Lying on the Couch

by Irvin D. Yalom

  "My heart went out to her each time . . . you know, we really touched. We touched in such a way that dishonesty is now impossible between us. In fact, right after that moment in the last session she moved incredibly deep into truth . . . started talking in a remarkably candid manner . . . about sexual frustration . . . about going nuts if she doesn't get laid."

  "Well, I see you two have a lot in common."

  "Yeah, yeah. I'm working on it. Paul, stop with the bean sprouts. You in serious training for the anorexic Olympics? Here, try some of these sizzling scallops—house specialty. Why is it always left to me to do the work of two at dinner? Look at this halibut—it's beautiful."

  21 8 / Lying on the Couch

  "No, thanks, I get my mercury from chewing on thermometers."

  "Very funny. Christ, what a week! My patient Eva died a couple of days ago. You remember Eva—I told you about her—the wife, or the mother, I wish I had? Ovarian cancer? A writing teacher. A great lady."

  "She the one who had that dream of her father saying, 'Don't stay home and eat chicken soup like me—go, go to Africa.'"

  "Oh yes. I'd forgotten that. Yeah, that was Eva, all right. I'm going to miss her. This death hurts."

  "I don't know how you work with cancer patients like that. How do you bear it, Ernest? You go to her funeral?"

  "No. That's where I draw the line. I've got to protect myself— have a buffer zone. And I keep limits on the number of dying patients I see. I'm treating a patient now who is a psychiatric social worker in the oncology clinic and sees only cancer patients—all day long—and let me tell you, this woman is hurting."

  "It's a high-risk profession, Ernest. You see the suicide rates for oncologists? As high as for psychiatry! You've got to be masochistic to keep doing it."

  "It doesn't have to be all dark," Ernest replied. "You can get something out of it, too. If you work with dying patients and you're in therapy yourself, you get in touch with different parts of yourself, reorder your priorities, trivialize the trivia—I know I usually come out of therapy hours feeling better about myself and my life. This social worker had had a successful five-year analysis, but after working with dying patients all kinds of new material emerged. Her dreams, for example, were filled with death anxiety.

  "She had a lulu last week after one of her favorite patients died. She dreamed she was present at a committee meeting that I was conducting. She had to bring me some folders and had to pass by a large open window that reached all the way to the floor. She was angry at my indifference to the risk she had to take. Then a storm arose and I took charge of the group and led everyone up a staircase with metal stairs, like a fire escape. They all climbed up, but the stairs dead-ended at the ceiling—no place to go—and everyone had to come back down again."

  "In other words," replied Paul, "you and no one else are going to be able to protect her or to lead her out of this sickness unto death."

  "Exactly. But the point I wanted to make is that, in five years of analysis, the topic of her mortality never even surfaced."

  Lying on the Couch ^ 2.19

  "It almost never does with my therapy patients either."

  "You have to go after it. It's always percolating under the surface."

  "So, what about you, Ernest, with all this ontological confrontation? New material coming up—does that mean more therapy in store?"

  "That's why I'm writing the book on death anxiety. Remember Hemingway used to say that his Corona was his therapist."

  "Corona cigar?"

  "Typewriter. Before your time. And, in addition to my writing, you're giving me good therapy."

  "Right, and here's my bill for the night." Paul signaled for the check and gestured that it be given to Ernest. He looked at his watch. "You've got to be at the bookstore in twenty minutes. Brief me quickly about your self-disclosure experiment with that new patient. What's she like?"

  "Strange lady. Highly intelligent, competent, yet strangely naive. Bad marriage—I'd like to get her to the point where she can find a way out of it. Wanted to divorce a couple of years ago, but her husband came down with prostatic cancer and now she feels bound to him for his remaining years. Her only successful previous therapy was with an East Coast psychiatrist. And—now catch this, Paul— she had a long sexual affair with this guy! He died a few years ago. Damnedest thing, she insists it was healing—she swears by this guy. That's a first for me. I've never known a patient who claimed sex with a therapist was helpful. Have you?"

