Lying on the Couch

by Irvin D. Yalom

  Ernest was puzzled. He looked her up and down, trying not to let his eyes linger on her bosom.

  "I think I need a harder and longer look—later." He smiled and glanced significantly at the growing audience, which would soon call him away.

  "Perhaps the name Nan Carlin might help."

  "Nan Carlin! Nan Carlin! Of course!" Ernest excitedly squeezed her shoulder, which jiggled her hand and splashed her coffee over her purse and skirt. He sprang up, circled the room awkwardly in search of a napkin, and finally returned with a wad of paper towels.

  While she blotted the coffee out of her skirt, Ernest rifled through his recollections of Nan Carlin. She had been one of his very first patients ten years ago, in the very beginning of his residency. The chief of training. Dr. Molay, a group therapy fanatic, had insisted that all residents start a therapy group during their first year. Nan Carlin had been one of the members of that group. Though it was years ago, it all came back clearly. Nan had been quite obese then—that was why he hadn't recognized her now. He remembered her also as shy and self-denigrating, again no resemblance to this self-possessed woman gazing at him. If he recalled. Nan was in the midst of a disintegrating marriage—yes, that was it. Her husband actually told her he was leaving her because she had gotten too fat. He charged her with breaking her marriage vows, claiming that she was deliberately dishonoring and disobeying him by making herself repulsive.

  "Do I remember?" Ernest responded. "I remember how shy you were in the group, how long it took you to utter a word. And then I remember how you changed, how angry you got at one of the men—Saul, I believe. You accused him, with good justification, of hiding behind his beard and lobbing grenades into the group."

  Ernest was showing off. He had a prodigious memory with near total retention, even years later, of individual and group psychotherapy sessions.

  Nan smiled and nodded vigorously. "I remember that group too: Jay, Mort, Bea, Germana, Irinia, Claudia. I was only in it for two or three months before I was transferred to the East Coast, but I think it saved my life. That marriage was destroying me."

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  "What a pleasure to learn you're in a better place. And that the group played a role in that. Nan, you look wonderful. Can it really be ten years? Honestly, honestly, and this is no therapist malarkey—^wasn't malarkey one of your favorite words.''" showing off again—"you look more confident, younger, more attractive. You feel that way, too?"

  She nodded and touched his hand as she spoke. "I'm in a very good place. Single, healthy, lean."

  "I remember you were always fighting the weight!"

  "That battle's been won. I'm really a new woman."

  "How have you done it? Maybe I should use your method." Ernest pinched a fold of belly between his fingers.

  "You don't need it. Men are lucky. They wear weight well—they even get rewarded with terms like powerful and husky. But my method? If you must know, I've had the help of a good doctor!"

  That was discouraging news to Ernest. "You've been in therapy all this time?"

  "No, I've stayed true to you, my one and only shrink!" She gave his hand a playful pat. "I'm talking about a doctor doctor, a plastic surgeon who carved me a new nose and waved his magic liposuction wand over my tummy."

  The room had filled, and Ernest listened to the introduction, which ended with the famihar "so please join me in welcoming Dr. Ernest Lash."

  Before rising, Ernest leaned over, clasped Nan's shoulder, and whispered, "Really good to see you. Let's talk some more later."

  He walked to the podium with his head in a swirl. Nan was beautiful. Absolutely stunning. And his for the taking. No woman had ever made herself more available to him. It was only a matter of finding the nearest bed—or couch.

  Couch. Yes, precisely! And therein lies the problem, Ernest reminded himself: ten years ago or not, she is still a patient and is off-limits. In the forbidden zone! No, not is —she was a patient, he thought, one of eight members of a therapy group for a few weeks. Aside from a pregroup screening session, I don't think I ever saw her in a one-to-one session.

  What difference does that makef A patient's a patient.

  Forever? After ten years? Sooner or later, patients graduate to full adulthood with all the concomitant privileges.

  Ernest yanked himself from his internal monologue and turned his attention to the audience.

