Becoming Myself: A Psychiatrist's Memoir

by Irvin D. Yalom

  We returned to Sfica’s and requested a refund. As though he were expecting us, he strode, without a word, to his cash register and with great dignity extracted an envelope containing our money. He handed it to us saying, “I return your money as I had promised but with one condition: you will no longer be welcome in this store.”

  As we continued on our trip around the island, we stopped at other coin shops and more than once described our encounter at Sfica’s. “What?” they all said. “You insulted Sfica? Sfica, the official appraiser for the National Museum?” They put their hands to their temples and rocked side-to-side saying, “You owe him an apology.”

  We never found a suitable replacement gift and began to question our decision to return the coins. On the last night of our stay in Crete we decided to make use of a vacation gift from a colleague at Oxford: a skinny marijuana joint. Unaccustomed to smoking, we lit up and went to dinner at one of the outdoor restaurants in the market area, where for hours we relished the magical food, music, and dancing. After dinner, we wandered through the streets of Heraklion and grew disoriented, then a bit paranoid, thinking we were being followed by the police. Unable to find a taxi, we rushed through the maze of streets trying to find our hotel, and somehow, late at night, ended up on an empty street in front of a store with a large bumblebee painted on the window—Sfica’s Coin Store! As we stood gawking at the bumblebee, an empty taxi miraculously appeared. We hailed it and were soon back in the safety of our hotel.

  Our flight back to London didn’t leave until early afternoon, and as Marilyn and I lingered over our breakfast of Cretan cheesecake, we discussed the previous night. Skeptic though I am, I could not help wondering if we had been sent some type of mysterious message by winding up in front of Sfica’s store. The more we discussed it, the more persuaded we grew that we had made a horrific mistake, a mistake that could be rectified only by our apologizing abjectly to Mr. Sfica and repurchasing those coins. We went back to the shop and, defying Sfica’s ban, stepped inside. When we encountered Sfica, we started to mutter some words of apology, but he cut them short by placing his fingers over his lips and, without a word, retrieved the three coins. We paid the same price as before. A few hours later, on the airplane back to London, I said to Marilyn, “If he and all the dealers on Crete are in cahoots, and if he had the balls to sell me the same phony coins twice, then I say, ‘Hats off to you, Mr. Sfica!’ ”

  On returning to Oxford, we took the coins to the Ashmolean Museum for an official appraisal. One week later we received the verdict: all the coins were fake except for the small Roman coins we had bought from the old Jewish dealer in the small basement shop! Thus began a lifetime of adventures in Greece.

  CHAPTER TWENTY-THREE

  EXISTENTIAL THERAPY

  Ever since reading Rollo May’s Existence early in my psychiatric residency and taking my first philosophy courses at Hopkins, I had been wondering how I could begin to incorporate the wisdom of the past into my field of psychotherapy. The more philosophy I read, the more I realized how many profound ideas psychiatry had ignored. I much regretted that I had only a rickety foundation in philosophy and the humanities in general, and was determined to begin to address these gaps in my education.

  I started auditing a number of Stanford undergraduate courses in phenomenology and existentialism, many of them taught by a remarkably lucid thinker and lecturer, Professor Dagfinn Føllesdal. I found the material fascinating, if dense and difficult, and struggled particularly with Edmund Husserl and Martin Heidegger. I found Heidegger’s Being and Time opaque, but also intriguing, so much so that I sat through Dagfinn’s Heidegger course twice. He and I were to develop a lifelong friendship. The other Stanford professor teaching courses in my area of interest was Van Harvey, who, despite his staunch agnosticism, was the long-term chair of the Stanford Department of Religious Studies. Sitting in the front row of his classroom, I listened, mesmerized, to his lectures on Kierkegaard and Nietzsche, two of the most unforgettable courses I’ve ever taken. Van Harvey, too, became a close friend, and to this day we meet for regular luncheons to talk about philosophy.

  My whole professional life was changing: less and less did I seek collaboration with scientific projects conducted by members of my department. When psychology professor David Rosenhan went on sabbatical, I stepped in to teach his large undergraduate course on abnormal psychology, but that would be my finale—the last such course I taught.

