Selections from

the Work of a
Master Therapist
and Storyteller

IRVIN D. YALOM, M.D.

Author of Love's Executioner and Lying NI the Coucb
EDITED BY BEN YALOM
 THE

YALOM
READER
r
I

THE

READER
Selections from the Work
of a Master Therapist
and Storyteller

IRVIN D. Y ALOM

BasicBooks
A Subsidiary of Perseus Books, L.L.C.
Copyright© 1998 by Irvin D. Yalom.

Published by BasicBooks,
A. Subsidiary of Perseus Books, L.L.C.

All rights reserved. Printed in the United States of America. No

part of this book may be used in any manner whatsoever without
written permission except in the case of brief quotations embod-
ied in critical articles and reviews. For information, address
BasicBooks, Io East 53rd Street, New York, NY rno22-5299.

FIRST EDITION

Designed by Elliott Beard

Library of Congress Cataloging-in-Publication Data

Yalorn, Irvin D., 1931-

The Yalom reader : selections from the work of a master
therapist and storyteller I by Irvin D. Yalom ; edited by Ben
Y alom. - r st ed.
P: cm.
Includes index.
ISBN 0-465-03610-4
1.Psychotherapy and literature. 2. Group psychotherapy.
3. Existential psychotherapy. I. Yalorn, Ben. II. Title.
RC480.5.Y 34 1997
616.89--dc21 97-21790

98 99 00 () I 02 •!•/RRD IO 98765432 I
 To Marilyn, wife, lover, editor.
Soulmate for fifty years-and not nearly long enough
If
I!
i

I
 Contents

.
Introduction lX

Note to the Text Xlll

PART I

GROUP THERAPY I

I The Therapeutic Factors: What It Is That Heals 5

2 The Therapist Working in the Here-and-Now 42
3 Group Therapy with Specialized Groups:
Hospitalized Patients, Patients Addicted to Alcohol,
the Terminally Ill, the Bereaved

PART II

EXISTENTIAL PSYCHOTHERAPY

4 The Four Ultimate Concerns

5 Death, Anxiety, and Psychotherapy

..
VII
 v111 Contents

PART III

ON WRITING 267

6 Literature Informing Psychology: Literary Vignettes

7 Psychology Informing Literature:

"Ernest Hemingway: A Psychiatric View"

8 The Journey from Psychotherapy to Fiction

9 The Teaching Novel 373

ro The Psychological Novel

Notes 475
Index 493
 Introduction

hen Basic Books, my publisher for the past three decades,

W first proposed this book, I shuddered. I had always thought

an anthology to be a posthumous collection of a writer's
work. Or, if not posthumous, then a retrospective-a collection com piled
at the very end of one's writing career. So it seemed to me that the pro-
posal was just one more life stage marker, another melancholy re-
minder of aging-like retiring from Stanford University; developing
senile plaques and aching knees; saying farewell to tennis; watching my
children marry, settle into professions, and have children themselves.
Gradually, however, I warmed to the idea of a reader-cum-
retrospective because I thought it offered a curtain call for many
beloved, long-forgotten works. Eagerly I blew the dust off old files and
reread my darling articles concerning such things as the hypnotic treat-
ment of plantar warts, postpartum blues, aggression in voyeurism,
LSD, Hemingway, organic brain diseases of senility, family therapy for
ulcerative colitis. But it did not take long to realize that I might be the
sole interested reader of such an arcane, disconnected, and often out-
dated collection. Consequently, I put them away (except for the Hem-
ingway article-that stayed) and saw the wisdom in the publisher's
I view that the sensible raison d'etre of such a reader would be to chart
r the arc of my writing career as it has progressed, over thirty years, from
research reports in professional journals to fiction.

IX
 x Introduction

My early books were texts of psychotherapy. My most recent works

are novels of psychotherapy. Hence, I have two sets of readers: psy-
chotherapists who have been assigned my textbooks during their formal
training, and lay readers, casually interested in psychotherapy, who are
drawn to the storytelling format of my later work. I hope in these pages
to introduce each of these audiences to the other pole of my work-to
expose, in a gentle fashion, the lay reader to a more theoretical, empiri-
cally based view of psychotherapy and, on the other hand, to instill in
practicing therapists a greater appreciation of the centrality of narrative
in the process of psychotherapy.
This volume has three parts, reflecting my major interests: (I) group
psychotherapy, (2) existential psychotherapy, and (3) writing. From the
beginning, in my effort to understand, illuminate, and teach psy-
chotherapy, I have been fascinated with two major therapy approaches:
group therapy and existential therapy. I was first trained to think as a
medical scientist, and my group therapy texts were informed, whenever
possible, by empirical research. Later, as I explored the field of existen-
tial therapy, it became apparent that empirical research had less to offer:
questions surrounding the deep subjective responses to the human con-
dition do not lend themselves to empirical investigation. Consequently
much of my work in existential therapy is informed primarily by philo-
sophical investigation-my own and that of others.
Part III of this volume, "On Writing," chronicles the powerful inter-
est in narrative that has lurked behind all my professional writing, has
inserted itself from time to time in my texts, and ultimately, in later
years, has taken over al together.
Although I can trace my attraction to literature to my earliest years,
there was a specific moment in my education that brought home to me
the power of narrative. In my first two years of medical school I had
performed well enough in my basic science classes. A diligent student, I
was always near the top of my class but performed mechanically with
no passion for any part of a scientific medical curriculum. As a third-
year student I took a psychiatry clerkship and was assigned my first pa-
tient. Though I've long since forgotten her name, I remember her well:
a young, depressed, freckled-faced lesbian with long red braids care-
lessly bound with thick rubber bands.
 Introduction xr

I was extremely uncomfortable in our initial meeting. It was obvious

to both of us that I knew next to nothing about psychiatry. Perhaps that
was a help; she was highly distrustful of my field (rightly so-those
were the days when homosexual acts were illegal, and she would have
been officially diagnosed as a sexual deviant). And not only was I igno-
rant about psychotherapy: I also knew nothing at all about lesbians aside
from one titillating passage in Proust where Swann spied on two
women making love.
What could I possibly offer her? All I could do, I ultimately decided,
was to allow her to be my guide and to explore her world as best I could.
Her previous experience with men had been horrendous, and I was the
first of my sex to listen, respectfully and attentively, to her. Her story
touched me. I thought about her often between our meetings, and over
the weeks we developed a tender, even loving, relationship. She seemed
to improve rapidly. Ho\V much of her improvement was real? How
much of it was a reward for listening and caring? I never knew.
All psychiatric students were asked to present a case at the weekly
case conference. When my turn came I looked around the room in ter-
ror at my audience of psychiatric faculty as well as several luminaries
of the Boston Psychoanalytic Institute. Finally I screened them out of
mind, gulped, and began. That was forty years ago. I remember little
of the conf ere nee aside from the stillness and deep silence in the confer-
ence room as I told them about my meetings with my patient and the
development of our loving feelings toward each another. No one moved
or took notes, and in the ensuing discussion, each participant psychia-
trist seemed oddly at a loss for words. To my astonishment many of-
fered lavish, even embarrassing, praise for my presentation; others
simply commented that my presentation spoke for itself and nothing
more needed to be said.
My experience in that conference was an epiphany--a moment of
sudden, deep, clarifying insight. How had I evoked such interest from
that distinguished audience? Certainly not by displaying any grasp of
theory. Nor by describing a course of systematic effective therapy. No,
what I had done was something quite different: I had conveyed the
essenceof my patient and our relationship in the form of an interesting story.
I had always known how to tell stories and now I believed I had found a
 xii Introduction

way to put that ability to good use. I walked out of that conference forty
years ago certain that psychiatry was my calling. And certain, too, that
in some manner, as yet unknown, my particular contribution to psychi-
atry would be as a storyteller.
Aside from the many section introductions and three new essays on
narrative, the text of this volume is excerpted from published books and
articles and edited for brevity, readability, and continuity. I have been
blessed with the opportunity to work on this project with my son, Ben
Yalom, a writer and editor extraordinaire. He has edited this volume
from inception to finish, and I am deeply indebted to him for his expert
advice in the organization of this volume, for the content of the intro-
ductions, and for the selection and editing of the excerpts. I am also
grateful to my publishers at Basic Books: Joann Miller for suggesting
this volume, and Gail Winston and John Donatich for supporting the
project to the finish.
Note to the Text

Shaded boxes are used throughout this volume to denote new text writ-
ten to introduce and accompany the excerpted material within.
 PART I

GROUP THERAPY

was fortunate to have had my psychiatric training at Johns Hopkins

I University, where I came under the tutelage of Jerome Frank, a pioneer

in group therapy and an eminent psychotherapy researcher and theo-
retician. Not only did Dr. Frank encourage his psychiatric residents to
conduct groups, but he permitted us to observe his groups through a
postage stamp-sized two-way mirror. Both his daring in having his work
observed and the two-way mirror were innovations at that time. After a
few months of observation I began leading groups for outpatients and in-
patients, and over the next thirty-five years I led a great variety of groups:
brief and long-term dynamic outpatient groups; inpatient groups; con-
joint family groups; multiple family groups; groups for cancer patients,
families of cancer patients, AIDS patients, bereaved spouses, bereaved
parents, anorexic patients, alcoholics, adult children of alcoholics, sex-
ual deviants, imprisoned murderers, schizophrenic patients, and sexually
abused women; and therapy/training groups for corporate CEOs, teach-
ers, hospital staff for chronic patients, psychiatric residents, psychology
interns, medical students, psychiatric nurses, and psychotherapists in pri-
vate practice.
 2 THE Y ALOM READER

My clinical group experience coupled with research findings-my

own and those of others-long ago persuaded me of the great power of
therapy groups. Yet the majority of clinicians persistently resist practicing
group therapy. Over many years I have written, lectured, and given
workshops in an attempt to diminish that resistance.
Why is there so much resistance? Certainly it is not based on rational
professional inquiry. A very persuasive body of research has demon-
strated, project by project, or through meta-analysis, that patients do as
well in the group format as in the individual format, or better. The resis-
tance comes from other sources. There are economic concerns (too
many therapists, too few patients) and practical concerns (organizing and
maintaining a group in private practice requires considerable energy and
a wide referral base); sometimes uninformed and unprepared patients
find the idea of a group frightening and choose the individual format for
its presumed safety and comfort; there is ingrained professional preju-
dice-the analytic one-to-one model has held sway for many decades,
and older therapists are loath to desert it for the scarier prospects of lead-
ing a group; and, finally, some therapists have personal fears and prefer
the role of authoritarian medical practitioner to the more egalitarian,
transparent role required of the group therapist.
One of the very few positive aspects of the contemporary economic
revolution in the delivery of mental health care today is that this resis-
tance, which has limited the use of group therapy and has withstood all
the persuasive research evidence demonstrating its effectiveness, may be
simply mandated away on the basis of economic concerns. Managed
health care will inevitably make greater use of therapy groups in the fu-
ture. Therapy groups have always been a more efficient form of therapy
(from the standpoint of manpower required), though I wish to make it
clear that economic expediency has never, in my view, been the raison
d'etre of group therapy. The arena of the psychotherapy group offers, as I
hope to demonstrate in this collection, unique opportunities in therapy:
groups are not a diluted individual therapy but instead offer possibilities
for therapeutic changes that are unavailable in individual therapy.
Early in my career I had a good deal of contact with encounter
groups, as a member, leader, and researcher. With two col leagues, Mor-
ton Lieberman and Matthew Miles, I conducted a f arge project research-
 Part I: Group Therapy 3

ing the process and outcome of ten models of group leadership in eight-
een different encounter groups, and we eventually published our find-
ings in a research monograph, Encounter Groups: First Facts. This is the
one book that I have not excerpted in this volume (the language is too
uncompromisingly technical}, but the research it describes, coupled with
my personal experience with encounter group leadership technology,
has had a significant influence on the model of group therapy I ulti-
mately evolved.
This section of the reader consists of three chapters: the first examines
the therapeutic factors in group psychotherapy; the second presents the
here-and-now, a core concept in my approach to group psychotherapy;
and the third reviews therapy with specialized groups.
'!
II

I
11

IiI
II
,,
II

I i
r
••
I

CHAPTER I

The Therapeutic Factors:

What It Is That Heals

INTRODUCTION

This chapter, as wel I as the next, is drawn from The Theory and Practice
of Group Psychotherapy, by far my most widely read book. Approxi-
mately six hundred thousand copies have been printed in the United
States and abroad, where it has been translated into several foreign lan-
guages. After the publication of the first edition in 1970, the textbook re-
quired continued care and maintenance: each subsequent edition (the
second, third, and fourth editions appeared at approximately eight-year
intervals) demanded two years of concentrated work. Between editions it
was necessary to stay abreast of the professional literature, to monitor
new developments in the field, and to keep careful records of any of my
own group therapy meetings that might serve a pedagogical purpose.
When I first began writing the text, my primary audience, I am cha-

-
•
grined to say, was the Stanford University promotion committee. Begin-
ning with two middle chapters, I wrote a labored and detailed critical
analysis of the world research literature on the selection of patients for

5
 6 THEY ALOM READER

group therapy and the composition of therapy groups. Shortly after fin-
ishing those chapters I was notified that I had been promoted and
granted academic tenure. Immediately thereafter I radically changed my
audience and my writing approach: I put the promotion committee out
of my mind; I eliminated all jargon, all detailed research analysis, and all
unnecessarily complex theoretical structures; and I wrote with only one
purpose in mind-to interest and to educate the group therapy student.
The Theory and Practice of Group Psychotherapy begins with a sur-
vey of the wide scope of group therapy practice. There is no single group
therapy; there are many group therapies. In the previous pages I offered a
list of the different types of groups I have led in my career; although the
list may seem long and varied, it represents only a small fraction of the
types of therapy groups to be found in contemporary clinical practice.
Each of these groups has its own ambiance, its own flavor, methods,
I;
technical problems and procedures. How, then, to write a text that will
1:
speak to all group leaders and all clinical therapy groups?
My pedagogical strategy in the textbook was to focus on the common ·II.
denominators of therapy groups: to ignore the variegated and often ex- I'I
otic trappings of various group approaches and to focus, instead, on the
question central to all-how do groups really help? The answer to this
question-the various "therapeutic factors" ("curative factors," I labeled
them in the first two editions)-constitutes the spine of the textbook. I de-
scribe twelve of these therapeutic factors in the first few chapters and
from them derive the basic rules of leadership procedure and technique.
In other words, I take the position that once we identify the basic healing
factors in therapy, we can, with assurance, know how therapists should
proceed: they should do whatever is necessary to facilitate the emer-
gence and maturation of these therapeutic factors.
The first selection-edited from the first four chapters of The Theory
and Practice of Group Psychotherapy-discusses the derivation and
meaning of the therapeutic factors.