  6 8 / Lying on the Couch

  "Why? Ladies and gentlemen, why write a book about bereavement? Look at the bereavement and loss section of this bookstore. The shelves groan with volumes. Why yet another book?"

  Even as he spoke, he continued the internal debate. She says she's never been better. She is not a psychiatric patient. She hasn't been in therapy for nine years! It's perfect. (/hy not, for Chrissakes? Two consenting adults!

  "As a psychological ailment, bereavement occupies a unique place. First of all, it is universal. No one our age ..."

  Ernest smiled and made eye contact with many people in the audience; he was good at that. He noted Nan in the last row, nodding and smiling. Sitting right next to Nan was a severe, attractive woman with short curly black hair, who seemed to be studying him intently. Was this another woman coming on? He caught her eye for just an instant. She turned away quickly.

  "No one our age," Ernest continued, "escapes bereavement. It is the one universal psychiatric ailment."

  No, that's the problem, Ernest reminded himself: Nan and I are not two consenting adults. I know too much about her. Because she's confided so much to me, she feels unusually tied to me. I remember her father died when she was a teenager —/ filled her father's role. I'd betray her if I got involved sexually with her.

  "Many have noted that it is easier to lecture to medical students about bereavement than about other psychiatric syndromes. Medical students understand it. Of all the psychiatric conditions, it most closely resembles other medical ailments, for example, infectious diseases or physical trauma. No other psychiatric ailment has such a precise onset, a specific identifiable cause, a reasonably predictable course, an efficient, time-limited treatment, and a well-defined specific end point."

  No, Ernest argued with himself, after ten years all bets are off. She may once have considered me fatherly. Sof That's then, this is now. She's experiencing me as an intelligent, sensitive male. Look at her: she's inhaling my words. She's incredibly attracted to me. Face it. I am sensitive. I am deep. How often does a single woman her age, any age, meet a man like me?

  "But, ladies and gentlemen, the fact that medical students or physicians or psychotherapists yearn for simple, straightforward diagnosis and treatment of bereavement does not make it so. To attempt to understand bereavement using a medical disease model is

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  to omit precisely that which is most human about us. Loss is not Hke a bacterial invasion, not like physical trauma; psychic pain is not analogous to somatic dysfunction; mind is not body. The amount, the nature, of the anguish we experience is determined not by the (or not only by the) nature of the trauma but by the meaning of the trauma. And meaning is precisely the difference between soma and psyche."

  Ernest was hitting his stride. He checked the faces in his audience to assure himself of their attention.

  Remember, Ernest chattered to himself, how she feared divorce because of her earlier experience with men, who used her sexually and then simply went on their wayf Remember how empty she feltf If I went home with her tonight, I'd simply be doing the same thing to her — I'd be another in a long string of exploiting men!

  "Let me give you an example of the importance of 'meaning' from my research. Consider this puzzle: two widows, recently bereaved, each having been married for forty years. One of the widows had gone through much suffering but had gradually reclaimed her life and enjoyed some periods of equanimity and, on occasion, even great pleasure. The other fared much worse: a year later, she was mired in deep depression, at times suicidal, and required ongoing
psychiatric attention. How can we account for the difference in outcome.'' It is a puzzle. Now let me offer a clue.

  "Though these two women resembled each other in many ways, they differed greatly in one significant respect: the nature of their marriages. One woman had had a tumultuous, conflicted marital relationship, the other a loving, mutually respectful, growing relationship. Now my question for you is: Which was which?"

  As Ernest waited for an answer from the audience, he caught Nan's eye again and thought. How do I know she'd feel empty? Or exploited? How about grateful? Maybe our relationship would lead somewhere. Maybe she's as sexually itchy as I am! Don't I ever get to be off duty? Do I have to be a shrink twenty-four hours a day? If I have to worry about the nuances of every single act, every relationship, I'll never get laid!

  Women, big boobs, getting laid . . . you're disgusting —he said to himself. Don't you have anything more important to do? Anything more elevated to think about?