  I gradually drifted away from my original affiliation with medical science and began grounding myself in the humanities. This was an exciting time, but also a time of self-doubt: I often felt like an outsider, losing touch with new developments in psychiatry and, at the same time, becoming just a dabbler in philosophy and literature. Gradually I would pick and choose among thinkers who seemed most relevant to my field. I embraced Nietzsche, Sartre, Camus, Schopenhauer, and Epicurus/Lucretius, and bypassed Kant, Leibniz, Husserl, and Kierkegaard because the clinical application of their ideas was less apparent to me.

  I also had the good fortune of attending classes given by English professor Albert Guerard, a remarkable literary critic and novelist, and then the honor of co-teaching with him. He and his wife, Maclin—also a writer—became dear friends. In the early 1970s Professor Guerard started a new PhD program in Modern Thought and Literature, and Marilyn and I both served on his board. I began teaching more in the humanities and less in the medical school. Some of the earliest offerings in Modern Thought and Literature included “Psychiatry and Biography,” which I co-taught with Tom Moser, the chair of the Stanford English Department, who also became a good friend. Marilyn and I co-taught “Death in Fiction,” and I also co-taught “Philosophy and Psychiatry” with Dagfinn Føllesdal.

  My reading had now shifted strongly to existential thinkers in fiction as well as philosophy: such authors as Dostoevsky, Tolstoy, Beckett, Kundera, Hesse, Mutis, and Hamsun were not dealing primarily with matters of social class, courtship, sexual pursuit, mystery, or revenge: their subjects were far deeper, touching on the parameters of existence. They struggled to find meaning in a meaningless world, openly confronting inevitable death and unbridgeable isolation. I related to these mortal quandaries. I felt they were telling my story: and not only my story, but also the story of every patient who had ever consulted me. More and more I grasped that many of the issues my patients struggled with—aging, loss, death, major life choices such as what profession to pursue or whom to marry—were often more cogently addressed by novelists and philosophers than by members of my own field.

  I began to believe that I could write a book that might bring some of the ideas of existential literature into psychotherapy, but at the same time worried about my hubris in taking such a step. Would not real philosophers see through my thin veneer of knowledge? Pushing these qualms aside, I started work, but I never eliminated the pretender-anxiety buzzing in the background. I also knew that this would be a formidable long-term project. I arranged to spend four hours every morning reading and taking notes in my small studio over the garage, and then, at noon, I biked twenty minutes to Stanford to spend the rest of the day with students and patients.

  In addition to reviewing the academic literature, I turned to reams of clinical notes on patients. Over and again I attempted to clear my mind of everyday concerns and meditate on the irreducible experience of being. Thoughts of death often floated into my waking mind and haunted me in my dreams. During my early work on the book, I had a powerful dream that remains as fresh as if I had dreamt it last night.

  My mother and her friends and relatives, all dead now, are seated very quietly on a flight of stairs. I hear my mother’s voice calling—shrieking—my name. I take particular notice of Aunt Minnie, sitting on the top stair, who is very still. Then she begins to move, slowly at first, then more and more quickly, until she is vibrating faster than a bumblebee. At that point, everyone on the stairs, all the big people of my childhood, all dead, begin to vi
brate faster and faster. Uncle Abe reaches out to pinch my cheek, clucking, “Darling Sonny,” as he used to do. Then others reach out for my cheeks. At first affectionate, the pinching grows fierce and painful. I awake in terror, cheeks throbbing, at 3 a.m.

