Lying on the Couch

by Irvin D. Yalom

  "Yes, yes, you can turn the recorder back on. I think I've answered your question about my feelings. So, we went along like this for over a year, struggling against outbreaks of symptoms. She'd have many slips, but on the whole we were doing well. I knew this was no cure. I was only 'containing' her, providing a holding environment, keeping her safe from session to session. But I could hear the clock ticking; she was growing restless and fatigued.

  "And then one day she came in looking all worn out. Some new, very clean stuff was on the streets, and she admitted she was very close to scoring some heroin. 'I can't keep living a life of total frustration,' she said. 'I'm trying like hell to make this work, but I'm running out of steam. I know me, I know me, I know how I operate. You're keeping me alive and I want to work with you. I think I can do it. But / need some incentive! Yes, yes, Seymour, I know what you're getting ready to say: I know your lines by heart. You're going to say that I already have an incentive, that my incentive is a better life, feeling better about myself, not trying to kill myself, self-respect. But that stuff is not enough. It's too far away. Too airy. I need to touch it. I need to touch it!'

  Lying on the Couch r"^ ^ 7

  "I started to say something placating, but she cut me off. Her desperation had escalated and out of it came a desperate proposition. 'Seymour, work with me. My way. I beg you. If I stay clean for a year—really clean, you know what I mean: no drugs, no purging, no bar scenes, no cutting, no nothing —then reward me! Give me some incentive! Promise to take me to Hawaii for a week. And take me there as man and woman—not shrink and sap. Don't smile, Seymour, I'm serious—dead serious. I need this. Seymour, for once, put my needs ahead of the rules. Work with me on this.'

  "Take her to Hawaii for a week! You smile, Ernest; so did I. Preposterous! I did as you would have done: I laughed it off. I tried to dismiss it as I had dismissed all of her previous corrupting propositions. But this one wouldn't go away. There was something more compelling, more ominous in her manner. And more persistent. She wouldn't let go of it. I couldn't move her off it. When I told her it was out of the question. Belle started negotiating: she raised the good-behavior period to a year and a half, changed Hawaii to San Francisco, and cut the week first to five and then to four days.

  "Between sessions, despite myself, I found myself thinking about Belle's proposition. I couldn't help it. I toyed with it in my mind. A year and a half— eighteen months —of good behavior? Impossible. Absurd. She could never do it. Why were we wasting our time even talking about it?

  "But suppose —just a thought experiment, I told myself—suppose that she were really able to change her behavior for eighteen months? Try out the idea, Ernest. Think about it. Consider the possibility. Wouldn't you agree that if this impulsive, acting-out woman were to develop controls, behave more ego-syntonically for eighteen months, off drugs, off cutting, off all forms of self-destruction, she'd no longer be the same person}

  "What? 'Borderline patients play games'? That what you said? Ernest, you'll never be a real therapist if you think like that. That's exactly what I meant earlier when I talked about the dangers of diagnosis. There are borderlines and there are borderlines. Labels do violence to people. You can't treat the label; you have to treat the person behind the label. So again, Ernest, I ask you: Wouldn't you agree that this person, not this label, but this Belle, this flesh and blood person, would be intrinsically, radically changed, if she behaved in a fundamentally different fashion for eighteen months?

  "You won't commit yourself? I can't blame you—considering

  18 ^ Lying on the Couch

  your position today. And the tape recorder. Well, just answer silently, to yourself. No, let me answer for you: I don't believe there's a therapist alive who wouldn't agree that Belle would be a vastly different person if she were no longer governed by her impulse disorder. She'd develop different values, different priorities, a different vision. She'd wake up, open her eyes, see reality, maybe see her own beauty and worth. And she'd see me differently, see me as you see me: a tottering, moldering, old man. Once reality intrudes, then her erotic transference, her necrophilia, would simply fade away and with it, of course, all interest in the Hawaiian incentive.

  "What's that, Ernest? Would I miss the erotic transference? Would that sadden me? Of course! Of course! I love being adored. Who doesn't? Don't you?