  "Yes, exactly!" said Ernest to a woman in the third row who had ventured a reply. "You're right: the woman with the conflicted rela-

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  tionship had the worse outcome. Very good. I bet you've already read my book—or maybe you don't need to," Adoring smiles from the audience. Ernest guzzled them and continued. "But doesn't that seem counterintuitive? One might think that the widow who had had a deeply gratifying, loving, forty-year relationship might fare less well. After all, hasn't she had the greater loss.^

  "Yet, as you suggest, the reverse is often the case. There are several explanations. I think 'regret' is the key concept. Think of the anguish of the widow who feels, deep down, that she has spent forty years married to the wrong man. So her grief is not, or not only, for her husband. She is in mourning for her own life."

  Ernest, he admonished himself, there are millions, billions, of women in the world. There are probably a dozen in the audience tonight who'd love to make it with you, if you had enough guts to approach them. Just stay away from patients! Stay away from patients!

  But she's not a patient. She's a free woman.

  She saw you, and still sees you, unrealistically. You helped her; she trusted you. The transference was powerful. And you're trying to exploit it!

  Ten years! Transference is immortalf Where is that writ?

  Look at her! She's gorgeous. She adores you. When has a woman like that ever picked you out of a crowd and come on to you like that? Look at yourself. Look at your paunch. A few more pounds and you won't be able to see your fly. You want proof? There's your proof!

  Ernest's attention was so split that he began to feel dizzy. The split was a familiar one for him. On the one hand, genuine concern for patients, students, his public. And genuine concern, as well, for the real issues of existence: growth, regret, life, death, meaningfulness. On the other hand, his shadow: selfishness and carnality. Oh, he was adept at helping his patients reclaim their shadows, draw strength from them: power, vital energy, creative drive. He knew all the words; he loved Nietzsche's proclamation that the mightiest trees must sink deep roots, deep into darkness, deep into evil.

  Yet those fine words held little meaning for him. Ernest hated his dark side, hated its dominion over him. He hated thralldom, hated being driven by animal instinct, hated being enslaved by early programming. And today was the perfect example: his barnyard sniff-

  ing and crowing, his primitive lust for seduction and conquest— what were they if not fossils direct from the dawn of history? And his passion for the breast, for the kneading and the sucking. Pathetic! A relic from the nursery!

  Ernest clenched his fist and dug his nails into his palm, hard! Pay attention'. You've got a hundred people out therel Give them, as much as you can.

  "And another thing about the conflicted marital relationship: death freezes it in time. It is forever conflicted, forever unfinished, unsatisfactory. Think of the guilt! Think of the times the bereaved widow or widower says, 'If only I had. . . . ' I think that's one reason that bereavement as a result of sudden death, for example an automobile accident, is so very difficult. In these instances husband and wife had no time to say good-bye, no time for preparation—too much unfinished business, too much unresolved conflict."

  Ernest was rolling now, and his audience was attentive and quiet. He no longer looked at Nan.

  "Let me leave you with one last point before stopping for questions. Think for a moment of how mental health professionals evaluate the process of spousal bereavement. What is successful mourning? When is it over? One year? Two years? Common sense has it that the work of mourning is over when the bereaved person has sufficiently detached from the dead spouse to resume a functional hfe again. But it's more complex than that! Far more complex!

  "One of the most interesting findings of my research is that a substantial proportion of bereaved spouses—perhaps twenty-five percent—don't just resume life or return to their previous level of functioning but instead undergo a substantial amount of personal growth."

  Ernest loved this part; audiences always found it meaningful.

  ^'^ Personal growth is not the perfect term. I don't know what to call it—maybe heightened existential awareness would be better. I only know that a certain proportion of widows, and occasionally widowers, learn to approach life in a very different fashion. They develop a new appreciation for the preciousness of life. And a new set of priorities. How to characterize it? One might say that they learn to trivialize the trivialities. They learn to say no to the things they do not want to do, to devote themselves to those aspects of life that provide meaning: love of close friends and family. They also

  7 2. ^-^ Lying on the Couch

  learn to sip from their own creative springs, to experience the changing of the seasons and the natural beauty around them. Perhaps most important of all, they gain a keen sense of their own finiteness and, as a consequence, learn to live in the immediate present, instead of postponing life for some future moment: the weekend, summer vacation, retirement. I describe all this at greater length in my book and also speculate about the causes and antecedents of this existential awareness.

