Love's Executioner and Other Tales of Psychotherapy

by Irvin D. Yalom

  Witnessing Carlos’s alarming weight loss reminded Betty of how, over a twelve-month period, she had watched her father shrink from an obese man to a skeleton wrapped in great folds of spare skin. Though she acknowledged that it was an irrational thought, Betty realized that since her father’s death she had believed that weight loss would make her susceptible to cancer.

  She had strong feelings about hair loss as well. When she first joined the group, Carlos (who had lost his hair as a result of chemotherapy) was wearing a toupee, but the day he informed the group about his cancer, he came bald to the meeting. Betty was horrified, and visions of her father’s baldness—he had been shaven for his brain surgery—returned to her. She remembered also how frightened she had been when, on previous strenuous diets, she herself had suffered considerable hair loss.

  These disturbing feelings had vastly compounded Betty’s weight problems. Not only did food represent her sole form of gratification, not only was it a method of assuaging her feeling of emptiness, not only did thinness evoke the pain of her father’s death, but she felt, unconsciously, that losing weight would result in her death.

  Gradually Betty’s acute anxiety subsided. She had never before talked openly about these issues: perhaps the sheer catharsis helped; perhaps it was useful for her to recognize the magical nature of her thinking; perhaps some of her horrifying thoughts were simply desensitized by talking about them in the daylight in a calm, rational manner.

  During this time, Carlos was particularly helpful. Betty’s parents had, until the very end, denied the seriousness of her father’s illness. Such massive denial always plays havoc with the survivors, and Betty had neither been prepared for his death nor had the opportunity to say goodbye. But Carlos modeled a very different approach to his fate: he was courageous, rational, and open with his feelings about his illness and his approaching death. Furthermore, he was especially kind to Betty—perhaps it was that he knew she was my patient, perhaps that she came along when he was in a generous (“everybody has got a heart”) state of mind, perhaps simply that he always had a fondness for fat women (which, I am embarassed to say, I had always considered further proof of his perversity).

  Betty must have felt that the obstructions to losing weight had been sufficiently removed because she gave unmistakable evidence that a major campaign was about to be launched. I was astonished by the scope and complexity of the preparatory arrangements.

  First, she enrolled in an eating-disorder program at the clinic where I worked and completed their demanding protocol, which included a complex physical workup and a battery of psychological tests. She then cleared her apartment of food—every can, every package, every bottle. She made plans for alternative social activities: she pointed out to me that eliminating lunches and dinners puts a crimp into one’s social calendar. To my surprise, she joined a square-dancing group (this lady’s got guts, I thought) and a weekly bowling league—her father had often taken her bowling when she was a child, she explained. She bought a used stationary bicycle and set it up in front of her TV set. She then said her goodbyes to old friends—her last Granny Goose Hawaiian-style potato chip, her last Mrs. Fields chocolate chip cookie, and, toughest of all, her last honey-glazed doughnut.

  There was considerable internal preparation as well, which Betty found difficult to describe other than to say she was “gathering inner resolve” and waiting for the right moment to commence the diet. I grew impatient and amused myself with a vision of an enormous Japanese sumo wrestler pacing, posturing, and grunting himself into readiness.

  Suddenly she was off! She went on a liquid Optifast diet, ate no solid food, bicycled forty minutes every morning, walked three miles every afternoon, and bowled and square-danced once a week. Her fatty casing began to disintegrate. She began to shed bulk. Large folds of overhanging flesh broke off and were washed away. Soon the pounds flowed off in rivulets—two, three, four, sometimes five pounds a week.

  Betty started each hour with a progress report: ten pounds lost, then twenty, twenty-five, thirty. She was down to two hundred forty pounds, then two hundred thirty, and two hundred twenty. It seemed astonishingly fast and easy. I was delighted for her and commended her strongly each week on her efforts. But in those first weeks I was also aware of a cruel voice within me, a voice saying, “Good God, if she’s losing it that fast, think of how much food she must have been putting away!”