THE THERAPEUTIC FACTORS

How does group therapy help patients? A naive question. But if we can
answer it with some measure of precision and certainty, we will have at
 The Therapeutic Factors: What It ls That Heals 7

our disposal a central organizing principle by which to approach the

most vexing and controversial problems of psychotherapy.
I suggest that therapeutic change is an enormously complex process
that occurs through an intricate interplay of human experiences, which
I will refer to as "therapeutic factors." From my perspective, natural
lines of cleavage divide the therapeutic experience into eleven primary
factors. The distinctions a1nong these factors are arbitrary; though I dis-
cuss them singly, they are interdependent and neither occur nor func-
tion separately. Keeping this in mind, we can view them as providing a
cognitive map. This grouping of the therapeutic factors is not set in ce-
ment: other clinicians and researchers have arrived at a different, and
also arbitrary, cluster of factors. No explanatory system can encompass
all of therapy.
The inventory of therapeutic factors I propose issues from my clini-
cal experience, from the experience of other therapists, from the views
of the successfully treated group patient, and from relevant systematic
research. None of these sources is beyond doubt, however; neither
group members nor group leaders are entirely objective, and our re-
search methodology is often crude and inapplicable.
From the group therapists we obtain a variegated and internally in-
consistent inventory of therapeutic factors. Therapists, by no means dis-
interested or unbiased observers, have invested considerable time and
energy in mastering a certain therapeutic approach. Their answers will
be determined largely by their particular school of conviction. Even
among therapists who share the same ideology and speak the same lan-
guage, there 1nay be no consensus about why patients improve. The his-
tory of psychotherapy abounds in healers who were effective, but not
for the reasons they supposed. At other times we therapists throw up
our hands in bewilderment. Who has not had a patient who made vast
improvement for entirely obscure reasons?
Patients at the end of a course of group therapy can supply data
about the therapeutic factors they considered most and least helpful; or,
during therapy, they can supply evaluations of the significant aspects of
I.
each group meeting. Yet we know that the completeness and accuracy
of the patients' evaluations will be limited. Will they not, perhaps, focus
I
~
primarily on superficial factors and neglect some profound healing
J. forces that may be beyond their awareness? Will their responses not be
 8 THE YALOM READER

influenced by a variety of factors difficult to control? For example, their

views may be distorted by the nature of their relationship to the thera-
pist or to the group. (One team of researchers demonstrated that when
patients were interviewed four years after the conclusion of therapy,
they were far more apt to comment on unhelpful or harmful aspects of
their group experience than when interviewed immediately at its termi-
nation.)'
Research has also shown, for example, that the therapeutic factors
valued by patients may differ greatly from those cited by their therapists
or by group observers.' Furthermore, many confounding factors in-
fluence the patient's evaluation of the therapeutic factors: for example,
the length of time in treatment and the level of a patient's functioning/
the type of group (that is, whether outpatient, inpatient, day hospital,
brief therapy),' the age and the diagnosis of a patient,' and the ideology
of the group leader." Another factor that complicates the search for
common therapeutic factors is the extent to which different group pa-
tients perceive and experience the same event in different ways.' Any
given experience may be important or helpful to some members and
inconsequential or even harmful to others.
Despite these limitations, patients' reports are a rich and relatively
untapped source of information. After all, it is their experience, theirs
alone, and the farther we move from the patients' experience, the more
inferential are our conclusions. To be sure, there are aspects of the
process of change that operate outside a patient's awareness, but it does
not follow that we should disregard what patients do say. ~
In addition to therapists' views and patients' reports, there is a third J
important method of evaluating the therapeutic factors: the systematic .
research approach. The most common research strategy by far is to cor-
relate in-therapy variables with outcome in therapy. By discovering
which variables are significantly related to successful outcome, one can
establish a reasonable base from which to begin to delineate the thera-
peutic factors. However, there are many inherent problems in this ap-
proach: the measurement of outcome is itself a methodological morass,
and the selection and measurement of the in-therapy variables are
equally problematic. (Generally the accuracy of the measurement is di-
rectly proportional to the triviality of the variable. It is easy, for exam-
ple, to measure a variable such as "verbal activity"-the number of
 The Therapeutic Factors: What It Is That Heals 9

words spoken by each patient. But it is extraordinarily difficult to exam-

ine insight: one can measure the incidence of interpretive statements of-
fered by the therapist, but how is one to determine the meaningfulness
to the patient of each statement?)
I have drawn from all these methods to derive the therapeutic factors
discussed in this book. Still) I do not regard these conclusions as defini-
tive; rather, I offer them as provisional guidelines that may be tested
and deepened by other clinical researchers. For n1y part, I am satisfied
that they derive from the best available evidence at this time and that
they constitute the basis of an effective approach to therapy.

Instillation of Hope
The instillation and maintenance of hope is crucial in any psychother-
apy. Not only is hope required to keep the patient in therapy so that
other therapeutic factors may take effect, but faith in a treatment mode
can in itself be therapeutically effective. Several research inquiries have
demonstrated that pretherapy high expectation of help is significantly
correlated with a positive therapy outcome." Consider also the massive
data documenting the efficacy of faith healing and placebo treatment-
therapies mediated entirely through hope and conviction.
Group therapists can capitalize on this factor by doing whatever we
can to increase patients' belief and confidence in the efficacy of the
group mode. This task begins before the group starts, in the pregroup
orientation in which the therapist reinforces positive expectations, re-
moves negative preconceptions, and presents a lucid and powerful ex-
planation of the group's healing properties.
Group therapy not only draws from the general ameliorative effects
of positive expectations but also benefits from a source of hope that is
unique to the group format. Therapy groups invariably contain individ-
uals who are at different points along a coping-collapse continuum.
Each member thus has considerable contact with others-often individ-
r uals with similar problems-s-who have improved as a result of therapy.
I have often heard patients remark at the end of their group therapy
t how important it was for them to have observed the improvement of
others.
F' Research substantiates that it is also vitally important that therapists
 10 THE Y ALOM READER

believe in themselves and in the efficacy of their group.9 I sincerely be-

lieve that I am able to help every motivated patient who is willing to
work in the group for at least six months. In my initial meetings with
patients individually, I share this conviction with them and attempt to
imbue them with my optimism.
Many of the self-help groups place heavy emphasis on the instillation
of hope." A major part of Recovery, Inc. (for current and former psychi-
atric patients), and Alcoholics Anonymous meetings is dedicated to tes-
timonials. At each meeting, members of Recovery, Inc., give accounts of
potentially stressful incidents in which they avoided tension by the ap-
plication of Recovery, Inc., methods, and successful Alcoholics Anony-
mous members tell their stories of downfa11 and then rescue by AA.
One of the great strengths of Alcoholics Anonymous is the fact that the
leaders are all ex-alcoholics-living inspirations to the others. Similarly,
substance-abuse treatment programs commonly mobilize hope in pa-
tients by using recovered drug addicts as group leaders. Members are
inspired and expectations raised by contact with those who have trod
the same path and found the way back.

Universality
Many patients enter therapy with the disquieting thought that they are
unique in their wretchedness, that they alone have certain frightening
or unacceptable problems, thoughts, impulses, and fantasies. Of course,
there is a core of truth to this notion, since most patients have had an
unusual constellation of severe life stresses and are periodically flooded
by frightening material that has leaked from the unconscious.
To some extent this is true for all of us, but many patients, because of
their extreme social isolation, have a heightened sense of uniqueness.
Their interpersonal difficulties preclude the possibility of deep inti-
macy. In everyday life they neither learn about others' analogous feel-
ings and experiences nor avail themselves of the opportunity to confide
in, and ultimately to be validated and accepted by, others.
In the therapy group, especially in the early stages, the disconfirma-
tion of a patient's feelings of uniqueness is a powerful source of relief.
After hearing other members disclose concerns similar to their own, pa-
tients report feeling more in touch with the world and describe the
 The Therapeutic Factors: What It Is That Heals 11

process as a "welcome to the human race" experience. Simply put, the

phenomenon finds expression in the cliche "We're all in the same boat,"
or perhaps more cynically, "Misery loves company."
There is no human deed or thought that is fully outside the experi-
ence of other people. I have heard group members reveal such acts as in-
cest, burglary, embezzlement, murder, attempted suicide, and fantasies
of an even more desperate nature. Invariably, I have observed other
group members reach out and embrace these very acts as within the
realm of their own possibilities. Long ago Freud noted that the
staunchest taboos (against incest and patricide) were constructed pre-
cisely because these very impulses are part of the human being's deepest
nature.
Nor is this form of aid limited to group therapy. Universality plays a
role in individual therapy also, although in that format less of an oppor-
tunity for consensual validation exists. Once I reviewed with a patient
his 600-hour experience in individual analysis with another therapist.
When I asked what he recalled as the most significant event in his ther-
apy, he described an incident when he was profoundly distressed about
his feelings toward his mother. Despite strong concurrent positive senti-
ments, he was beset with death wishes for her-he stood to inherit a siz-
able estate. His analyst, at one point, commented simply, "That seems to
be the way we're built." That artless statement offered considerable re-
lief and furthermore enabled the patient to explore his ambivalence in
great depth.
Despite the complexity of human problems, certain common de-
nominators are clearly evident, and the members of a therapy group
soon perceive their similarities. An example is illustrative: for many
years I asked members of T-groups or "process groups" to engage in a
"top-secret" task. They were to write, anonymously, on a slip of paper
the one thing they would be most disinclined to share with the group.
The secrets prove to be startlingly similar, with a couple of major
themes predominating. The most common secret is a deep conviction of
basic inadequacy-a feeling that one is basically incompetent, that one
glides through life on a sleek intellectual bluff. Next in frequency is a
deep sense of interpersonal alienation-that, despite appearances, one
.. really does not, or cannot, care for or love another person. The third
r most frequent category is some variety of sexual secret. These chief con-
 12 THE YALOM READER

cerns of nonpatients are qualitatively the same in individuals seeking

professional help. Almost invariably, our patients experience deep con-
cern about their sense of worth and their ability to relate to others.
Some specialized groups composed of individuals for whom secrecy
has been an especially important and isolating factor place a particularly
great emphasis on universality. For example, short-term structured
groups for bulimic patients build into their protocol a strong require-
ment for self-disclosure, especially disclosure about attitudes toward
body image and detailed accounts of each patient's eating rituals and
purging practices. With rare exceptions, patients express great relief at
discovering that they are not alone, that others share the same dilemmas
and life experiences."
Members of sexual abuse groups, too, profit enormously from the ex-
perience of universality. An integral part of these groups is the intimate
sharing, often for the first time in each member's life, of the details of
the abuse and the ensuing internal devastation. Members can encounter
others who have suffered similar violations as children, who were not
responsible for what happened to them, and who have also suffered
deep feelings of shame, guilt, rage, and uncleanliness. '
2

In multicultural groups, therapists may need to pay particular atten-

tion to this therapeutic fact. Cultural minorities in a predominantly
Caucasian group may feel excluded because of different attitudes to-
ward disclosure, interaction, and affective expression. Therapists must
help the group move past a focus on concrete cultural differences to
transcultural responses to human situations and tragedies that all of us
share. '·1
Universality, like the other therapeutic factors, does not have sharp
borders; it merges with other therapeutic factors. As patients perceive
their similarity to others and share their deepest concerns, they benefit
further from the accompanying catharsis and from ultimate acceptance
by other members.