  "Now, for some questions." Ernest enjoyed fielding questions: "How long have you worked on the book?" "Were the case histories real and, if so, what about confidentiality?" "Your next book?" "The usefulness of therapy in bereavement?" Questions about therapy were always asked by someone in the midst of personal bereavement, and Ernest took great care to treat such questions delicately. Thus he pointed out that bereavement is self-limited—bereaved individuals, for the most part, are going to improve with or without therapy—and that no proof exists that, for the average bereaved person, those in therapy are better off at the end of a year than those not in therapy. But, lest he appear to be trivializing therapy, Ernest hastened to add that there is evidence that therapy may make the first year less painful and indisputable evidence for efficacy of therapy with bereaved people who suffer from intense guilt or anger.

  The questions were all routine and genteel—he had expected no less from a Palo Alto audience—not like the quarrelsome, irritating questions from a Berkeley crowd. Ernest glanced at his watch and signaled to his hostess that he was finished, closed his folder of notes, and sat down. After a formal statement of gratitude from the bookstore proprietor, a robust burst of applause broke out. A swarm of book purchasers surrounded Ernest. He smiled graciously as he signed each book. Perhaps it was sheer fancy, but it seemed to him that several attractive women looked at him with interest and held his gaze an extra second or two. He did not respond: Nan Car-lin was waiting for him.

  Slowly the crowd dispersed. Finally he was free to rejoin her. How should he handle this? A cappuccino in the bookstore cafe? A less public spot? Or perhaps simply a few minutes of conversation in the bookstore and let the whole confounded matter drop? What to do? Ernest's heart starting pounding again. He looked around the room. Where was she?

  Lying on the Couch r^^ 7 3

  Ernest closed his briefca
se and rushed, searching, through the bookstore. No sign of Nan. He poked his head back into the reading room to take one last look. It was entirely empty aside from a woman sitting quietly in the seat that Nan had occupied—the severe, slender woman with short curly black hair. She had angry, penetrating eyes. Even so, Ernest tried again to catch her gaze. Again, she looked away.

  FOUR

  last-minute patient cancellation gave Dr. Marshal Streider a free hour before his weekly supervisory appointment with Ernest Lash. He had mixed feelings about the cancellation. He felt troubled about the depth of the patient's resistance: not for a minute did he buy the feeble excuse of a business trip, yet he welcomed the free time. The money was the same in either case: he would, of course, bill the patient for the hour regardless of the excuse.

  After returning phone calls and answering correspondence, Marshal stepped outside onto his small deck to water the four bonsais that sat on a wooden shelf outside his window: a snow rose with miraculously delicate exposed roots (some meticulous gardener had planted it so that it grew over a rock, and then four years later meticulously chipped away the rock); a gnarled five-needle pine, at least sixty years old; a nine-tree maple grove; and a juniper. Shirley, his wife, had spent the previous Sunday helping him shape the

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  juniper, and it looked transformed, much like a four-year-old after his first real haircut; they had clipped off all the shoots on the underside of the two opposing main branches, amputated a maverick forward-growing branch, and trimmed the tree into a jaunty scalene-triangle shape.

  Then Marshal indulged himself with one of his great pleasures: he turned to the stock tables of the Wall Street Journal and extracted from his wallet the two credit card-sized accoutrements that permitted him to calculate his profits: a magnifying sheet to read the small print of the market prices and a solar-powered calculator. A low-volume market yesterday. Nothing had moved except his largest holding, Silicon Valley Bank—bought on a good tip from an ex-patient—which was up one and an eighth; with fifteen hundred shares, that came to almost seventeen hundred dollars. He looked up from the stock tables and smiled. Life was good.