  The weeks passed, the campaign continued. After three months, she weighed in at two hundred ten. Then two hundred, a fifty-pound loss! Then one hundred ninety. The opposition stiffened. Sometimes she came into my office in tears after a week without food and no compensating weight loss. Every pound put up a fight, but Betty stayed on the diet.

  Those were ghastly months. She hated everything. Her life was a torment—the disgusting liquid food, the stationary bicycle, the hunger pangs, the diabolic McDonald’s hamburger ads on television, and the smells, the ubiquitous smells: popcorn in the movies, pizza in the bowling alley, croissants in the shopping center, crab at Fisherman’s Wharf. Was there nowhere in the world an odor-free place?

  Every day was a bad day. Nothing in her life gave her pleasure. Others in the eating-disorder clinic’s weight-reduction group gave up—but Betty hung tough. My respect for her grew.

  I like to eat, too. Often I look forward all day to a special meal; and, when the craving strikes, no obstacle can block my way to the dim sum restaurant or the gelato stand. But as Betty’s ordeal continued, I began to feel guilty eating—as though I were acting in bad faith toward her. Whenever I sat down to eat pizza or pasta al pesto or enchiladas con salsa verde or German-chocolate-cake ice cream, or any other special treat I knew Betty liked, I thought of her. I shuddered when I thought of her dining, can opener in hand, on Optifast liquid. Sometimes I passed up seconds in her honor.

  It happened that, during this period, I passed the upper weight limit I allow myself, and went on a three-week diet. Since my diets consist primarily of eliminating ice cream and French fries, I could hardly say to Betty that I was joining hands with her in a sympathy fast. Nonetheless, during these three weeks I felt her deprivation more keenly. I was moved now when she told me how she cried herself to sleep. I ached for her when she described the starving child within her howling, “Feed me! Feed me!”

  One hundred eighty. One hundred seventy. An eighty-pound weight loss! Betty’s mood now fluctuated wildly, and I grew increasingly concerned for her. She had occasional brief periods of pride and exhilaration (especially when she went shopping for slimmer clothing), but mainly she experienced such deep despondency that it was all she could do to get herself to work each morning.

  At times she grew irritable and raised several old grievances with me. Had I referred her to a therapy group as a way of dumping her or, at least, sharing the load and getting her partly off my hands? Why had I not asked her more about her eating habits? After all, eating was her life. Love her, love her eating. (Careful, careful, she’s getting close.) Why had I not disagreed with her when she listed the reasons that medical school was not possible for her (her age, lack of stamina, laziness, having taken few of the prerequisite courses, and lack of funds)? She viewed, she told me now, my suggestion about a possible career in nursing as a put-down, and accused me of saying, “The girl’s not smart enough for medical school—so let her be a nurse!”

  At times, she was petulant and regressed. Once, for example, when I inquired about why she had become inactive in her therapy group, she simply glared and refused to answer. When I pressed her to say exactly what was on her mind, she said in a singsong child’s voice, “If I can’t have a cookie, I won’t do anything for you.”

  During one of her depressed periods, she had a vivid dream.

  I was in a place like Mecca where people go to commit suicide legally. I was with a close friend but I don’t remember who. She was going to commit suicide by jumping down a deep tunnel. I promised her I’d retrieve her body but, later, I realized that to do this I’d have
to crawl down this terrible tunnel with all sorts of dead and decaying bodies around and I didn’t think I could do it.

  In associating to this dream Betty said that, earlier the day of the dream, she had been thinking that she had shed a whole body: she had lost eighty pounds, and there was a woman in her office who weighed only eighty pounds. At the time she had imagined granting an autopsy and holding a funeral for the “body” she had shed. This macabre thought, Betty suspected, was echoed in the dream image of retrieving her friend’s dead body from the tunnel.

  The imagery and depth of the dream brought home to me how far she had come. It was hard to remember the giggling, superficial woman of a few months before. Betty had my full attention for every minute of every session now. Who could have imagined that, out of that woman whose vacuous chatter had so bored me and her previous psychiatrist, this thoughtful, spontaneous, and sensitive person could have emerged?