  "Helpful? Helped the therapist get his rocks off! But for the patient—always bad news for the patient!"

  "How can you say 'always'? One minute ago I told you about a case where it was helpful. Let's not let the facts stand in the way of scientific truth!"

  "Right, Ernest. I stand corrected. Let me try to be objective. Let's see, let me think. I remember that case you were involved with a few years ago as expert witness—Seymour Trotter, wasn't it? He claimed it helped his patient—that it was the only way he could treat her successfully. But that guy was so narcissistic—a menace—who can believe him? Years ago I once worked with a patient who had slept a couple of times with her aging therapist after his wife died. A 'mercy fuck,' she called it. Claims it neither particularly hurt nor helped—but, if anything, it was more positive than negative.

  "Of course," Paul continued, "there have been many therapists

  2-2.0 Ssi- Lying on the Couch

  who got involved with patients and then married them. Gotta count them, too. I've never seen any data on that. Who knows about the fate of those marriages—maybe they work out better than we'd predict! The truth is, we just don't have the data. We know about the casualties only. In other words we just know the numerator, but not the denominator."

  "Strange," said Ernest, "that's exactly—word for word—the argument my patient presented."

  "Well, it's obvious: We know the casualties but not the total pool from which they spring. Maybe there are patients out there who profited from such a relationship and we never hear about them! The reasons for their silence are not hard to imagine. First, it's not the kind of thing you talk publicly about. Second, maybe they were helped and we don't hear about them because they don't come for more therapy. Third, if it were a good experience, then they would try to protect their therapist-lover with silence.

  "So, Ernest, there's the answer to your question about scientific truth. Now I've paid my homage to science. But, for me, the question of therapist-patient sex is a moral question; there's no way science is going to prove to me that immorality is moral. I believe sex with your patients is not therapy or love—it's exploitation, violation of a trust. Yet, I don't know what to do with your series of one patient who says otherwise—no reason why this patient should lie to you!"

  Ernest paid the check. As they left the restaurant for the short walk to the bookstore, Paul asked, "So . . . tell me more about the experiment. How much are you revealing?"

  "I'm breaking new ground with my own transparency, but it's not going the way I had hoped. Not what I had in mind."

  "Why not?"

  "Well, I had wanted a more human, more existential, kind of revelation—one that would result in a 'here we are together facing the exigencies of existence.' I thought I'd be talking about my here-and-now feelings about her, about our relationship, about my own anxieties, the fundamental concerns she and I share. But she doesn't ask about anything deep or meaningful; instead she's pressing me on trivial stuff: my marriage, my dating practices."

  "How do you answer her?"

  "I'm struggling to find my way. Trying to differentiate between responding authentically and satisfying prurient curiosity."

  "What does she want from you?"

  "Rehef. She's caught up in a miserable hfe situation but generally fixates narrowly on her sexual frustration. She's got a real sexual itch. And she's taken to hugging me at the end of each session."

  "Hugging? And you go along with that?"

  "Why not? I'm experimenting
with a complete relationship. In your hermitage you may be losing sight of the fact that in the real world people touch all the time. It is not a sexual hug. I know sexual."

  "And I know you. Careful, Ernest."

  "Paul, let me set your mind at ease. Do you remember the passage in Memories, Dreams, and Reflections where Jung says that the therapist must invent a new therapy language for each patient? The more I think about his words, the more inspired they seem. I think it's the most interesting thing Jung ever said about psychotherapy, except that I don't think he took it far enough, didn't realize it wasn't the invention of a new language or, indeed, a new therapy for each patient but the inventing that was important! In other words, what's important is the process of the therapist and patient working, inventing together in honesty. That's something I learned from old Seymour Trotter."

  "Great teacher," Paul replied. "Look where he ended up."