Impartin
g Information
Under the general rubric of imparting information, I include didactic
instruction about mental health, mental illness, and general psychody-
 The Therapeutic factors: What It Is That Heals 13

namics given by the therapists, as well as advice, suggestions, or direct

guidance from either the therapist or other patients.
Most patients, at the conclusion of successful interactional group
therapy, have learned a great deal about psychic functioning, the mean-
ing of symptoms, interpersonal and group dynamics, and the process of
psychotherapy. Generally, the educational process is implicit; most
group therapists do not offer explicit didactic instruction in interac-
tional group therapy. Over the past decade, however, many group ther-
apy approaches have made formal instruction, or psycho-education, an
important part of the progratn.
For example, Recovery, Inc., the nation's oldest and largest self-help
program for current and former psychiatric patients, is basically orga-
nized along didactic lines." Founded in 1937 by the late Abraham Low,
this organization had almost 1,000 operating groups by 1993, with an
annual attendance of over 275,000. Membership is voluntary, and the
leaders spring from the membership. Though there is no formal profes-
sional guidance, the conduct of the meetings has been highly structured
by Dr. Low; parts of his textbook, Mental Health Through Will Training,
are read aloud and discussed at every meeting. 15 Psychological illness is
explained on the basis of a few simple principles, which the members
memorize. For example: the neurotic symptom is distressing but not
dangerous; tension intensifies and sustains the symptom and should be
avoided; the use of free will is the solution to the nervous patient's
dilemmas.
Many other self-help groups strongly emphasize the imparting of in-
formation. Groups such as Adult Survivors of Incest, Parents Anony-
mous, Gamblers Anonymous, Make Today Count (for cancer patients),
Parents Without Partners, and Mended Hearts encourage the exchange
of information among members and often invite experts to address the
group."
Recent group therapy literature abounds with descriptions of spe-
cialized groups for patients who have some specific disorder or face
some definitive life crisis-for example, obesity," bulimia," adjustment
after divorce,'? rape," self-image adjustment after mastectomy," and
chronic pain. n
In addition to offering mutual support, these groups generally build

I
 14 THE Y AL0!\1 REA DER

in a cognitive therapy approach by offering explicit instruction about

the nature of a patient's illness or life situation and examining patients'
misconceptions and self-defeating responses to their illness. For exam-
ple, the leaders of a group for patients with panic disorders describe the
physio1ogic cause of panic disorders: heightened stress and arousal in-
crease the flow of adrenaline, which may result in hyperventilation,
shortness of breath, and dizziness; this in turn is misinterpreted by the
patient ("I'm dying; I'm going crazy"), which only exacerbates the vi-
cious cycle. The therapists discuss the benign nature of panic attacks
and off er group members instruction, first, in how to bring on a mild
attack, and then in how to prevent it. The leaders pay special attention
to providing detailed instruction in proper breathing techniques and
progressive m uscular relaxation.
Leaders of groups for HIV-positive patients offer considerable
illness-related medical information, correct irrational fears (for exam-
ple, greatly exaggerated fears about infectiousness), and give advice
about telling others about one's condition, fashioning a different, less
guilt-provoking lifestyle, and seeking both professional and nonprofes-
sional hel r-"
Leaders of bereavement groups may provide information about the
natural cycle of bereavement to help members realize that there is a se-
quence of pain through which they are progressing and there will be a
natural, almost inevitable, subsiding to their distress. Leaders may help
patients anticipate, for example, the acute anguish they will feel with
each significant date (holidays, anniversaries, birthdays) during the first
year of bereavement.
Didactic instruction has thus been employed in a variety of fashions
l
~

in group therapy: to transfer information, to alter sabotaging thought

patterns, to structure the group, to explain the process of illness. Often
such instruction functions as the initial binding force in the group, until
other therapeutic factors become operative. In part, however, explana-
tion and clarification function as effective therapeutic agents in their
own right. Human beings have always abhorred uncertainty and
through the ages have sought to order the universe by providing expla-
nations, primarily religious or scientific. The explanation of a phenome-
non is the first step toward its control. If a volcanic eruption is caused by
a displeased god, then at least there is hope of pleasing the god.
 The Therapeutic Factors: What Ir ls That Heals 15

Frieda Fromm-Reichman underscores the role of uncertainty in

producing anxiety." She points out that being aware that one is not
one's own helmsman, that one's perceptions and behavior are controlled
by irrational forces. is in itself an important source of anxiety. Jerome
Frank, in a post-World War II study of Americans' reactions to an un-
familiar South Pacific disease (schistosorniasis), demonstrated that anxi-
ety stemming from uncertainty often creates more havoc than the
disease itself."
And so it is with psychiatric patients: fear and anxiety that stern from
uncertainty of the source, meaning, and seriousness of psychiatric syn1p-
toms may so compound the total dysphoria that effective exploration
becomes vastly more difficult. Didactic instruction, through its provi-
sion of structure and explanation, has intrinsic value and deserves a
place in our repertoire of therapeutic instruments.
Unlike explicit didactic instruction from the therapist, direct advice
from the members occurs without exception in eYery therapy group. In
dynamic interactional therapy groups, it is invariably part of the early
life of the group and occurs with such regularity that it can be used to
estimate a group's age. If I observe a group in which the patients with
some regularity say things like, "I think you ought to ," or "What
you should do is ," or "Why don't you ? "then I can be reason-
ably certain either that the group is young or that it is an older group
facing some difficulty that has impeded its development or effected
temporary regression. Advice giving is common in early interactional
group therapy, but it is rare that a specific suggestion for some problem
will directly benefit any patient. Indirectly, however, advice giving
serves a purpose; the process, rather than the content of the advice, may
be beneficial, implying and con veying, as it does, mutual interest and
.
caring.
Advice-giving or advice-seeking behavior is often an important due
in the elucidation of interpersonal pathology. The patient who, for ex-
ample, continuously pulls advice and suggestions from others, ulti-
mately only to reject them and frustrate others, is well known to group
therapists as the "help-rejecting complainer" or the "yes ... but" pa-
tient." Some patients may bid for attention and nurturance by asking
for suggestions about a problem that either is insoluble or has already
been solved. Other patients soak up advice with an unquenchable thirst.
 16 THF. YALOM READER

yet never reciprocate to others who are equally needy. Some group
members are so intent on preserving a high-status role in the group or a
facade of cool self-sufficiency that they never ask directly for help; some
are so anxious to please that they never ask for anything for themselves;
some are excessively effusive in their gratitude; others never acknowl-
edge the gift but take it home, like a bone, to gnaw on privately.
Other types of groups, noninteractionally focused, make explicit and
effective use of direct suggestions and guidance. For example, behavior-
shaping groups, partial hospitalization groups (preparing patients for
autonomous living), communicational skills groups, Recovery, Inc., and
Alcoholics Anonymous all proffer considerable direct advice. A com-
municational skills group for chronic psychiatric patients reports excel-
lent results with a structured group program that includes focused
feedback, videotape playback, and problem-solving projects." AA
makes use of guidance and slogans: for example, patients are asked to
remain abstinent for only the next twenty-four hours-"one day at a
time." Recovery, Inc., teaches members how to spot symptoms, how to
erase and retrace, how to rehearse and reverse, how to apply willpower
effectively.
Is some advice better than others? Researchers who studied a
behavior-shaping group of male sex offenders noted not only that ad-
vice was common but that it was differentially useful. The least effec-
tive form of advice was a direct suggestion; most effective were more
systematic, operationalized instructions or a series of alternative sugges-
tions about how to achieve a desired goal."

Altruism
There is an old Hasidic story of a rabbi who had a conversation with the
Lord about Heaven and Hell. "I will show you Hell," said the Lord,
and led the rabbi into a room containing a group of famished, desperate
people sitting around a large, circular table. In the center of the table
rested an enormous pot of stew, more than enough for everyone. The
smell of the stew was delicious and made the rabbi's mouth water. Yet
no one ate. Each diner at the table held a very long-handled spoon-
long enough to reach the pot and scoop up a spoonful of stew, but too
 The Therapeutic Factors: What It Is That Heals 17

long to get the food into one's mouth. The rabbi saw that their suffering
was indeed terrible and bowed his head in compassion. "Now I will
show you Heaven/ said the Lord, and they entered another room, iden-
tical to the first-same large, round table, same enormous pot of stew,
same long-handled spoons. Yet there was gaiety in the air: everyone ap-
peared well nourished, plump, and exuberant. The rabbi could not un-
derstand and looked to the Lord. "It is simple," said the Lord, "but it
requires a certain skill. You see, the people in this room have learned to
feed each other!"
In therapy groups, too, patients receive through giving, not only as
part of the reciprocal giving-recei\·ing sequence but also from the in-
trinsic act of giving. Psychiatric patients beginning therapy are demor-
alized and possess a deep sense of having nothing of value to offer
others. They have long considered themselves as burdens, and the expe-
rience of finding that they can be of importance to others is refreshing
and boosts self-esteem.
And, of course, patients are enormously helpful to one another in
the group therapeutic process. They offer support, reassurance, sugges-
tions, insight; they share similar problems with one another. Not in-
frequently group members will accept observations from another
member far more readily than from the group therapist. To many pa-
tients, the therapist remains the paid professional; but the other mem-
bers represent the real world: they can be counted on for spontaneous
and truthful reactions and feedback. Looking back over the course of
therapy, almost all patients credit other members as having been im-
portant in their improvement. Sometimes they cite their explicit sup-
port and advice, sometimes their simply having been present and
allowing their fellow patients to grow as a result of a facilitative, sus-
taining relationship.
Altruism is a venerable therapeutic factor in other systems of heal-
ing. In primitive cultures, for example, a troubled person is often given
the task of preparing a feast or performing some type of service for the
community." Altruism plays an important part in the healing process at
Catholic shrines such as Lourdes, where the sick pray not only for
themselves but for one another. Warden Duffy, a legendary figure at
San Quentin Prison, once claimed that the best way to help a man is to
 18 THr: YALOM READER

let him help you. People need to feel they are needed and useful. It is
commonplace for ex-alcoholics to continue their AA contacts for years
after achieving complete sobriety; many members have related the story
of downfall and subsequent reclamation at least a thousand times.
Neophyte group members do not at first appreciate the healing im-
pact of other members. In fact, many prospective candidates resist the
suggestion of group therapy with the question, "How can the blind lead
the blind?" or "What can I possibly get from others as confused as I?
We'll end up pulling one another down." Such resistance is best worked
through by exploring a patient's critical self-evaluation. Generally, a pa-
tient who deplores the prospect of getting help from other patients is re-
ally saying, "I have nothing of value to offer anyone."
There is another, more subtle benefit inherent in the altruistic act.
Many patients who complain of meaninglessness are immersed in a
morbid self-absorption, which takes the form of obsessive introspection
or a teeth-gritting effort to actualize oneself. I agree with Victor Frankl
that a sense of life meaning ensues but cannot be deliberately, self-
consciously pursued: it is always a derivative phenomenon that materi-
alizes when we have transcended ourselves, when we have forgotten
ourselves and become absorbed in someone (or something) outside our-
selves." The therapy group implicitly teaches its members that lesson
and provides a new counter-solipsistic perspective.