  "Come on, Ernest. Don't youf Don't you love the applause when you finish giving grand rounds? Don't you love the people, especially the women, crowding around?

  "Good! I appreciate your honesty. Nothing to be ashamed of. Who doesn't? Just the way we're built. So to go on, I'd miss her adoration, I'd feel bereft: but that goes with the territory. That's my job: to introduce her to reality, to help her grow away from me. Even, God save us, to forget me.

  "Well, as the days and the weeks went on, I grew more and more intrigued with Belle's wager. Eighteen months of being clean, she offered. And remember that was still an early offer. I'm a good negotiator and was sure I could probably get more, increase the odds, provide even more room. Really cement the change. I thought about other conditions I could insist upon: some group therapy for her, perhaps, and a more strenuous attempt to get her husband into couples therapy.

  "I thought about Belle's proposition day and night. Couldn't get it out of my mind. I'm a betting man, and the odds in my favor looked fantastic. If Belle lost the bet, if she slipped—by taking drugs, purging, cruising bars, or cutting her wrists— nothing would be lost. We'd merely be back to where we were before. Even if I got only a few weeks or months of abstinence, I could build on that. And if Belle won, she'd be so changed that she would never collect. This was a no-brainer. Zero risk downside and a good chance upside that I could save this woman.

  "I've always liked action, love the races, bet on anything—baseball, basketball. After high school I joined the navy and put myself

  Lying on the Couch .-'^^ ^ 9

  through college on my shipboard poker winnings; in my internship at Mount Sinai in New York I spent many of my free nights in a big game on the obstetrics unit with the on-call Park Avenue obstetricians. There was a continuous game going on in the doctors' lounge next to the labor room. Whenever there was an open hand, they called the operator to page 'Dr. Blackwood.' Whenever I heard the page, 'Dr. Blackwood wanted in the delivery room,' I'd charge over as fast as I could. Great docs, every one of them, but poker chumps. You know, Ernest, interns were paid almost nothing in those days, and at the end of the year all the other interns were in deep debt. Me? I drove to my residency at Ann Arbor in a new De Soto convertible, courtesy of the Park Avenue obstetricians.

  "Back to Belle. I vacillated for weeks about her wager and then, one day, I took the plunge. I told Belle I could understand her needing incentive, and I opened serious negotiation. I insisted on two years. She was so grateful to be taken seriously that she agreed to all my terms, and we quickly fashioned a firm, clear contract. Her part of the deal was to stay entirely clean for two years: no drugs (including alcohol), no cutting, no purging, no sex pickups in bars or highways or any other dangerous sex behavior. Urbane sexual affairs were permitted. And no illegal behavior. I thought that covered everything. Oh, yes, she had to start group therapy and promise to participate with her husband in couples therapy. My part of the contract was a weekend in San Francisco: all details, hotels, activities were to be her choice—carte blanche. I was to be at her service.

  "Belle treated this very seriously. At the finish of negotiation, she suggested a formal oath. She brought a Bible to the session and we each swore on it that we would uphold our part of the contract. After that we solemnly shook hands on our agreement.

  "Treatment continued as before. Belle and I met approximately two times a week—three might have been better, but her husband began to grumble about the therapy bills. Since Belle stayed clean and we didn't have to spend time analyzing her 'slips,' therapy went faster and deeper. Dreams, fantasies—everything seemed more accessible. For the fir
st time I began to see seeds of curiosity about herself; she signed up for some university extension courses on abnormal psychology, and she began writing an autobiography of her early life. Gradually she recalled more details of her childhood, her sad search for a new mother among the string of disinterested governesses, most of whom left within a few months because of her

  2-0 Szr^ Lying on the Couch

  father's fanatical insistence on cleanliness and order. His germ phobia controlled all aspects of her life. Imagine: until she was fourteen she was kept out of school and educated at home because of his fear of her bringing home germs. Consequently she had few close friends. Even meals with friends were rare; she was forbidden to dine out and she dreaded the embarrassment of exposing her friends to her father's dining antics: gloves, hand washing between courses, inspections of the servants' hands for cleanliness. She was not permitted to borrow books—one beloved governess was fired on the spot because she permitted Belle and a friend to wear each other's dresses for a day. Childhood and daughterhood ended sharply at fourteen, when she was sent to boarding school at Grenoble. From then on, she had only perfunctory contact with her father, who soon remarried. His new wife was a beautiful woman but a former prostitute—according to a spinster aunt, who said the new wife was only one of many whores her father had known in the previous fourteen years. Maybe, Belle wondered—and this was her very first interpretation in therapy— he felt dirty, and that was why he was always washing and why he refused to let his skin touch hers.

