion, my unconscious had transmitted some of my Aline irritation to Joyce?

  Joyce began our fourth session uncharacteristically. After a brief silence, she said, “I don’t know where to start.” Knowing that it was imperative for us to focus on our problematic relationship, I responded, “Tell me how you felt at the end of our previous meeting.”

  She had previously skirted such inquiries, but today she startled me: “Exactly the same way I felt after each of our sessions: I felt awful. Totally confused. I suffered for hours afterwards.”

  “I’m so sorry to hear that, but say more, Joyce. Suffered how?”

  “You know so much. You write all those books. That’s why I contacted you. You’re wise. And I feel so inferior. And I know you think I’m nothing. I’m sure you know all about my problem but you’re not telling me what it is.”

  “I see how painful this is for you, Joyce, but at the same time I’m glad you’re speaking out honestly: this is exactly what we must do.”

  “Then why don’t you tell me what’s wrong? What is my problem? How do I solve it?”

  “You give me too much credit. I don’t know your problem. But I do know that we can find it out together. And I do know you’re frightened and you’re angry. And, considering what you’ve gone through, I can understand that: I’d feel like that, too. I can help you if we keep working like we are today.”

  “But why do I feel like this? That I’m not worth your time? Why am I getting worse?”

  I knew what I had to do and took the plunge. “Let me say something that may be important for you to hear.” I hesitated—this was heavy-duty self-disclosure and I felt very unsure of myself. “You look remarkably like the wife of one of my close friends—and at our last session there were a couple of times when, for just a moment or two, I had the strange thought it was her, not you, sitting in your chair. Though I’m friendly now with this person, I did not get along with her at first. I found her sharp and off-putting and just didn’t enjoy being with her. I’m telling you this because—and I know this sounds strange and I’m embarrassed by it—I may have unconsciously conveyed these feelings that belonged to her toward you. And I think you may be picking that up.”

  We were silent for a few moments and I added, “But, Joyce, I want to be clear, that is not what I feel for you. I’m entirely on your side. I feel only compassion and I’m committed to helping you.”

  Joyce seemed astonished and tears flowed down her cheeks. “Thank you for that gift. I’ve seen a lot of shrinks but this is the first time any of them has ever shared something personal with me. I don’t want to leave your office today—I want us to talk for the next twelve hours. I feel good.”

  My patient had received my disclosure in the spirit that I had offered it, and from that time on, everything changed. We worked well and hard and I looked forward to each of our meetings. How to describe my intervention? I believe it was an act of compassion, of love. I can find no other words for it.

  CHAPTER THIRTY-FOUR

  TWO YEARS WITH SCHOPENHAUER

  My philosophical reading has always been concentrated on Lebensphilosophie, the school of thinkers who address life’s meaning and values. These include many of the ancient Greeks, Kierkegaard, Sartre, and, of course, Nietzsche. Only later did I discover Arthur Schopenhauer, whose ideas about the unconscious influence of the sexual drive foreshadowed Freud’s theories. To my mind, Schopenhauer set the stage for the birth of psychotherapy. As Philip, a character in my novel The Schopenhauer Cure, says, “Without Schopenhauer there could have been no Freud.”

  Schopenhauer was abrasive, fearless, and exceedingly isolated. He was the nineteenth-century Don Quixote, attacking all forces, including religion. Schopenhauer was also a tormented man, and his unhappiness, pessimism, and relentless misanthropy provided much of the energy behind his work. Consider his view of human relationships in his well-known Porcupine Parable: The cold air drives porcupines to huddle together for warmth, but their huddling causes them to prick one another with their quills. Eventually they discover they are best off remaining at some distance from one another. Thus, a man (like Schopenhauer) who has an abundance of inner heat is well advised to stay entirely away from others.

  Schopenhauer’s profound pessimism bowled me over when I first encountered it. I wondered how, given such despair, he continued to think and to work. Over time I came to realize that he believed that understanding can lighten the burden of even the most wretched character. Though we are ephemeral beings, we take pleasure in understanding even when that knowledge reveals our basest impulses and confronts us with the brevity of life. In “On the Vanity of Existence,” he wrote:

  A man never is happy, but spends his whole life in striving after something which he thinks will make him so; he seldom attains his goal, and when he does, it is only to be disappointed; he is mostly shipwrecked in the end, and comes into harbor with mast and rigging gone. And then, it is all one whether he has been happy or miserable; for his life was never anything more than a present moment always vanishing; and now it is over.

  In addition to such extreme pessimism, Schopenhauer’s intense sexual drive tormented him, and his inability to relate to others in nonsexual ways left him chronically bad tempered. Only in childhood, before sexuality arose, and in later life when his appetites mellowed, did he experience happiness. For example, in his major work The World as Will and Representation, he wrote:

  Just because the terrible activity of the genital system still slumbers, while that of the brain already has its full briskness, childhood is the time of innocence and happiness, the paradise of life, the lost Eden on which we look back longingly through the whole remaining course of our life.

  But no affirmation is to be found in Schopenhauer: his pessimism was unrelenting:

  At the end of his life, no man, if he be sincere and in possession of his faculties, would ever wish to go through it again. Rather than this he will much prefer to choose complete nonexistence.

  The more I learned about Arthur Schopenhauer, the more tragic I found his life: how sad that one of our great geniuses was so relentlessly tormented. He was a man, it seemed to me, desperately in need of therapy. His relationship to his parents resembles a stark Oedipal drama. First he infuriated his father by refusing to enter the family mercantile business. He adored his mother, a popular novelist, and when his father committed suicide, the sixteen-year-old Arthur was so persistent in his attempts to possess and control her that she ultimately broke off their relationship, refusing to see him during the last fifteen years of her life. He was so terrified of being buried when not yet fully dead that he ordered in his will that he not be interred for several days, until the stench of his body pervaded the nearby countryside.

  As I considered his sad life, I began to wonder whether Schopenhauer might have been helped b
y psychotherapy. If he had consulted me, could I have found a way to offer him comfort? I began to imagine scenes of our therapy, and gradually the outline of a novel about Schopenhauer materialized.

  Schopenhauer in treatment—imagine that! Oh yes, yes—what a deliciously challenging thought! But who could have served as his therapist in this story? Schopenhauer was born in 1788, more than a century before the first stirrings of psychotherapy. For weeks I considered a compassionate, literate, philosophically trained ex-Jesuit, who could have offered intensive meditational retreats that Schopenhauer would have been willing to attend. This idea had some merit. During Schopenhauer’s lifetime, there were hundreds of Jesuits out of work: the pope had disbanded the Jesuit order in 1773 and did not reinstate it for forty-one years. But that plot never cohered and I abandoned the idea.

  Instead, I decided to create a Schopenhauer clone, a contemporary philosopher endowed with Schopenhauer’s intelligence, interests, and personality characteristics (including misanthropy, sexual compulsivity, and pessimism). And so the character Philip was conceived. I would set Philip down in the twentieth century when psychotherapy was readily available. But what type of therapy might be most effective for Philip? Such acute interpersonal problems cried out for an intensive therapy group. And the group therapist? I needed an experienced, skillful group therapist, and I created Julius, a wise, elderly practitioner with an approach to group therapy similar to my own.

  Next, I created the other characters (the members of the therapy group), introduced Philip into the group, and then set the characters free to interact with one another. I had no pre-formulations: I simply recorded the action as it ensued in my imagination.