The Corrective Recapitulation of

the Primary Family Group
The great majority of patients who enter groups-with the exception of
those suffering from post-traumatic stress syndrome or from some
medical or environmental stress-have a background of a highly unsat-
isfactory experience in their first and most important group: the pri-
mary family. The therapy group resembles a family in many aspects:
there are authority/parental figures, peer siblings, deep personal revela-
tions> strong emotions, and deep intimacy as well as hostile, competitive
feelings. In fact, therapy groups are often led by a male and female ther-
apy team in a deliberate effort to simulate the parental configuration as
closely as possible. Once the initial discomfort is overcome, it is in-
 The Therapeutic Factors: What It Is That Heals 19

evitable that, sooner or later, the members will interact with leaders and
other members in modes reminiscent of the way they once interacted
with parents and siblings.
There is an enormous variety of patterns: some members become
helplessly dependent upon the leaders, whom they imbue with unrealis-
tic knowledge and power; others blindly defy the leaders, who are per-
ceived as infantilizing and controlling; others are wary of the leaders,
whom they believe attempt to strip members of their individuality;
some members try to split the co-therapists in an attempt to incite
parental disagreements and rivalry; some compete bitterly with other
members, hoping to accumulate units of attention and caring from the
therapists; others expend energy in a search for allies among the other
patients, in order to topple the therapists; still others neglect their own
interests in a seemingly selfless effort to appease the leaders and the
other members.
Obviously, similar phenomena occur in individual therapy, but the
group provides a vastly greater number and array of recapitulative pos-
sibilities. In one of my groups, Betty, a patient who had been silently
pouting for a couple of rneetings, bemoaned the fact that she was not in
one-to-one therapy. She claimed she was inhibited because she knew
the group could not satisfy her needs. She knew she could speak freely
of herself in a private conversation with the therapist or with any one of
the members. When pressed, Betty expressed her irritation that others
were favored over her in the group. In a recent meeting, another mem-
ber had been welcomed warmly upon returning from a vacation,
whereas her return from a vacation went largely unnoticed by the
group. Furthermore, another patient was praised for offering an impor-
tant interpretation to a member, whereas she had made a similar state-
ment weeks ago that had gone unnoticed. For some time, too, she had
noticed her growing resentment at sharing the group time; she was irn-
patient while waiting for the floor and irritated whenever attention was
shifted a \Vay from her.
Was Betty right? Was group therapy the wrong treatment for her?
Absolutely not! These very criticisms-s-which had roots stretching
down into her early relationships with her siblings--did not constitute
valid objections to group therapy. Quite the contrary: the group format
 20 TH E YA LO M RE A DER

was particularly valuable for her, since it allowed her envy and her crav-
ing for attention to surface. In individual therapy-where the therapist
attends to the patient's every word and concern, and the patient is ex-
pected to use up all the allotted time-these particular conflicts might
emerge belatedly, if at all.
What is important, though, is not only that early familial conflicts
are relived but that they are relived correctively. Growth-inhibiting re-
lationships must not be permitted to freeze into the rigid, impenetrable
system that characterizes n1any family structures. Instead, fixed roles
must be constantly explored and challenged, and ground rules for in-
vestigating relationships and testing new behavior must be constantly
encouraged. For n1any patients, then, working out problems with ther-
apists and other members is also working through unfinished business
from long ago.

Development of Socializing Techniques

Social learning-the development of basic social skills-is a therapeutic
factor that operates in all therapy groups, although the nature of the
skills taught and the explicitness of the process vary greatly depending
on the type of group therapy. There may be explicit emphasis on the de-
velopment of social skills in, for example, groups preparing hospitalized
patients for discharge or adolescent groups. Group members may be
asked to role-play approaching a prospective employer or asking some-
one out on a date.
In other groups, social learning is more indirect. Members of dy-
namic therapy groups, which have ground rules encouraging open
feedback, may obtain considerable information about maladaptive so-
cial behavior. A patient may, for example, learn about a disconcerting
tendency to avoid looking at the person with whom he or she is convcrs-
ing; about others' impressions of his or her haughty, regal attitude; or
about a variety of other social habits that, unbeknownst to the patient,
have been undermining social relationships. For individuals lacking in-
timate relationships, the group often represents the first opportunity for
accurate interpersonal feedback. One patient, for example, who had
been aware for years that others either avoided or curtailed social con-
 The Therapeutic Factors: What It Is That Heals 21

tact with him, learned in the therapy group that his obsessive inclusion
of minute, irrelevant details in his social conversation was exceedingly
off-putting. Years later he told me that one of the most important events
of his life was when a group member (whose name he had long since
forgotten) told him: "When you talk about your feelings, I like you and
want to get closer; but when you start talking about facts and details, I
want to get the hell out of the room!"
Frequently senior members of a therapy group acquire highly so-
phisticated social skills: they are attuned to process; they have learned
how to be helpfully responsive to others; they have acquired methods of
conflict resolution; they are less likely to be judgmental and more capa-
ble of experiencing and expressing accurate empathy, These skills can-
not but help to serve these patients well in future social interactions.

Imitative Behavior
Patients during individual psychotherapy may, in time, sit, walk, talk,
and even think like their therapists. There is considerable evidence that
group therapists influence the communicational patterns in their groups
by modeling certain behaviors, for example, self-disclosure or support."
In groups the imitative process is more diffuse: patients may model
themselves on aspects of the other group members as well as of the ther-
apisr." The importance of imitative behavior in the therapeutic process
is difficult to gauge, but social psychological research suggests that ther-
apists may have underestimated it. Bandura, who has long claimed that
social learning cannot be adequately explained on the basis of direct re-
inforcement, has experimentally demonstrated that imitation is an ef-
fective therapeutic force." For example, he has successfully treated a
large number of individuals with snake phobias by asking them to ob-
serve him handling a snake. In group therapy it is not uncommon for a
patient to benefit by observing the therapy of another patient with a
similar problem constellation-a phenomenon generally referred to as
vicarious or spectator therapy."
Imitative behavior generally plays a more important role in the early
stages of a group than in its later stages, as members look for more se-
nior members or therapists with whom to identify." Even if imitative
 22 THE Y ALO ~{ R E .-\ l) ER

behavior is, in itself, short-lived, it may help to unfreeze the individual

enough to experiment with new behavior, which in turn can launch an
adaptive spiral. In fact, it is not uncommon for patients throughout
therapy to "try on," as it were, bits and pieces of other people and then
relinquish them as ill fitting. This process n1ay have solid therapeutic
impact; finding out what we are not is progress toward finding out
what we are.

Catharsis
Catharsis has always assumed an important role in the therapeutic
process, though the rationale behind its use has varied considerably. For
centuries, patients have been purged to cleanse them of excessive bile,
evil spirits, and infectious toxins (the word itself is derived from the
Greek root, "to clean"). Since Breuer and Freud's 1895 treatise on the
treatment of hysteria," many therapists have attempted to help patients
rid themselves of suppressed, choked affect. What Freud and subse-
quently all dynamic psychotherapists have learned is that catharsis is not
enough. After all, we have emotional experiences, sometimes very in-
tense ones, all our lives without their leading to change.
The data support this conclusion. Although the research into the pa-
tient's appraisal of the therapeutic factors reveals the importance of
catharsis, the research also suggests important qualifications. In a study
of 210 participants in encounter groups, 1ny colleagues and I found that
catharsis was necessary to good outcome but not sufficient for it." Mem-
bers who cited the sole importance of catharsis were, in fact, more likely
to have had a negative experience in the group. Those who had a
growth experience characteristically coupled catharsis with some form
of cognitive learning.
Similar conclusions emerged from a study in which my colleagues
and I administered a sixty-item Q-sort to patients who had a successful
group therapy experience. Ventilation, in and of itself, was not deemed
highly useful by patients. Effectiuc catharsis was linked to other factors.
For one thing, it was part of an interpersonal process: group members
did not express emotions in a closet-they did so in a social context. The
same is true in individual therapy. When a patient weeps in my office I
 The Therapeutic Factors: What It Is That Heals 23

am, of course, interested in the reasons for weeping, but I am often

more interested in how it felt for that patient to weep at that time, in 1ny
presence. I invariably inquire about this and often the discussion leads
us into important areas such as trust, shame, or fear of judgment. In ad-
dition catharsis is intr icatelv, related to cohesiveness. Catharsis is more
helpful once supportive group bonds have formed. Freedman and Hur-
ley show that catharsis is more valued late rather than early in the
course of the group.1~ Conversely, strong expression of emotion en-
hances the development of cohesiveness: members who express strong
feelings toward one another and work honestly with these feelings will
develop close mutual bonds. In groups of patients dealing with loss, Mc-
Callum, Piper, and Morin found that expressions of positive affect were
associated with positive outcomes, and increased throughout the course
of short-term groups. The expression of negative affect, on the other
hand, was therapeutic only when it occurred in the context of genuine
attempts to understand oneself or other group members."
In summary, then, the open expression of affect is, without question,
vital to the group therapeutic process; in its absence, a group would de-
generate into a sterile academic exercise. Yet it is only part of the process
and must be complemented by other factors.
One last point. The intensity of emotional expression is highly rela-
tive and must be appreciated not from the leader's perspective but from
that of each member's experiential world. A seemingly muted expres-
sion of emotion may, for a highly constricted individual, represent an
event of considerable intensity. On many occasions I have witnessed stu-
dents who, after viewing a videotape of a group meeting, complain
about the session being muted and boring, whereas the members them-
selves experienced the session as highly intense and charged.

Existential Factors
Successful group therapy patients consider existential Factors to be sig-
nificant in their improvement. In my Q-sort study three existentially
oriented items were heavily weighted by patients: ( 1) recognizing that no
matter how dose I get to other people, I must still face lf(c· alone; (2) facing
the basic issues of my life and death, and thus living my life more honestly

••
 24 THE Y ALOM READER

and being less caught up in trivialities;(3) learning that I must take the ulti-
mate responsibilityfor the way I live my life no matter how much guidance
and support I get from others. ~0

Such factors play a paramount role in specialized groups where pa-

tients are starkly confronted with existential issues-for example,
groups of patients with life-threatening illness or groups of bereaved
patients. But if the leader has a highly developed sensibility to these is-
sues, they will play an important role in any psychotherapy group.
Members learn there is a limit to the guidance they can get from others.
They learn that they must bear ultimate responsibility for the autonomy
of their group and their life. They learn that there is a basic isolation in
existence that cannot be breached: everyone is thrown into the world
alone, and must die alone. Still, despite this, there is a deep comfort
from relating intimately to other fellow travelers in the world. The ba-
sic encounter provides presence and a "being with" in the face of harsh
existential facts of life.*

Group Cohesiveness?"
Group cohesiveness and interpersonal learning are of greater power
and complexity than any of the other therapeutic factors examined thus
far, and for this reason I discuss them in considerably greater detail in
the sections that follow.
Over the past thirty years, a vast number of controlled studies of psy-
chotherapy outcome have been performed. One particularly rigorous
review of 475 controlled studies concluded that the average person who
receives psychotherapy is better off at the end of it than 80 percent of
people who do not, and that the outcome from group therapy is virtu-
ally identical to that of individual therapy." Other reviews of rigorous

"Exisrenrial issues are discussed more fully in chapters 3 and 4 of the present
volume.
**(;roup cohesiveness and interpersonal learning are of greater power and
complexity than any of the other therapeutic factors examined thus far, and
for this reason I discuss them in considerably greater detail in the sections that
follow.
 The Therapeutic Factors: \.Vhat lt Is That Heals 25

research support the effectiveness of group therapy, both in an absolute

sense and in comparison to other psychotherapies."
So what is it that makes for successful therapy? After all, not all
psychotherapy is successful, and there is evidence that treatment may be
for better or for worse: though most therapists help their patients, some
therapists make some patients worse." Although n1any factors are
involved, a sine qua non for effectivetherapy outcome is a proper therapeu-
tic relationship.H The best research evidence available overwhelmingly
supports the conclusion that successful therapy is mediated by a rela-
tionship between therapist and patient that is characterized by trust,
warmth, empathic understanding, and acceptance."
Furthermore, it has long been established that the quality of the rela-
tionship is independent of the individual therapist's school of convic-
tion. Experienced and effective clinicians from different schools
(Freudian, nondirective, gestalt, transactional analytic, encounter, psy-
chodrama) resemble one another (and differ from nonexperts in their
own school) in their conception of the ideal therapeutic relationship and
in the nature of the relationship they themselves establish with their pa-
tients." It has also been demonstr ated that the warm, cohesive quality of
the relationship is no less important in the more impersonal, behavioral,
or systems-oriented forms of psychotherapy." The nature of the rela-
tionship has proved to be so critical in individual psychotherapy that we
are compelled to ask whether relationship plays an equally critical role
in group psychotherapy. But it is obvious that the group therapy analogue
of the patient-therapist relationship in individual therapy must be a broader
concept: it must encompass the patient's relationship not 011/y to the group
therapist but to the other group members and to the group as a whole. At the
risk of courting semantic confusion, I refer to all these factors under the
term group cohesiveness.
Cohesiveness is a widely researched basic property of groups. Several
hundred research articles exploring cohesiveness have been written,
many with widely varying definitions. In general, however, there is
agreement that groups differ from one another in the amount of
"groupness" present. Those with a greater sense of solidarity, or "we-
ness," value the group more highly and will defend it against internal
and external threats. Such groups have a higher rate of attendance, par-
 26 TH E Y A LO ;1,f R EA D ER