  One hundred sixty-five. Another kind of emergence was taking place. One day in my office I looked over at Betty and noticed, for the first time, that she had a lap. I looked again. Had it always been there? Maybe I was paying more attention to her now. I didn’t think so: her body contour, from chin to toes, had always been smoothly globular. A couple of weeks later, I saw definite signs of a breast, two breasts. A week later, a jawline, then a chin, an elbow. It was all there—there had been a person, a handsome woman, buried in there all the time.

  Others, especially men, had noticed the change, and now touched and poked her during conversations. A man at the office walked her out to her car. Her hairdresser, gratuitously, gave her a scalp massage. She was certain her boss was eyeing her breasts.

  One day Betty announced, “one hundred fifty-nine,” and added that this was “virgin territory”—that is, she hadn’t weighed in the one hundred fifties since high school. Though my response—asking whether she worried about entering “nonvirgin territory”—was a sorry joke, it nonetheless initiated an important discussion about sex.

  Though she had an active sexual fantasy life, she had never had any physical contact with a man—not a hug, not a kiss, not even a lascivious grab. She had always craved sex and was angry that society’s attitude toward the obese sentenced her to sexual frustration. Only now, when she was approaching a weight when sexual invitations might materialize, only now when her dreams teemed with menacing male figures (a masked doctor plunging a large hypodermic needle into her abdomen, a leering man peeling the scab off a large abdominal wound), did she recognize that she was very frightened of sex.

  These discussions released a flood of painful memories about a lifetime of rejection by males. She had never been asked on a date and never attended a school dance or party. She played the confidante role very well and had helped many friends plan their weddings. They were just about all married off now, and she could no longer conceal from herself that she would forever play the role of the unchosen observer.

  We soon moved from sex into the deeper waters of her basic sexual identity. Betty had heard that her father had really wanted a son and been silently disappointed when she was born. One night she had two dreams about a lost twin brother. In one dream she and he wore identification badges and kept switching them with each other. She finished him off in another dream: he squeezed into a crowded elevator into which she couldn’t fit (because of her size). Then the elevator crashed, killing all the passengers, and she was left sifting through his remains.

  In another dream, her father gave her a horse called “She’s a Lady.” She had always wanted a horse from him, and in the dream not only was that childhood wish fulfilled but her father officially christened her a lady.

  Our discussions about sexual practice and her sexual identity generated so much anxiety and such an agonizing sense of emptiness that, on several occasions, she binged on cookies and doughnuts. By now Betty was permitted some solid food—one diet TV dinner a day—but found this more difficult to follow than the liquid-only diet.

  Looming ahead was an important symbolic marker—the loss of the one-hundredth pound. This specific goal, never to be attained, had powerful sexual connotations. For one thing Carlos had, months before, only half jokingly told Betty he was going to take her to Hawaii for a weekend when she had lost a hundred pounds. Furthermore, as part of her pre-diet mental preparation, Betty had vowed herself that when she lost a hundred pounds she was going to contact George, the man whose personal ad she had answered, to surprise him with her new body and reward his gentlemanly behavior with her sexual favors.

  In an effort to reduce her anxiety, I urged moderation and suggested she approach sex with less drastic steps: for example, by spending time talking to men; by educating herself about such topics as sexual anatomy, sexual mechanics, and masturbation. I recommended reading material and urged her to visit a female gynecologist and to explore these issues with her girlfriends and her therapy group.

  Throughout this period of rapid weight loss, another extraordinary phenomenon was taking place. Betty experienced emotional flashbacks and would spend much of a therapy hour tearfully discussing startlingly vivid memories, such as the day she left Texas to move to New York, or her college graduation, or her anger at her mother for being too timid and fearful to attend her high school graduation.