  The dream was an encounter with death. First, my dead mother calls me, and I see all the dead of my family sitting in eerie stillness on the stairs. Next they all begin to move. I especially note my aunt Minnie, who had died after existing for a year in a locked-in syndrome. A cataclysmic stroke had left her paralyzed for several months, unable to move a muscle in her body aside from her eyes. I had been horrified to think of her in that state. In the dream, Minnie begins to move, but quickly veers into frenzy. I try to alleviate my dread by imagining the dead affectionately pinching my cheeks. But the pinching grows fierce and then malignant: I am being drawn in to join them and death will come for me as well. The image of my aunt vibrating like a bumblebee haunted me for days. I couldn’t shake it loose. Her total paralysis, her death in life, was too horrible to bear, and so in the dream I tried to undo it by making her vibrate. I’ve often been visited by nightmares touched off by films about death or violence, particularly Holocaust films. My chief method of dealing with death terror? Without doubt, avoidance.

  I had always believed I would die at age sixty-nine, my father’s age at death. Since early childhood I remember my extended family saying two things about Yalom males: they were always gentle and always died young. My father’s two brothers died from coronaries in their fifties, and my father’s coronary almost killed him when he was forty-seven. When, in medical school, I learned more about physiology and about the impact of diet on coronary arterial plaques, I abruptly and permanently changed my eating habits, sharply reducing my intake of animal fats. I avoided red meat and gradually moved to a diet that was primarily vegetarian. I’ve taken statins for decades, watched my weight carefully, and exercised regularly, and have surprised myself by living long past sixty-nine.

  After months of study and contemplation I reached the conclusion that the confrontation with death would have to be the major focus of an existential approach to therapy. I believed this was because of the intensity and universality of our dread of death, but now, as I look back on that decision, I can’t dismiss the possibility that my view may have been unbalanced because of my own personal angst about death. For months I read all I could find about death, beginning with Plato and ending with Leo Tolstoy’s Death of Ivan Ilyich, Jacques Choron’s Death and Western Thought, and Ernest Becker’s Denial of Death.

  The scholarly literature on death was so vast, so sprawling, and often so esoteric and removed from psychiatry that I realized my unique contribution could come from my work with patients. At that time, very little had been written about death in the clinical literature, and I knew I would have to find my own way. Yet, no matter how much I tried to discuss concerns about death with my psychotherapy patients, I could not engage them in a sustained discussion. We would address the topic for a few moments and then soon drift elsewhere. Looking back on that era, I now think I must have unconsciously communicated to my patients that I was not ready to talk about it.

  Hence I made an important decision that determined my next ten years of clinical practice: I would work with patients who had to talk about death because they were imminently confronted with it. I began consulting with patients in Stanford’s oncology service who had been diagnosed with untreatable cancer. At that time I attended a lecture by Elisabeth Kübler-Ross, a pioneer in working with the dying, and was struck by her first question to a seriously ill patient: “How sick are you?” I found that question to be of great value: it conveys so much—namely, that I am open and willing to go wherever the patient wishes, even into the darkest places.

  I was particularly struck by the great isolation that comes with facing a terminal illness. The isolation is bidirectional: first, patients refrain from discussing their morbid, frightening thoughts, for fear of depressing their family and friends, and, second, those close to the patient stay clear of the subject to avoid upsetting the patient even more. The more patients with cancer I saw, the more persuaded I became that a therapy group could help alleviate this isolation. The oncologists to whom I spoke of my plans were at first wary and unsupportive. This was still the early 1970s, and such a group felt rash and potentially noxious. Moreover, it was unprecedented: there was not a single report of a group for cancer patients in the scientific literature.

  But as I gained experience, I became even more persuaded that such a group could offer a great deal, and I began to spread the word in the Stanford medical community. Before long, Paula West, a patient with metastatic breast cancer, showed up at my office. She was to become important to me in my work with cancer patients. Though Paula was dealing with painful metastases in her spinal column, she faced her condition with extraordinary grace. Later I described my relationship with her in the story “Travels with Paula,” published in Momma and the Meaning of Life. The story begins:

  When she first entered my office, I was instantaneously captivated by her appearance: by the dignity in her bearing, by her radiant smile which gathered me in, by her shock of short, exuberantly boyish, glowing white hair, and by something I can only call luminosity, that seemed to emanate from her wise and intensely blue eyes.