ticipation, and mutual support and will defend the group standards
much more than groups with less esprit de corps.
Cohesiveness is a complex and abstruse variable that has defied re-
searchers and resisted precise definition. A recent comprehensive and
thoughtful review concluded that cohesiveness "is like dignity: everyone
can recognize it but apparently no one can describe it, much less mea-
sure it."4~ The problem is that cohesiveness refers to overlapping dimen-
sions. On the one hand, there is a group phenomenon-e-the total esprit
de corps; on the other hand, there is the individual member cohesive-
ness (or, more strictly, the individual's attraction to the group).49
There are, in fact, many methods of measuring cohesiveness," and a
precise definition depends upon the method employed. Cohesiveness
may be broadly defined as the resultant of all the forces acting on all the
members to remain in the group51 or, more simply, the attractiveness of
a group for its members." It refers to the condition of members feeling
warmth and comfort in the group, feeling they belong, valuing the
group and feeling, in turn, that they are valued and unconditionally ac-
cepted and supported by other members."
Group esprit de corps and individual cohesiveness are interdepen-
dent: in fact, group cohesiveness is often computed simply by summing
the individual members' level of attraction to the group. Newer meth-
ods of measuring group cohesiveness from raters' evaluations of group
climate make for greater quantitative precision but do not negate the
fact that the group esprit de corps remains a function and a summation
of the individual members' sense of belongingness." Keep in mind,
however, that group members are differentially attracted to the group
and that cohesiveness is not fixed-once achieved, forever held-but
instead fluctuates greatly during the course of the group." Recent re-
search has differentiated between the individual's sense of belonging
and his or her appraisal of total group engagement-how well the en-
tire group is working. It is not infrequent for an individual to feel "that
this group works well, but I'm not part of it.':"
It is essential to note that group cohesiveness is more than a potent
therapeutic force in its own right. Perhaps even more important, it is a
necessary precondition for other therapeutic factors to function opti-
mally. When, in individual therapy, we say that it is the relationship
 The Therapeutic Factors: What It Is That Heals 27

that heals, we do not mean that love or lo\·ing acceptance is enough; we

mean that an ideal therapist-patient relationship creates conditions in
which the necessary risk taking, catharsis, and intrapersonal and inter-
personal exploration may unfold. It is the same for group therapy: cohe-
siveness is necessary for other group therapeutic factors to operate.
Although I have discussed the therapeutic factors separately, they
are, to a great degree, interdependent. Catharsis and universality, for
example, are not complete processes. It is not the sheer process of venti-
lation that is important; it is not only the discovery of others' problems
similar to one's own and the ensuing disconfinnation of one's wretched
uniqueness that are important. It is the affective sharing of one's inner
world and then the acceptance by others that seem of paramount impor-
tance. To be accepted by others brings into question the patient's belief
that he or she is basically repugnant, unacceptable, or unlovable. The
group will accept an individual, provided that the individual adheres to
the group's procedural norms, regardless of his or her past life experi-
ences, transgressions, or social failings. Deviant lifestyles, history of
prostitution, sexual perversion, heinous criminal offenses-all can be
accepted by the therapy group, so long as norms of nonjudgmental ac-
ceptance and inclusiveness are established early in the group.
For the most part, the disturbed interpersonal skills of psychiatric
patients have limited their opportunities for affective sharing and ac-
ceptance in intimate relationships. Furthermore, patients' convictions
that their impulses and fantasies are abhorrent have limited their inter-
personal sharing even more. I have known many isolated patients for
whom the group represented their only deeply human contact. After
just a few sessions, they have a deeper sense of being at home in the
group than anywhere else. Later, even years afterward, when most
other recollections of the group have faded from memory, they may still
remember the warm sense of belonging and acceptance.
As one successful patient, looking back over two and a half years of
therapy, put it, "The most important thing in it was just having a group
there, people that I could always talk to, that wouldn't walk out on me.
There was so much caring and hating and loving in the group, and I
was a part of it. I'm better now and have my own life. but it's sad to
think that the group's not there anymore."
 28 THE YA LO .\l RE A DER

Some patients internalize the group: "It's as though the group is sit-
ting on my shoulder, watching me. I'm forever asking, 'What would the
group say about this or that?"' Often therapeutic changes persist and are
consolidated because, even years later, the members are disinclined to
let the group down."
Group membership, acceptance, and approval are of the utmost im-
portance in the individual's developmental sequence. The importance
of belonging to childhood peer groups, adolescent cliques, sororities or
fraternities, or the proper social "in" group can hardly be overestimated.
~othing seems to be of greater importance for the self-esteem and well-
being of the adolescent, for example, than to be included and accepted
in some social group, and nothing is more devastating than exclusion."
Most psychiatric patients, however, have an impoverished group his-
tory; never before have they been valuable and integral to a group. For
these patients, the sheer successful negotiation of a group experience
may in itself be curative.
Thus, in a number of ways, members of a therapy group come to
mean a great deal to one another. The therapy group, at first perceived
as an artificial group that does not count, may in fact come to count very
much. I have known groups to experience together severe depressions,
psychoses, marriage, divorce, abortions, suicide, career shifts, sharing of
innermost thoughts, and incest (sexual activity among the group mem-
bers). I have seen a group physically carry one of its members to the hos-
pital and seen many groups mourn the death of members. Relationships
are often cemented by moving or hazardous adventures. How many re-
lationships in life are so richly layered?
Along with the many positive aspects described above, other ele-
ments, such as anger and hostility, play a crucial role in the life of the
group. Once the group is able to deal constructively with conflict in the
group, therapy is enhanced in many ways. I already mentioned the im-
portance of catharsis, of risk taking, of gradually exploring previously
avoided or unknown parts of oneself and recognizing that the antici-
pated dreaded catastrophe is chimerical. Many patients are desperately
afraid of anger-their own and that of others. A highly cohesive group
permits working through these fears.
It is important for patients to realize that their anger is not lethal.
 The Therapeutic Factors: What It Is That Heals 29

Both they and others can and do survive an expression of their impa-
tience, irritability, or even outright rage. It is also important for some
patients to have the experience of weathering an attack. In the process,
as J. Frank suggests, one 1nay become better acquainted with the rea-
sons for one's position and learn to withstand pressure from others . .,Q
Conflict may also enhance self-disclosure, as each opponent tends to re-
veal more and more to clarify his or her position. As members are able
to go beyond the mere statement of position, as they begin to under-
stand the other's experiential world, past and present, and view the
other's position from their own frame of reference, they may begin to
understand that the other's point of view may be as appropriate for that
person as their own is for themselves. The coming to grips with, work-
ing through, and eventual resolution of extreme dislike or hatred of an-
other person is an experience of great therapeutic power. A clinical
illustration demonstrates 1nany of these points.

Susan, a forty-six-year-old very proper school principal, and Jean, a twenty-

one-year-old high school dropout, were locked into a vicious struggle. Susan
despised Jean because of her libertine lifestyle and what she imagined to be
sloth and promiscuity. Jean was enraged by Susan's[udgmcntalism, her sanc-
timoniousness, her embittered spinsterhood, her closed posture to the world.
Fortunately, both women were deeply committed members of the group.
(Fortuitous circumstances played a part here. Jean had been a core member
of the groupfor a year and then married and went abroadfor three months.
Just at that time Susan became a member and, during Jean's absence, be-
came heavily involved in the group.)
Both had had considerable past difficulty in tolerating and expressing
anger. Over a four-month period, they interacted heavily, at times in pitched
battles. For example, Susan erupted sanctimoniously when she found out
that Jean was obtaining food stamps illegally; and Jean, learning of Susan's
virginity, ventured the opinion that she was a curiosity, a museum piece, a
mid-Victorian relic. Much good group work tuas done. Jean and Susan, de-
spite their conflict, never broke off communication. They learned a great
deal about each other and eventually realized the cruelty of their mutual
judgmentalism. Finally, they could both understand how much each meant
for the other on both a personal and a symbolic level. Jean desperately
 30 THE YALOM READER

wanted Susan's approval; Susan deeply envied Jean for the freedom she had
never permitted herself. In the working-through process, both fully experi-
enced their rage; they encountered and then accepted previously unknown
parts of themselves. Ultimately, they developed an empathic understanding
and then an acceptance of each other. Neither could possibly have tolerated
the extreme discomfort of the conflict were it not for the strong cohesion that,
despite the pain, bound them to the group.

Interpersonal Learning
From whatever perspective we study human society-whether we scan
humanity's broad evolutionary history or scrutinize the development of
the single individual-we are at all times obliged to consider the human
being in the matrix of his or her interpersonal relationships. Humans
have always lived in groups that have been characterized by intense and
persistent relationships arnong members. Interpersonal behavior has
clearly been adaptive in an evolutionary sense: without deep, positive,
reciprocal interpersonal bonds, neither individual nor species survival
would have been possible.
All modern American schools of dynamic psychotherapy are inter-
personally based and draw heavily, though implicitly, on the American
neo-Freudian theorists Karen Horney, Erich Fromm, and especially
and most systematically, Harry Stack Sullivan and his interpersonal
theory of psychiatry .60
Sullivan contends that the personality is almost entirely the product
of interaction with other significant human beings. The need to be
closely related to others is as basic as any biological need and is, in the
light of the prolonged period of helpless infancy, equally necessary to
survival. The developing child, in the quest for security, tends to cultivate
and to stress those traits and aspects of the self that meet with approval, and
will squelch or deny those that meet with disapproval. Eventually the indi-
vidual develops a concept of the self (self-dynamism} based on these per-
ceived appraisals of significant others.
Sullivan suggests that the proper focus of research in mental health is
the study of processes that involve or go on between people." Mental
disorder, or psychiatric symptornatology in all its varied manifestations,
 The Therapeutic Factors: \Vhat It Is That Heals .>1

should be translated into interpersonal terms and treated accordingly.

"Mental disorder" refers to interpersonal processes that are either inade-
quate to the social situation or excessively complex because of the intro-
duction of illusory persons into the situations." Accordingly, psychiatric
treatment should be directed toward the correction of interpersonal distor-
tions, thus enabling the individual to lead a more abundant life, to par-
ticipate collaboratively with others, to obtain interpersonal satisfactions
in the context of realistic, mutually satisfying interpersonal relation-
ships: "One achieves mental health to the extent that one becomes aware
of one's interpersonal relationships."? Psychiatric cure is the "expand-
ing of the self to such final effect that the patient as known to himself is
much the same person as the patient behaving to others."?'
These ideas-that therapy is broadly interpersonal, both in its goals
and in its means-are exceedingly gennane to group therapy. That
does not mean that all, or even most, patients entering group therapy
ask explicitly for help in their interpersonal relationships. Yet I have
observed that the therapeutic goals of patients, somewhere between the
third and the sixth months of group therapy, often undergo a shift.
Their initial goal, relief of suffering, is modified and eventually re-
placed by new goals, usually interpersonal in nature. Goals may change
from wanting relief from anxiety or depression to wanting to learn to
communicate with others, to be more trusting and honest with others,
to learn to love.
The goal shift from relief of suffering to change in interpersonal
functioning is an essential early step in the dynamic therapeutic process.
It is important in the thinking of the therapist as well. Therapists cannot,
for example, treat depression per se: depression offers no effective thera-
peutic handhold. It is necessary, first, to translate depression into inter-
personal terrns and then to treat the underlying interpersonal pathology.
The theory of interpersonal relationships has become so much an in-
tegral part of the fabric of psychiatric thought that it needs no further
underscoring. People need people-for initial and continued survival,
for socialization, for the pursuit of satisfaction. No one transcends the
need for hurnan contact.
For instance, the outcasts-those individuals thought to be so inured
to rejection that their interpersonal needs have become heavily cal-
 32 TH E YA LO M R EA DER

loused-have compelling social needs. I once had an experience in a

prison that provided me with a forceful reminder of the ubiquitous na-
ture of this human need. An untrained psychiatric technician consulted
me about his therapy group, composed of twelve inmates. The members
of the group were all hardened recidivists, whose offenses ranged from
pedophilia to murder. The group, he complained, was sluggish and per-
sisted in focusing on extraneous, extragroup material. I agreed to ob-
serve his group and suggested that first he obtain some sociometric
information by asking each member privately to rank-order everyone
in the group for general popularity. (I had hoped that the discussion of
this task would induce the group to turn its attention upon itself.) Al-
though we had planned to discuss these results before the next group
session, unexpected circumstances forced us to cancel our presession
consultation.
During the next group meeting, the therapist, enthusiastic but pro-
fessionally inexperienced and insensitive to interpersonal needs, an-
nounced that he had decided simply to read aloud the results of the
popularity poll. Hearing this, the group members grew agitated and
fearful. They made it clear that they did not wish to know the results.
Several members spoke so vehemently of the devastating possibility that
they might appear at the bottom of the list that the therapist quickly and
permanently abandoned his plan of reading the list aloud.
I suggested an alternative plan for the next meeting: each member
would indicate whose vote he cared about most and then explain his
choice. This device, also, was too threatening, and only one-third of the
members ventured a choice. Nevertheless, the group shifted to an inter-
actional level and developed a degree of tension, involvement, and ex-
hilaration previously unknown. These men had received the ultimate
message of rejection from society at large: they were imprisoned, segre-
gated, and explicitly labeled as outcasts. To the casual observer, they
seemed hardened, indifferent to the subtleties of interpersonal approval
and disapproval. Yet they cared, and cared deeply.
The need for acceptance by and interaction with others is no differ-
ent among people at the opposing pole of human fortunes-those who
occupy the ultimate realms of power, renown, or wealth. I once worked
 The Therapeutic Factors: \Vhat It Is That Heals 33

with an enormously wealthy woman whose major issues revolved

around the wedge that rnoney created between herself and others. Did
anvone
, value her for herself rather than her monev?. Was she continu-
ally being exploited by others? To whom could she corn plain of the bur-
dens of a forty-million-dollar fortune? The secret of her weal th kept
her isolated from others.
Every group therapist has, I am sure, encountered patients who pro-
fess indifference to or detachment from the group. They proclaim: ''I
don't care what they say or think or feel about me: they're nothing to
me; I have no respect for the other members," or words to that effect.
My experience has been that if I can keep such patients in the group
long enough, other sentiments inevitably surface. They are concerned at
a very deep level about the group. One patient who maintained her in-
different posture for rnany months was once invited to ask the group
her secret question, the one question she would like most of all to place
before the group. To everyone's astonishment, this seemingly aloof, de-
tached woman posed this question: ''How can you put up with me?"
Many patients anticipate meetings with great eagerness or with anx-
iety; some feel too shaken afterward to drive home or to sleep that
night; many have imaginary conversations with the group during the
week. Moreover, this engagement with other members is often long-
lived; I have known many patients who chink and dream about the
group members months, even years, after the group has ended.
In short, people do not feel indifferent toward others in their group
for long. And patients do not quit the therapy group because of bore-
dom. Believe scorn, contempt, fear, discouragement, shame, panic, ha-
tred! Believe anv' of these! But never believe indifference!