  "During these months Belle raised the topic of our wager only in the context of expressing her gratitude to me. She called it the 'most powerful affirmation' she'd ever gotten. She knew that the wager was a gift to her: unlike 'gifts' she had received from other shrinks— words, interpretations, promises, 'therapeutic caring'—this gift was real and palpable. Skin to skin. It was tangible proof that I was entirely committed to helping her. And proof to her of my love. Never before, she said, had she ever been loved like that. Never before had anyone put her ahead of his self-interests, ahead of the rules. Certainly not her father, who never gave her an ungloved hand and until his death ten years ago sent her the same birthday present every year: a bundle of hundred-dollar bills, one for every year of her age, each bill freshly washed and ironed.

  "And the wager had another meaning. She was tickled by my willingness to bend the rules. What she loved best about me, she said, was my willingness to take chances, my open channel to my own shadow. 'There's something naughty and dark about you, too,' she'd say. 'That's why you understand me so well. In some ways I think we are twin brains.'

  "You know, Ernest, that's probably why we hit it off so quickly, why she knew immediately that I was the therapist for her—just

  Lying on the Couch ^ ^ 2. i

  something mischievous in my face, some irreverent twinkle in my eyes. Belle was right. She had my number. She was a smart cookie.

  "And you know, I knew exactly what she meant—exactly! I can spot it in others the same way. Ernest, just for a minute, turn off the recorder. Good. Thanks. What I wanted to say is that I think I see it in you. You and I, we sit on different sides of this dais, this judgment table, but we have something in common. I told you, I'm good at reading faces. I'm rarely wrong about such things.

  "No? C'mon! You know what I mean! Isn't it precisely for this reason that you listen to my tale with such interest? More than interest! Do I go too far if I call it fascination} Your eyes are like saucers. Yes, Ernest, you and me. You could have been me in my situation. My Faustian wager could have been yours as well.

  "You shake your head. Of course! But I don't speak to your head. I aim straight at your heart, and the time may come when you open yourself to what I say. And more—perhaps you will see yourself not only in me but in Belle as well. The three of us. We're not so different from one another! Okay, that's all—let's get back to business.

  "Wait! Before you turn the recorder back on, Ernest, let me say one more thing. You think I give a shit about the ethics committee? What can they do? Take away hospital admitting privileges? I'm seventy, my career is over, I know that. So why do I tell you all this? In the hope that some good will come of it. In the hope that maybe you'll allow some speck of me into you, let me course in your veins, let me teach you. Remember, Ernest, when I talk about your having an open channel to your shadow, I mean that positively —I mean that you may have the courage and largeness of spirit to be a great therapist. Turn the recorder back on, Ernest. Please, no reply is necessary. When you're seventy, you don't need replies.

  "Okay, where were we? Well, the first year passed with Belle definitely doing better. No slips whatsoever. She was absolutely clean. She placed fewer demands on me. Occasionally she asked to sit next to me, and I'd put my arm around her and we'd spend a few minutes sitting like that. It never failed to relax her and make her more productive in therapy. I continued to give her fatherly hugs at the end of sessions, and she usually planted a restrained, daughterly kiss on my cheek. Her husband refused couples therapy but agreed to meet with a Christian Science practitioner for several sessions. Belle told me that their communication had improved, and both of them seemed more content with their relationship.