  At first it seemed that these flashbacks, as well as the accompanying extreme mood swings, were chaotic, random occurrences; but after several weeks, Betty realized that they were following a coherent pattern: as she lost weight she re-experienced the major traumatic or unresolved events of her life that had occurred when she was at a particular weight. Thus her descent from two hundred fifty pounds set her spinning backward in time through the emotionally charged events of her life: leaving Texas for New York (210 pounds), her college graduation (190 pounds), her decision to drop the pre-med curriculum (and to give up the dream of discovering the cure for the cancer that killed her father) (180 pounds), her loneliness at her high school graduation—her envy of other daughters and fathers, her inability to get a date for the senior prom (170 pounds), her junior high graduation and how much she missed her father at that graduation (155 pounds). What a wonderful proof of the unconscious realm! Betty’s body had remembered what her mind had long forgotten.

  Memories of her father permeated these flashbacks. The closer we looked, the more apparent it was that everything led back to him, to his death, and to the one hundred fifty pounds Betty weighed at that time. The closer she approached that weight, the more depressed she grew and the more her mind swarmed with feelings and recollections of her father.

  Soon we spent entire sessions talking about her father. The time had come to unearth everything. I plunged her into reminiscence and encouraged her to express everything she could remember about his illness, his dying, his appearance in the hospital the last time she saw him, the details of his funeral, the clothes she wore, the minister’s speech, the people who attended.

  Betty and I had talked about her father before but never with such intensity and depth. She felt her loss as never before and, over a two-week period, wept almost continuously. We met thrice weekly during this time, and I attempted to help her understand the source of her tears. In part she cried because of her loss, but in large part because she considered her father’s life to have been such a tragedy: he never obtained the education he wanted (or that she wanted for him), and he died just before he retired and never enjoyed the years of leisure for which he had longed. Yet, as I pointed out to her, her description of his life’s activities—his large extended family, his wide social circle, his daily bull sessions with friends, his love of the land, his youth in the navy, his afternoons fishing—was a picture of a full life in which her father was immersed in a community of people who knew and loved him.

  When I urged her to compare his life with her own, she realized that some of her grief was misplaced: it was her own life, not her father’s, that was tragically unfulfilled. How much of her grief, then, was for all her unrealized hopes? This quest
ion was particularly painful for Betty who, by that time, had visited a gynecologist and been told that she had an endocrine disorder that would make it impossible for her to have children.

  I felt cruel during these weeks because of the pain our therapy was uncovering. Every session was an ordeal, and Betty often left my office badly shaken. She began to have acute panic attacks and many disturbing dreams, and, as she put it, she died at least three times a night. She could not remember the dreams except for two recurrent ones that had begun in adolescence, shortly after her father’s death. In one dream, she lay paralyzed in a small closet which was being bricked up. In the other, she was lying in a hospital bed with a candle, which represented her soul, burning at the head of the bed. She knew that when the flame went out she would die, and she felt helpless as she watched it get smaller and smaller.

  Discussing her father’s death obviously evoked fears of her own death. I asked Betty to talk about her first experiences and early conceptions of death. Living on a ranch, she was no stranger to death. She watched her mother kill chickens and heard the squeal of hogs being slaughtered. Betty was extremely unsettled by her grandfather’s death when she was nine. According to her mother (Betty told me she had no recollection of this), she was reassured by her parents that only old people die, but then she pestered them for weeks by chanting she didn’t want to grow old and by repeatedly asking her parents how old they were. But it was not until shortly after her father died that Betty grasped the truth about the inevitability of her own death. She remembered the precise moment.

  “It was a couple days after the funeral, I was still taking off from school. The teacher said I should return when I felt ready. I could have gone back earlier, but it didn’t seem right to go back so soon. I was worried that people wouldn’t think I was sad enough. I was walking in the fields behind the house. It was cold out—I could see my breath, and it was hard to walk because the earth was clumped and the plow ridges were frozen. I was thinking of my father lying beneath the ground and how cold he must have been, and I suddenly heard a voice from above saying to me, ‘You’re next!’”