  On a beautiful Caribbean beach^ Ernest was tempted to say, but said instead: "Don't dismiss everything about him. He knew a thing or two. But with this patient—it'll be easier to talk about her if I give her a name; let's call her Mary—with Mary I'm taking all of this very seriously. I'm committed to being totally honest with her, and so far the result feels pretty authentic. And the hug is just one part of that—it's no big deal. This is a touch-deprived woman, and touch is just a symbol of caring. Trust me, the hug represents agape, not lust."

  "But, Ernest, I believe you. I believe that's what the hug represents for you. But to her} What's it mean to her?"

  "Let me answer by telling you about a talk I heard last week on the nature of the therapeutic bond. The speaker described a terrific dream of one of his patients toward the end of therapy. The patient dreamed that she and her therapist were attending a conference together at a hotel. At some point the therapist suggested she get a room adjoining his, so they could sleep together. She went to the desk and arranges it. Then a little later the therapist changes his

  2-2.2 Sz- Lying on the Couch

  mind and says it's not a good idea. So she then goes back to the desk to cancel the transfer. But it's too late. All of her things had been moved to the new room. It turns out that the new room is a much nicer room—larger, higher, better view. And, numerologically, the room number, 929, is more propitious."

  "Nice. Nice. I get the point," said Paul: "with the hope of sexual union the patient makes some important positive changes—the better room. By the time the hope of sex proves to be mere illusion, the changes are irreversible—she can't change back again, any more than she could get her old hotel room again."

  "Exactly. So that's my answer to you. It's the key to my strategy with Mary."

  They strolled in silence for a few minutes and then Paul said, "When I was a medical student at Harvard, I remember Elvin Sem-rad—a marvelous teacher—saying something very similar . . . about the advantages, even the necessity, of some patients to have some sexual tension in the relationship. Still, it's a risky strategy for you, Ernest. I hope you got a big enough margin of safety. She attractive.''"

  "Very! Not necessarily my style, but, no question, a neat-looking woman."

  "Is it possible you're misreading her? Is it possible she's coming on to you? Wants a therapist to love her just like the last one?"

  "She does want that. But I'm going to use that for leverage in therapy. Trust me. And, for me, the hug is nonsexual. Avuncular."

  They stopped in front of Tower Bookstore. "Well, here we are," said Ernest.

  "We're early. Ernest, let me ask you one more thing before you go in. Tell me the truth: You enjoy the avuncular hugs with Mary?"

  Ernest hesitated.

  "The truth, Ernest."

  "Yes, I enjoy hugging her. I like this lady a lot. She wears this incredible perfume. If I didn't enjoy it, I wouldn't do it!"

  "Oh? That's an interesting comment. I thought this avuncular hug was for the patient."

  "It is. But if I didn't enjoy it, she'd sense it and the gesture would lose all authenticity."

  "Talk about mumbo-jumbo!"

  "Paul, we're talking about a quick friendly hug. I'm handling it."

  "Well, keep zipped up. Otherwise your tenure on the State Medical Ethics Board will be embarrassingly short. When's that board meeting? Let's meet for dinner."

  "Two weeks from tonight. I hear there's a new Cambodian restaurant."

  "My turn to select. Trust me, I've got a treat in store for you—a big macrobiotic surprise!"

  FOURTEEN

  he following evening Carol called Ernest at home, saying she felt panicked and needed an emergency session. Ernest spoke to her at length, gave her an appointment

  for the next morning, and offered to phone in a prescription for an

  anxiety-relieving drug to an all-night pharmacy.

  As she sat in the waiting room, Carol read through her notes of

  the previous session.

  called me an attractive, a very attractive, woman . . . gave me his home phone, asks me to call him there . . . probed deeply into my sex life .... reveals his personal life, his wife's death, dating, singles world . . . hugged me at end of session — longer than last time . . . says he enjoys me having sex fantasies about him, runs ten minutes over . . . strangely uncomfortable at accepting my money.