The Group as Social Microcosm

A freely interactive group with few structural restrictions will, in time.
develop into a social microcosm of the participant members. Given
enough time, group members will begin to he themselves: they will in-
 34 TH E YA LO M RE A DER

teract with the group members as they interact with others in their so-
cial sphere, will create in the group the same interpersonal universe they
have always inhabited. In other words, patients will, over time, auto-
matically and inevitably begin to display their maladaptive interper-
sonal behavior in the therapy group. There is no need for them to
describe or give a detailed history of their pathology: they will sooner or
later enact it before the group members' eyes.
This concept is of paramount importance in group therapy and
constitutes a keystone upon which rests the entire approach to such
therapy. It is widely accepted by clinicians, although each therapist's
perception and interpretation of group events and descriptive lan-
guage will be determined by his or her school of conviction. Thus,
Freudians rnay see patients manifesting their oral, sadistic, or
masochistic needs in their relationship to other members; object-rela-
tions theorists may focus on the patients' manifesting the defenses of
splitting, projective identification, idealization, devaluation; correc-
tional workers may see conning, exploitative behavior; whereas stu-
dents of Horney may see the detached, resigned person putting
energies into acting noncommittal and indifferent, or the arrogant-
vindictive person struggling to prove himself or herself right by prov-
ing others wrong.
The important point is that, regardless of the type of conceptual
spectacles worn by the therapist-observer, each member's interpersonal
style will eventually appear in his or her transactions in the group. The
development of the ability to identify and put to therapeutic advantage
maladaptive interpersonal behavior as seen in the social microcosm of
the small group is one of the chief tasks of a training program for group
psychotherapists. Some clinical examples may make these principles
more graphic.*

*In order to ensure each patient's right to privacy, I have altered certain
facts, such as name, occupation, and age. In addition, the interaction described
in the text is not verbatim but has been reconstructed from detailed clinical
notes taken after each therapy meeting.
 The Therapeutic Factors: What It Is That Heals 35

Valerie, a twenty-seven-year-old musician, sought therapy with me

primarily because of severe marital discord of several years' standing.
She had had considerable, unrewarding individual and hypnotic un-
covering therapy. Her husband, she reported, was an alcoholic who
was reluctant to engage her socially, intellectually, or sexually. Now
the group could have, as some groups do, investigated her marriage
interminably. The members might have taken a complete history of
the courtship, of the evolution of the discord, of her husband's pathol-
ogy, of her reasons for marrying him, of her role in the conflict; they
might have given advice for neto behavior or for a trial or permanent
separation.
But all this historical, problem-solving activity would have been in
vain: this entire line of inquiry not only disregards the unique poten-
tial of therapy groups but is also based on the highly questionable
premise that a patient's account of a marriage is even reasonably accu-
rate. Groups that function in this manner fail to help the protagonist
and also suffer demoralization because of the ineffectiveness of a prob-
lem-solving, historical group therapy approach. Let us instead observe
Valerie's behavior as it unfolds in the here-and-now of the group.
Valerie's group behavior was flamboyant. First, there was her
grand entrance, always five or ten minutes late. Bedecked in fash-
ionable but flashy garb, she would sweep in, sometimes throwing
kisses, and immediately begin talking, oblivious to whether some
other member was in the midst of a sentence. Here was narcissism in
the raw! Her worldview was so solipsistic that it did not take in the
possibility that life could have been going on in the group before her
arrival.
After very few meetings, Valerie began to give gifts: to an obese fe-
male member, a copy of a new diet book: to a woman with strabismus,
the name of a good ophthalmologist; to an effeminate gay patient, a
subscription to Field and Stream magazine (to masculinize him); to
a uoenty-four-vear-old virginal male, an introduction to a promiscu-
ous divorced friend of hers. Gradually it became apparent that the
gifts were not duty-free. For example, she pried into the relationship
between the young man and her divorcedfriend and insisted 011 seru-
 36 THE Y ALOM READER

ing as a go-between, thus exerting considerable control over both indi-

viduals.
Her efforts to dominate soon colored all of her interactions in the
group. I became a challenge to her, and she made various efforts to
control me. By sheer chance, a few months previously I had seen her
sister in consultation and referred her to a competent therapist, a clini-
cal psychologist. In the group Valerie congratulated me for the bril-
liant tactic of sending her sister to a psychologist; I must have divined
her deep-seated aversion to psychiatrists. Similarly, on another occa-
sion, she responded to a comment from me, "How perceptive you were
to have noticed my hands trembling."
The trap was set! In fact, I had neither "divined" her sister's alleged
aversion to psychiatrists (I had simply referred her to the best therapist I
knew), nor noted Valerie's trembling hands. If I silently accepted her
undeserved tribute, then I would enter into a dishonest collusion with
Valerie; if, on the other hand, I admitted my insensitivity either to the
trembling of the hands or to the sister's aversion, then in a sense I would
also be bested. She would control me either way! In such situations, the
therapist has only one real option: to change the frame and to comment
upon the process- the nature and the meaning of the entrapment.
Valerie vied with me in 1nany other ways. Intuitive and intellectu-
ally gifted, she became the group expert on dream and fantasy inter-
pretation. On one occasion she saw me between group sessions to ask
whether she could use my name to take a book out of the medical li-
brary. On one level the request was reasonable: the book (on music
therapy) was related to her profession.furthermore, having no univer-
sity affiliation, she was not permitted to use the library.
However, in the context of the group process, the request was com-
plex in that she was testing limits; granting her request would have
signaled to the group that she had a special and unique relationship
with me. I clarified these considerations to her and suggestedfurther
discussion in the next session. Following this perceived rebuttal, how-
ever, she called the three male members of the group at home and, af-
ter swearing them to secrecy, arranged to see them. She engaged in
sexual relations with two; the third, a gay man, was not interested in
 The Therapeutic Factors: What It Is That Heals 37

her sexual advances but she launched a mighty seduction attempt

nonetheless.
The following group meeting was horrific. Extraordinarily tense
and unproductive, it demonstrated the axiom that if something im-
portant in the group is heing actively avoided, then nothing else
of import gets talked about either. Two days later Valerie, over-
come unth anxiety and guilt, asked for an individual session with me
and made afull confession. It was agreed that the whole matter should
be discussedin the next group meeting.
Valerie opened the next meeting with the words: "This is confes-
sion day! Go ahead, Charles!" and then later, "Your turn, Louis."
Each man performed as she bade him and, later in the meeting, re-
ceivedfrom her a critical evaluation of his sexual performance. A few
weeks later, Valerie let her estranged husband know what had hap-
pened, and he sent threatening messagesto all three men. That was the
last straw! The members decidedthey could 110 longer trust her and, in
the only such instance I have k11ou.1n, voted her out of the group. (She
continued her therapy by joining another group.) The saga does not
end here, but perhaps I have gone far enough to illustrate the concept
of the group as social microcosm.
Let us summarize. The first step was that Valerie clearly dis-
played her interpersonal pathology in the group. Her narcissism,
her need for adulation, her need to control, her sadistic relationship
with men-the entire tragic behavioral scroll-unrolled in the here-
and-now of therapy. The next step was reaction and feedback. The
men expressed their deep humiliation and anger at having to "jump
through a hoop" for her and at receiving "gradcs'l for their sexual per-
formance. They drew atvay from her. They began to reflect: "I don't
want a report card every time I have sex. It's controlling, like sleeping
with my mother! I'm beginning to understand more about your hus-
band moving out!" and so on. The others in the group, the female
members and the therapists, shared the men'sfeelingsabout the wan-
tonly destructive course of Valerie's behavior-destructive for the
group as well asforherself.
Most important of all, she had to deal with this fact:she had joined
 38 TH E Y ALO 1-1 RE A DER

a group of troubled individuals who were eager to help one another

and whom she grew to like and respect; yet, in the course of several
weeks, she had so poisoned her environment that, against her conscious
wishes, she became a pariah, an outcastfrom a group that had had the
potential to be very helpful to her. Facing and working through these
issues in her subsequent therapy group enabled her to make substantial
personal changes and to employ much of her considerable potential
constructively in her later relationshipsand endeavors.

Ron, a forty-eight-year-oldattorney who was separatedfrom his wife,

entered therapy because of depression, anxiety, and intensefeelings of
loneliness. His relationships, with both men and women, were highly
problematic. He yearned for a close male [riend hut had not had one
since high school. His current relationshipswith men assumed one of
two forms: either he and the other man related in a highly competitive,
antagonistic fashion, which veered dangerously close to combative-
ness, or he assumed an exceedingly dominant role and soon found the
relationship empty and dull.
His relationships with u/omen had always followed a predictable
sequence: instant attraction, a crescendo of passion, a rapid withering.
His lovefor his wife had decayed years ago and he was currentlyin the
midst of a painfuldivorce.
Intelligent and highly articulate, Ron immediately assumed a posi-
tion of great influence in the group. He offered a continuous stream of
usefuland thoughtful observations to the other members, yet kept his
own pain and his own needs well concealed. He requested nothing
and accepted nothing from me or my co-therapist. Infact, each time I
set out to interact with Ron, 1 felt myself bracing for battle. His an-
tagonistic resistance u/as so great that for months my major interaction
with him consisted of repeatedlyrequesting him to examine his reluc-
tance to experience me as someone who could offer help.
"Ron," l asked, giving it my best shot, "let's understand what's
happening. You have many areas of unhappiness in your life. I'm an
experienced therapist, and you come to me for help. You come regu-
 The Therapeutic Factors: \Vhat It Is That Heals 39

larly, you never miss a meeting, you pay me for my services, yet you
systematically prevent me from helping. Either you so hide your pain
that I find little to offer you, or when I do extend some help, you reject
it in one fashion or another. Reason dictates that we should be allies,
working together to help you. How does it come about that u/« are ad-
versaries?"
But even that failed to alter our relationship. Ron seemed bemused
and speculated that 1 might be identifying one of my problems rather
than his. HiJ relationship with the other group members was charac-
terized by his insistence 011 seeing them outside the group. He system-
atically arranged for some extragroup activity with each of the
members. He was a pilot and took some members flying, others sail-
ing, others to lavish dinners; he gave legal advice to some and became
romantically involved with one of the female members; and (the final
straw) he invited my co-therapist, a female psychiatric resident, for a
skiing weeke12d.
Furthermore, he refusedto examine his behavior or to discuss these
extragroup meetings in the group, even though the pregroup prepara-
tion had emphasized to all the members that such unexamined, undis-
cussed extragroup meetings generally sabotage therapy.
After a meeting in which we strongly pressured him to examine the
meaning of the extragroup invitations, especially the skiing invitation
to my co-therapist, he left the session confused and shaken. On his way
home, Ron unaccountably began to think of the legend of Robin
Hood, his favorite childhood story, which he had not thought about
for decades.
Following an impulse, he drove directly to the nearest public li-
brary to sit in a small child's chair in the children's section and read
the story one more time. In a flash, the meaning of his
behavior was illuminated! fVhy had the Robin Hood legend always
fascinated and delighted him? Because Robin Hood rescued people,
especially women, from tyrants!
That motif had played a powerful role in his interior life beginning
with the Oedipal struggles i12 his own family. Later, in early adult-
hood, he built up a successful law firm by first assisting 111 a partner-
 40 T H E Y A LO !\1 RE AD£R

ship and then enticing his boss's employees to workfor him. He had
often been most attracted to women who were attached to some pow-
e1f ul man. Even his motives for marrying were blurred: he could not
distinguish between love for his wife and desire to rescue her from a
tyrannical father.
The first stage of interpersonal learning is pathology display.
Ron's characteristic modes of relating to both men and women un-
foldedvividly in the microcosm of the group. His major interpersonal
motif was to struggle with and to vanquish other men. He competed
openly and, because of his intelligence and his great verbal skills, soon
procured the dominant role in the group. He then began to mobilize
the other members in the final conspiracy: the unseating of the thera-
pist. He formed close alliances through cxtragroup meetings and
through placing other members in his debt by offeringfavors. Next he
endeavored to capture "my women"-first the most attractive female
member and then my co-therapist.
Not only was Ron's interpersonal pathology displayed in the
group, but so also were its aduerse, self-defeating consequences. His
struggles with men resulted in the undermining of the very reason he
had come to therapy: to obtain help. In fact, the competitive struggle
was so powerful that any help I extended to him was experienced not
as help but as defeat, a sign of weakness.
Furthermore, the microcosm of the group revealed the conse-
quences of his actions on the texture of his relationship with his peers.
In time the other members became aware that Ron did not really re-
late to them. He only appeared to relate but, in actuality, was using
them as a way of relating to me, the powerful and feared male in the
group. The others soon felt used) felt the absence of a genuine desire in
Ron to know them, and gradually began to distance themselves from
him. Only after Ron was able to understand and to alter his intense
and distorted ways of relating to me was he able to turn to and relate
in good faith to the other members of the group.