  “My name is Paula West,” she said. “I have terminal cancer. But I am not a cancer patient.” And, indeed, in my travels with her through many years I never regarded her as a patient. She went on to describe in clipped, precise fashion her medical history: cancer of the breast diagnosed five years earlier, surgical removal of that breast, then cancer of the other breast, that breast also removed. Then came chemotherapy with its familiar awful entourage: nausea, vomiting, total loss of hair. And then radiation therapy, the maximum permitted. But nothing would slow the spread of her cancer—to her skull, spine, and the orbits of her eyes. Paula’s cancer demanded to be fed and, though the surgeons tossed it sacrificial offerings—her breasts, lymph nodes, ovaries, adrenal glands—it remained voracious.

  When I imagined Paula’s nude body I saw a chest crisscrossed with scars, without breasts, flesh, or muscle, like the rib-planks of some shipwrecked galleon, and below her chest, a surgically scarred abdomen, and all supported by thick, ungainly, steroid-thickened hips. In short, a fifty-five-year-old woman sans breasts, adrenals, ovaries, uterus, and, I’m sure, libido.

  I have always relished women with firm graceful bodies, full breasts, and a readily apparent sensuality. Yet the most curious thing happened to me the first time I met Paula: I found her quite beautiful and fell in love with her.

  Paula agreed to join a small group with three other dying patients. The five of us met for ninety minutes in a comfortable group room in the psychiatry building. I began by saying simply that all the members were dealing with cancer and that I believed we could help one another by sharing our thoughts and feelings.

  One of the members was Sal, a thirty-year-old man in a wheelchair who, like Paula, was larger than life. Though he had advanced multiple myeloma (a painful invasive bone cancer causing many fractured bones) and was encased in a full body cast from neck to thigh, his spirit was indomitable. The imminence of death had flooded his life with a new sense of meaning and so transformed him that he now thought of his illness as a ministry. He agreed to join the group hoping to help the others find similar deliverance.

  Although Sal entered our group six months too early—when it was still too small to give him the audience he sought—he found other platforms, primarily high schools, where he addressed troubled teenagers. I heard him deliver his message to them in a thundering voice.

  You want to corrupt your body with drugs? Want to kill it with booze, with grass, with cocaine? You want to smash your body in autos? Kill it? Throw it off the Golden Gate Bridge? You don’t want it? Well, then, give me your body! Let me have it. I need it. I’ll take it—I want to live!

 
I trembled when I heard him speak. The force of his delivery was augmented by the particular power we always give to the words of the dying. The high school students listened in silence, sensing, as I did, that he was speaking truly, that he no longer had time for game playing or pretense.

  Another patient, Evelyn, gravely ill with leukemia, provided Sal with another opportunity for ministry. Evelyn, wheeled into the group with a blood transfusion in process, told the group, “I know I’m dying: I can accept that. It no longer matters. But what does matter is my daughter. She is poisoning my final days!” Evelyn described her daughter as “a vindictive, unloving woman.” Months earlier, they had had a bitter and foolish argument after her daughter, caring for Evelyn’s cat, had fed it the wrong food. They hadn’t spoken since.

  After hearing her out, Sal spoke to her simply and passionately: “Listen to what I have to say, Evelyn. I’m dying, too. Let me ask: What does it matter what your cat eats? What does it matter who gives in first? You know you don’t have much time left. Let’s stop pretending. Your daughter’s love is the most important thing in the world to you. Don’t die, please don’t die, without telling her that! It will poison her life, she’ll never recover, and she’ll pass on the poison to her daughter! Break the cycle! Break the cycle, Evelyn!”

  Sal’s appeal worked. Although Evelyn died a few days later, the ward nurses told us that Evelyn, swayed by Sal’s words, had had a tearful reconciliation with her daughter. I was very proud of Sal. It was our group’s first triumph!

  After several months, I felt I had learned enough to begin working with larger numbers of patients. I also thought a homogeneous group might be more effective. The majority of patients I had seen in consultation had metastatic breast cancer, so I decided to form a group consisting entirely of patients with that disease. Paula began to recruit in earnest. We interviewed and accepted seven new patients and officially opened for business.