  Lying on the Couch . ^^ 2,2 5

  Things were progressing well, Carol thought. Inserting a micro-cassette into her miniature recorder, she slipped it into a porous straw purse bought especially for the occasion. She entered Ernest's office excited by the knowledge that the trap was set, that every word, every irregularity, would be captured.

  Seeing that the urgency of the previous evening had disappeared, Ernest turned his attention to understanding the panic attack. He and his patient, it quickly became apparent, held very different viewpoints. Ernest thought Carolyn's anxiety had been evoked by the previous session. She, on the other hand, claimed she was exploding with sexual tension and frustration, and continued her attempts to pry suggestions about possible sexual outlets from him.

  When Ernest inquired more systematically into Carol's sexual life, he got more than he bargained for. She described, in graphic detail, many masturbatory fantasies in which he played a prominent role. Without a trace of self-consciousness, she related her arousal at unbuttoning his shirt, kneeling before his chair in the office, unzipping his pants, slipping him into her mouth. She enjoyed the thought of bringing him, again and again, just to the point of orgasm and then slowing and waiting till he softened and then beginning over again. That, she said, was usually sufficient to bring her to orgasm as she masturbated. If not, she continued the fantasy by dragging him to the floor and imagining him lifting her skirt and hurriedly sliding her underpants to the side and pounding into her. Ernest listened attentively and tried not to squirm.

  "But masturbation," Carol continued, "has never really been satisfying to me. Partly, I believe, it's the shame attached to it. Except once or twice with Ralph, this is the first time I've talked about it with anyone—man or woman. The problem is that often it doesn't culminate in a full orgasm but, instead, I get a lot of minor sexual spasms that leave me still in a state of heightened arousal. I'm beginning to wonder if it might be my masturbation technique. Could you can give me some instruction about that?"

  Carol's question brought the blood to Ernest's face. He was getting used to her casualness about sex. In fact, he admired her ability to speak of her sexual practices—for example, the way she had, in the past, picked up men in bars whenever she traveled or was angry with her husband. It seemed all so easy, so natural for her. He thought of the hours of agony—and futility—he had endured in singles bars and at parties. He had spent a year in Chicago during his

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  internship. Why, oh why, Ernest thought, couldn't I have run into Carolyn when she was prowling Chicago barsf

  As for her question about masturbatory technique, what did he know about that? Virtually nothing, except for th
e obvious necessity of clitoral stimulation. People so often assumed psychiatrists knew more than they did.

  "I'm no expert in that, Carolyn." Where, Ernest wondered, did she imagine he could have learned about female masturbation? Medical school? Perhaps his next book should be Things They Didn't Teach You in Medical Schooll

  "The only thing that comes to mind now, Carolyn, is a lecture I heard by a sex therapist recently on the advisability of freeing the clitoris of all adhesions."

  "Oh, is that something you can check in a physical examination, Dr. Lash? That's okay with me."

  Ernest flushed again. "No, I hung up my stethoscope and did my last physical exam seven years ago. I'd suggest you bring this up with your gynecologist. Some women find it easier to speak of such things to a female gynecologist."

  "Is it different for men. Dr. Lash, I mean do you ... do men have a problem in masturbation with partial orgasm?"

  "Again, I'm no expert but I believe men generally have an all-or-nothing experience. Have you discussed this with Wayne?"

  "With Wayne? No, we don't talk about anything. That's why I ask you these questions. You're it. Right now you're the main man, the only man, in my life!"

  Ernest felt lost. His resolution to be honest offered no direction. Carolyn's aggressiveness was confusing him; he was losing his bearings. He turned to his touchstone, his supervisor, and tried to imagine how Marshal might have responded to Carolyn's question.

  The proper technique. Marshal would have said, was to obtain more data: to conduct a systematic, dispassionate sexual history, including the details of Carolyn's masturbation practice and accompanying fantasies—both current and past.