The idea of the social microcosm is, I believe, sufficiently clear: if the
group is so conducted that the members can behave in an unguarded,
 The Therapeutic Factors: What It Is That Heals 41

unself-conscious manner, they will, most vividly, re-create and display

their pathology in the group. Furthermore, in the in vivo drama of the
group meeting, the trained observer has a unique opportunity to understand
the dynamicsof each patient's behavior.
 CHAPTER 2

The Therapist Working in

the Here-and-Now

INTRODUCTION

I have chosen the following excerpt (from chapter 6 of The Theory and
Practice of Croup Psychotherapy) for a number of reasons. As the last se-
lection indicates, I value the entire range of therapeutic factors, but I
place particular importance on interpersonal learning (and its accompa-
nying here-and-now focus). In some groups this therapeutic factor plays
little role (for example, in Alcoholics Anonymous, cognitive therapy
groups, psychoeducational groups, cancer support groups), but in groups
that have goals of both symptom alleviation and change in relationship
patterns, interpersonal learning is of crucial importance. I believe that
the here-and-now focus is the power cell of the small dynamic group,
and whenever I am called to consult about a stalled or lifeless therapy
group, I find, almost invariably, that the problems emanate from the ther-
apists' failing to make proper use of the here-and-now.
l include this section to underscore the importance of the here-and-

42
 The Therapist Wor king in the Herc-and-Xow 43

now and to delineate the techniques of the therapist which harvest the
here-and-now approach. This is the area of group psychotherapy where I
have made my most original contributions-it is the signature of my par-
ticular approach to therapy, both individual and group therapy.
Another reason for stressing the material in this selection is that group
members and therapists do not naturally and automatically develop a
here-and-now focus: it doesn't just happen on its own; it is a learned skill
and has to be taught explicitly. We are not used to operating in the here-
and-now. It does not occur elsewhere in our experience. In fact, it is pre-
cisely the here-and-now focus that distinguishes the effective therapy
group from the group without trained therapeutic leadership-the lead-
erless, or self-help, group.
One additional point about the section entitled "Process Commen-
tary: A Theoretical Overview." I have generally stressed that my interests
in group psychotherapy and existential psychotherapy are separate and
discrete: not only do the therapies have different formats (existential psy-
chotherapy generally takes place in a one-to-one setting} but they oper-
ate from different frames of reference. Group therapists make the
assumption that their patients fall into despair because of their inability
to establish and maintain stabilizing and intimate relationships with oth-
ers. Existentially oriented therapists make a fundamentally different as-
sumption about the source of dysphoria-namely, that patients fall into
despair as a result of a confrontation with the brute facts of the human
condition (more about th is in Part II).
The process commentary excerpt demonstrates one of the ways in
which these two streams of thought, existential and interpersonal, come
together to work synergistically by incorporating the existential concepts
of personal freedom and responsibility assumption into the group process.

THE THERAPIST:
WORKING IN THE HERE-AND-No,v
The major difference between an outpatient therapy group that hopes
to effect extensive and enduring behavioral and characterological
change and such groups as AA, Recovery. Inc., psychoeducational
 44 THE Y ALOM READER

groups, weight-reduction groups, and cancer support groups is that the

therapy group strongly emphasizes the importance of the here-and-now
.
expenence.
The here-and-now focus, to be effective, consists of tu/o symbiotic tiers,
neither of which has therapeutic power without the other. The first tier is
an experiencing one: the members live in the here-and-now; they de-
velop strong feelings toward the other group members, the therapist,
and the group. These here-and-now feelings become the major dis-
course of the group. The thrust is ahistoric: the immediate events in the
meeting take precedence over events both in the current outside life and in
the distant past of the members. This focus greatly facilitates the develop-
ment and emergence of each member's social microcosm. It facilitates
feedback, catharsis, meaningful self-disclosure, and acquisition of so-
cializing techniques. The group becomes more vital, and all of the
members (not only the one who is working that session) become in-
tensely involved in the meeting.
But the here-and-now focus rapidly reaches the limits of its useful-
ness without the second tier, which is the illumination of process. If the
powerful therapeutic factor of interpersonal learning is to be set in mo-
tion, the group must recognize, examine, and understand process. It
must examine itself; it must study its own transactions; it must tran-
scend pure experience and apply itself to the integration of that experi-
ence.
Thus, the effective use of the here-and-now requires two steps: the
group lives in the here-and-now, and it also doubles back on itself; it
performs a self-reflective loop and examines the here-and-now behavior
that has just occurred.
If the group is to be effective, both aspects of the here-and-now are
essential. If only the first-the experiencing of the here-and-now-is
present, the group experience will still be intense, members will feel
deeply involved, emotional expression may be high, and members will
finish the group agreeing, "Wow, that was a powerful experience!" Yet
it will also prove to be an evanescent experience: members will have no
cognitive framework that will permit them to retain the group experi-
ence, to generalize from it, and to transfer their learning from the group
to situations back home.
If, on the other hand, only the second part of the here-and-now-the
 The Therapist \Vorking in the Here-and-Now 45

examination of process-is present, then the group loses its liveliness

and meaningfulness. It degenerates in to a sterile intellectual exercise.
This is the error made by overly formal, aloof, rigid therapists. Accord-
ingly, the therapist has two discrete functions in the here-and-now: to
steer the group into the here-and-now and to facilitate the self-reflective
loop (or process commentary).

Definition of Process
The term process has a highly specialized meaning in many fields, in-
cluding law, anatomy, sociology, anthropology, psychoanalysis, and de-
scriptive psychiatry. In interactional psychotherapy, also, process has a
specific technical meaning: it refers to the nature of the relationship be-
tween interacting individuals.
It is useful to contrast process with content. Imagine two individuals
in a discussion. The content of that discussion consists of the explicit
words spoken, the substantive issues, the arguments advanced. The
process is an altogether different matter. When we ask about process,
we ask, "What do these explicit words, the style of the participants, the
nature of the discussion, tell about the interpersonal relationship of the
participants?"
Therapists who are process-oriented are concerned not primarily
with the verbal content of a patient's utterance, but with the "how" and
the "why" of that utterance, especially insofar as the how and the why
illuminate aspects of the patient's relationship to other people. Thus,
therapists focus on the metacommunicational aspects of the message and
wonder why,from the relationship aspect, a patient makes a statement at
a certain time in a certain manner to a certain person.
Metacommunication refers to the communication about the com-
munication. Consider, for example, this transaction: during a lecture, a
student raises her hand and asks what the date of Freud's death was.
The lecturer replies, "1938," only to have the student inquire, "But, sir,
wasn't it 1939?'' Obviously the student's motivation was not a quest for
information. (A question ain't a question if you know the answer.) The
metacommunication? Most likely the student wished to demonstrate
her knowledge, or to humiliate the lecturer.
Frequently, in the group therapy setting, the understanding of
 ,
46 TH E Y A LO M R EA DER

process becomes more complex; we search for the process not only be-
hind a simple statement but behind a sequence of statements made by a
patient or several patients. The group therapist endeavors to under-
stand what a particular sequence reveals about the relationship between
one patient and the other group members, or between clusters or cliques
of members, or between the members and the leader, or, finally, be-
tween the group as a whole and its primary task.
Some clinical vignettes may further clarify the concept.

Early in the course of a group therapy meeting, Burt, a tenacious, intense,

bulldogfaced graduate student, exclaimed to the group in general and to
Rose (an unsophisticated, astrologicallyinclined cosmetologist and mother of
four) in particular, "Parenthood is degrading!" This provocative statement
elicited considerable responsefrom the group, all of whom possessedparents,
and many of whom were parents. The free-for-all that followed consumed
the remainder of the group session.

Burt's statement can be viewed strictly in terms of content. In fact,

this is precisely what occurred in the group; the members engaged Burt
in a debate over the virtues versus the dehumanizing aspects of parent-
hood-a discussion that was affect-laden but intellectualized and
brought none of the members closer to their goals in therapy. Subse-
quently, the group felt discouraged about the meeting and angry with
themselves and with Burt for having dissipated a meeting.
On the other hand, the therapist might have considered the process
of Burt's statement from any one of a number of perspectives:

1.Why <lid Burt attack Rose? What was the interpersonal process
between them? In fact, the two had had a smoldering conflict for many
weeks, and in the previous meeting Rose had wondered why, if Burt
was so brilliant, he was still, at the age of thirty-two, a student. Burt had
viewed Rose as an inferior heing who functioned primarily as a mam-
mary gland; once, when she had been absent, he referred to her as a
brood mare.
2. Why was Burt so judgmental and intolerant of nonintellectuals?

Why did he always have to maintain his self-esteem by standing on the

carcass of a vanquished or humiliated adversary?
 The Therapist Working in the Here-and-Now 47

3. Assuming that Burt's chief intent was to attack Rose, why did he
proceed so indirectly? ls this characteristic of Burt's expression of ag-
gression? Or is it characteristic of Rose that no one dares, for some un-
clear reason, to attack her directly?
4. Why did Burt, through an obviously provocative and indefensi-
ble statement, set himself up for a universal attack by the group? Al-
though the words were different, this was a familiar melody for the
group and for Hurt, who had on many previous occasions placed him-
self in this position. Was it possible that Burt was most comfortable
when relating to others in this fashion? He once stated that he had al-
ways loved a fight; indeed, he glo,ved with anticipation at the appear-
ance of a quarrel in the group. His early family environment was
distinctively a fighting one. Was fighting, then, a form (perhaps the
only available fonn) of involvement for Burt?
5. The process may be considered from the even broader perspec-
tive of the entire group. Other relevant events in the life of the group
must be considered. For the past two months, the session had been
dominated by Kate, a deviant, disruptive, and partially deaf member
who had, two weeks previously, dropped out of the group with the face-
sa ving proviso that she would return when she obtained a hearing aid.
Was it possible that the group needed a Kate, and that Burt was merely
filling the required role of scapegoat? Through its continual climate of
conflict, through its willingness to spend an entire session discussing in
non personal terms a single theme, was the group avoiding something-
possibly an honest discussion of members' feelings concerning Kate's re-
jection by the group or their guilt or fear of a similar fate? Or were they
perhaps avoiding the anticipated perils of self-disclosure and intimacy?

Was the group saying something to the therapist through Burt (and
through Kate)? For example, Burt may have been bearing the brunt of
an attack really aimed at the co-therapists but displaced from them. The
therapists-aloof figures with a proclivity for rabbinical pronounce-
ments-had never been attacked or confronted by the group. Surely
there were strong, avoided feelings toward the therapists, which rnay
have been further fanned by their failure to support Kate and by their
complicity through inactivity in her departure from the group.
Which one of these many process observations is correct? Which one
 48 THE YALOM READER

could the therapist have employed as an effective intervention? The an-

swer is, of course, that any and all may be correct. They are not mutu-
ally exclusive; each views the transaction from a slightly different
\'antage point. By clarifying each of these in turn, the therapist could
have focused the group on many different aspects of its life. Which one,
then, should the therapist have chosen?
The therapist's choice should be based on one primary consideration:
the needs of the group. Where was the group at that particular time?
Had there been too much focus on Burt of late, leaving the other mem-
bers feeling bored, uninvolved, and excluded? In that case, the therapist
might best have wondered aloud what the group was avoiding. The
therapist might have reminded the group of previous sessions spent in
similar discussions that left them dissatisfied, or might have helped one
of the members verbalize this point by inquiring about the member's
inactivity or apparent uninvolvement in the discussion. If the group
communications had been exceptionally indirect, the therapist might
have commented on the indirectness of Burt's attacks or asked the
group to help clarify, via feedback, what was happening between Burt
and Rose. If, as in this group, an important group event was being
strongly avoided (Kate's departure), then it should be pointed out. In
short, the therapist must determine what he or she thinks the group
needs most at a particular time and help it move in that direction.