  2-2. -- Lying on the Couch

  "At the sixteen-month mark, all was still well. No heroin—no drugs at all—no cutting, bulimia, purging, or self-destructive behavior of any sort. She got involved with several fringe movements—a channeler, a past-lives therapy group, an algae nutritionist, typical California flake stuff, harmless. She and her husband had resumed their sexual life, and she did a little sexual acting out with my colleague—that jerk, that asshole, she met at the tennis club. But at least it was safe sex, a far cry from the bar and highway escapades.

  "It was the most remarkable therapy turnabout I've ever seen. Belle said it was the happiest time of her life. I challenge you, Ernest: plug her into any of your outcome studies. She'd be the star patient! Compare her outcome with any drug therapy: Risperidone, Prozac, Paxil, Effexor, Wellbutrin—you name it—my therapy would win hands down. The best therapy I've ever done, and yet I couldn't publish it. Publish it? I couldn't even tell anyone about it. Until now! You're my first real audience.

  "At about the eighteen-month mark, the sessions began to change. It was subtle at first. More and more references to our San Francisco weekend crept in, and soon Belle began to speak of it at every session. Every morning she'd stay in bed for an extra hour daydreaming about what our weekend would be like: about sleeping in my arms, phoning for breakfast in bed, then a drive and lunch in Sausalito, followed by an afternoon nap. She had fantasies of our being married, of waiting for me in the evenings. She insisted that she could live happily the rest of her life if she knew that I'd come back home to her. She didn't need much time with me; she'd be willing to be a second wife, to have me next to her for only an hour or two a week—she could live healthy and happy with that forever.

  "Well, you can imagine that by this time I was growing a little uneasy. And then a lot uneasy. I began to scramble. I did my best to help her face reality. Practically every session I talked about my age. In three or four years I'd be in a wheelchair. In ten years I'd be eighty. I asked her how long she thought I would live. The males in my family die young. At my age my father had been in his coffin for fifteen years. She would outlive me at least twenty-five years. I even began exaggerating my neurological impairment when I was with her. Once I staged an intentional fall—that's how desperate I was growing. And old people don't have much energy, I repeated. Asleep at eight-thirty, I'd tell her. Been five years since I'd been awake for the ten o'clock news. And my failing vision, my shoulder bursitis,

  my dyspepsia, my prostate, my gassiness, my constipation. I even thought of getting a hearing aid, just for the effect.

  "But all this was a terrible blunder. One hundred eighty degrees wrong! It just whet her appetite even more. She had some perverse infatuation with the idea of my being infirm or incapacitated. She had fa
ntasies of my having a stroke, of my wife leaving me, of her moving in to care for me. One of her favorite daydreams involved nursing me: making my tea, washing me, changing my sheets and my pajamas, dusting me with talcum powder, and then taking off her clothes and climbing under the cool sheets next to me.

  "At the twenty-month mark. Belle's improvement was even more pronounced. On her own she had gotten involved with Narcotics Anonymous and was attending three meetings a week. She was doing volunteer work at ghetto schools to teach teenage girls about birth control and AIDS, and had been accepted in an MBA program at a local university.

  "What's that, Ernest? How did I know she was telhng me the truth? You know, I never doubted her. I know she has her character flaws but truth telling, at least with me, seemed almost a compulsion. Early in our therapy—I think I mentioned this before—we established a contract of mutual and absolute truth telling. There were a couple of times in the first few weeks of therapy when she withheld some particularly unseemly episodes of acting out, but she couldn't stand it; she got into a frenzy about it, was convinced that I could see inside her mind and would expel her from therapy. In each instance she could not wait till the next session to confess but had to phone me—once after midnight—to set the record straight.

  "But your question is a good one. Too much was riding on this to simply take her word for it, and I did what you would have done: I checked all possible sources. During this time I met with her husband a couple of times. He refused therapy but agreed to come in to help accelerate the pace of Belle's therapy, and he corroborated everything she said. Not only that but he gave me permission to contact the Christian Science counselor—who, ironically enough, was getting her Ph.D. in clinical psychology and was reading my work— and who also corroborated Belle's story: working hard on her marriage, no cutting, no drugs, community volunteer work. No, Belle was playing it straight.