In another group, Saul sought therapy because of his deep sense of isola-
tion. He was particularly interested in a group therapeutic experience be-
cause of his feelingthat he had never been a part of a primary group. Even in
his primary family, he had felt himself an outsider. He had been a spectator
all his life, pressing his nose against cold windowpanes, gazing longingly at
warm, convivial groups within.
At Saul's fourth therapy meeting, another member, Barbara, began the
meeting by announcing that she had just broken up with a man who had
been very important to her. Barbara's major reasonfor being in therapy had
been her inability to sustain a relationship with a man, and she was pro-
foundly distressedin the meeting. Barbara had an extremely poignant way of
describingher pain, and the group was swept along with her feelings. Every-
one in the group was very moved; I noted silently that Saul, too, had tears in
his eyes.
 The Therapist Working in the Here-and-Now 49

The group members (with the exception of Saul) did everything i11 their
power to offer Barbara support. They passed Kleenex; they reminded her of
all her assets; they reassured Barbara that she had made a wrong choice, that
the man was not good enough for her, that she was "lucky to be rid of that
. k,,
rr«
Suddenly Saul interjected, "I don't like u/hat's going on here in the group
today, and I don't like the way it's being led" (a thinly veiled allusion to me,
I thought). He went on to explain that the group members had no justifica-
tion for their criticism of Barbara's ex-boyfriend. They didn't really know
what he was like. They could see him only through Barbara's eyes, and prob-
ably she was presenting him in a distorted way. (Saul had a personal ax to
grind on this matter, having gone through a divorce a couple of years previ-
ously. His wife had attended a women's support group, and he had been the
''jerk" of that group.)
Saul's comments, of course, changed the entire tone of the meeting. The
softness and support disappeared. The room felt cold; the warm bond among
the members was broken. Everyone was on edge. I felt justifiably repri-
manded. Saul's position was technically correct: the group was probably
wrong to condemn Barbara's ex-boyfriend.
So much for the content. Now examine the process of this interaction.
First, note that Saul's comment had the effect of putting him outside the
group. The rest of the group was caught up in a warm, supportive atmos-
pherefrom which he excluded himself. Recall his chief complaint that he was
never a member of a group, but always the outsider. The meeting provided
an in vivo demonstration of how that came to pass. In his fourth group meet-
ing, Saul had, kamikaze-style, attacked and voluntarily ejected himselffrom
a group he wished to join.
A second issue had to do not with what Saul said but with what he did not
say. In the early part of the group, everyone except Saul had made warm sup-
portive statements to Barbara. I had no doubt but that Saul felt supportive of
her. The tears in his eyes indicated that. Why had he chosen to be silent? Why
did he always choose to respond from his critical self and not from his
warmer, more supportive self?
The examination of the process of this interaction led us to some very im-
portant issuesfor Saul. Obviously it was difficultfor him to expressthe softer,
affectionate part of himself. Hefeared being vulnerable and exposing his de-
. pendent cravings. Hefeared losing himself, his precious individuality, by be-
 50 T HE Y A LO M RE A DER

coming a member of a group. Behind the aggressive, ever-vigilant, hard-

nosed defenderof honesty (honesty of expression of negative but not positive
sentiments) there is always the softer, submissive child thirsting for accep-
tance and love.

In another group, Kevin, an overbearing business executive, opened the

meeting by asking the other members-housewives, teachers, clerical work-
ers, and shopkeepers-for help with a problem: he had received "downsiz-
ing" orders. He had to cut his staff immediately by 50 percent-to fire
twenty out of his staff offorty.
The content of the problem was intriguing, and the group spent forry-fioe
minutes discussing such aspectsas justice versus mercy: that is, whether one
retains the most competent workers or workers with the largest families or
those who would have the greatest difficulty infinding otherjobs. Despitethe
fact that most of the members engaged animatedly in the discussion, which
involved important problems in human relations, the therapist strongly felt
that the session was unproductive: the members remained in safe territory,
and the discussion could have appropriately occurred at a dinner party or any
other social gathering. Furthermore, as time passed, it became abundantly
clear that Kevin had already spent considerable time thinking through all as-
pects of this problem, and no one was able to provide him with novel ap-
proaches or suggestions.
The continued focus on content was unrewarding and eventually frus-
trating for the group. The therapists began to wonder about process-what
this content revealed about the nature of Kevin's relationship to the other
members. As the meeting progressed, Kevin, on two occasions, let slip the
amount of his salary (which was more than double that of any other mem-
ber). In fact, the overall interpersonal effect of Kevin's presentation was to
make others aware of his affluence and power.
The process became even more clear when the therapists recalled the pre-
vious meetings in which Kevin had attempted, in vain, to establish a special
kind of relationship with one of the therapists (he had sought some technical
information on psychological testingfor personnel). Furthermore, in the pre-
ceding meeting, Kevin had been soundly attacked by the group for his funda-
mentalist religious convictions, which he used to criticize others' behavior
but not his own propensityfor extramarital affairs and compulsive lying. At
that meeting, he had also been termed "thick-skinned" becauseof his appar-
 The Therapist Working in the Here-and-Now 51

ent insensitivity to others. One other important aspect of Kevin's group be-
havior was his dominance; almost invariably, he was the most active, central
figure in the group meetings.
With this information about process, a number of alternatives u/ere avail-
able. The therapists might have focused 011 Kevin's bid for prestige, especially
following his loss offace in the previous meeting. Phrased in a nonaccusatorv
manner, a clarification of this sequence might have helped Kevin become
aware of his desperate need for the group members to respect and admire
him. At the same time, the self-defeating aspects of his behavior could have
been pointed out. Despite his effortsto the contrary, the group had come to
resent and, at times, even to scorn him. Perhaps, too, Kevin was attempting
to disclaim the appellation of thick-skinned by sharing u/ith the group in
melodramatic fashion the personal agony he experienced in deciding how to
cut his staff The style of the intervention would have depended on Kevin's
degree of defensiveness: if he had seemed particularly brittle or prickly, then
the therapists might have underscored how hurt he must have been at the
previous meeting. If Kevin had been more open, the therapists might have
asked him directly what type of response he would have liked from the others.
Other therapists might have preferred to interrupt the content discussion
and ask the group what Kevin's question had to do with last week's session.
Still another alternative would be to call attention to an entirely different
type of process by reflecting on the group's apparent unllingness to permit
Kevin to occupy center stage in the group week after week. By encouraging
the members to discuss their response to his monopolization, the therapist
could have helped the group initiate an exploration of their relationship to
Kevin.

Process Focus: The Power Source of the Group

Process focus is not just one of many possible procedural orientations;
on the contrary, it is indispensable and a common denominator to all ef-
fective interactional groups. One so often hears words to this effect: "No
matter what else may be said about experiential groups (therapy groups,
encounter groups, and so on), one cannot deny that they are potent-
that they offer a compelling experience for participants." Why are these
groups potent? Precisely because they encourage process exploration!
The process focus is the power cell of the group!
 52 THE Y Al.OM READER

A process focus is the one truly unique feature of the experiential

group; after all, there are many socially sanctioned activities in which
one can express emotions, help others, give and receive advice, confess
and discover similarities between oneself and others. But where else is it
permissible, in fact encouraged, to comment, in depth, on here-and-
now behavior, on the nature of the immediately current relationship be-
tween people? Possibly only in the parent-young child relationship, and
even then the flow is unidirectional. The parent, but not the child, is
permitted process comments: "Don't look away when I talk to you!";
"Be quiet when someone else is speaking"; "Stop saying, 'I dunno."'
But process commentary among adults is taboo social behavior; it is
considered rude or impertinent. Positive comments about another's im-
mediate behavior often denote a seductive or flirtatious relationship.
When an individual comments negatively about another's manners,
gestures, speech, physical appearance, we can be certain that the battle is
bitter and the possibility of conciliation chancy.

The Therapist's Tasks in the Here-and-Now

In the first stage of the here-and-now focus, the activating phase, the
therapist's task is to move the group into the here-and-now. By a variety
of techniques, group leaders steer the group members away from dis-
cussion of outside material and focus their energy on their relationships
with one another. Group therapists expend more time and effort on this
task early in the course of the group. As the group progresses, the mem-
bers come to value the here-and-now and will themselves focus on it
and, by a variety of means, encourage their fellow members to do like-
wise.
It is altogether another matter with the second phase of the here-
and-now orientation, process illumination. Forces prevent members
from fully sharing that task with the therapist. One who comments on
process sets himself or herself apart from the other members and is
viewed with suspicion, as "not one of us." When a group member
makes observations about what is happening in the group, the others of-
ten respond resentfully about the presumptuousness of elevating oneself
above the others. If a member comments, for example, that "nothing is
 The Therapist Working in the Here-and-Now 53

happening today," or that "the group is stuck," or that "no one is self-re-
vealing," or that "there seem to be strong feelings toward the therapist,"
then that member is courting danger. The response of the other mem-
bers is predictable. They will challenge the challenging member: "You
make something happen today," or "you reveal yourself," or "you talk
about your feelings to the therapist." Only the therapist is relatively ex-
empt from that charge. Only the therapist has the right to suggest that
others work, or that others reveal themselves, without having to engage
personally in the act he or she suggests.
Throughout the life of the group, the members are involved in a
struggle for positions in the hierarchy of dominance. At times, the con-
flict around control and dominance is flagrant; at other times, quies-
cent. But it never vanishes. Some members strive nakedly for power;
others strive subtly; others desire it but are fearful of assertion; others al-
ways assume an obsequious, submissive posture. Statements by mem-
bers that suggest that they place themselves above or outside the group
generally evoke responses that emerge from the dominance struggle
rather than from consideration of the content of the statement. Even
therapists are not entirely immune to evoking this response; some pa-
tients are inordinately sensitive to being controlled or manipulated by
the therapist. They find themselves in the paradoxical position of apply-
ing to the therapist for help and being unable to accept help because all
statements by the therapist are viewed through spectacles of distrust.
This is a function of the specific pathology of some patients (and it is, of
course, good grist for the therapeutic mill). It is not a universal response
of the en tire group.
The therapist is an observer-participant in the group. The observer
status affords the objectivity necessary to store information, to make ob-
servations about sequences or cyclical patterns of behavior, to connect
events that have occurred over long periods of time. Therapists act as
the group historian. Only they are permitted to maintain a temporal
perspective; only they remain immune from the charge of not being one
of the group, of elevating themselves a hove the others. It is also only the
therapists who keep in mind the original goals of the patient and the re-
lationship between these goals and the events that gradually unfold in
the group.
 54 TH E Y A LO M RE A D F. R

Tu/o patients, Tim and Marjorie, had a sexual affair that eventually
came to light in the group. The other members reacted in various ways but
none so condemnatory nor so vehemently as Diana, a forty-five-year-old
nouveau-moralist, who criticized them both for breaking group rules: Tim,
for "being too intelligent to act like such a fool,"Marjoriefor her "irresponsi-
ble disregardfor her husband and child," and the Lucifer therapist (me) who
"just sat there and let it happen." I eventually pointed out that, in her formi-
dable moralistic broadside, some individuals had been obliterated, that the
Marjorie and Tim with all their struggles and doubts and fears whom Diana
had known for so long had suddenly been replaced by faceless one-dimen-
sional stereotypes. Furthermore, I was the only one to recall, and to remind
the group, of the reasons (expressed at the first group meeting) why Diana
had sought therapy: namely, that she needed help in dealing with her rage to-
u/ard a nineteen-year-old, rebellious, sexually awakening daughter who was
in the midst of a search for her identity and autonomy! From there it was but
a short stepfor the group, and then for Diana herself, to understand that her
conflict with her daughter was being played out in the here-and-now of the
group.

There are many occasions when the process is obvious to all the
members in the group but they cannot comment on it simply because
the situation is too hot: they are too much a part of the interaction to
separate themselves from it. In fact, often, even at a distance, the thera-
pist too feels the heat and is wary about naming the beast.

One neophyte therapist, when leading an experiential group of pediatric

oncology nurses (a support group intended to help members decrease the
stress experienced in their work), learned through collusive glances between
members in the first meeting that there was considerable unspoken tension
between the young, progressive nurses and the older, conservative nursing su-
pervisors in the group. The therapistfelt that the issue, reaching deep into
taboo regions of the authority-ridden nursing profession, was too sensitive
and potentially explosive to touch. His supervisor assured him that it was too
important an issue to leave unexplored and that he should broach it, since it
was highly unlikely that anyone else in the group could do what he dared not.
In the next meeting, the therapist broached the issue in a manner that is
 The Therapist \Vorking in the Here-and-Now 55

almost invariably effective in minimizing dcfensiucness: he stated bis ou/n

dilemma about the issue. He told the group that he sensed a hierarchical
struggle betu/een the junior nurses and the powe,ful senior nurses, but that
he was hesitant to bring it up lest the younger nurses either deny it or so at-
tack the supervisorsthat the latter would sufferinjury or decide to scuttle the
group. His comment was enormously helpful and plunged the group into an
open and constructive exploration of a vital issue.

I do not mean that only the leader should make process comments.
Other members arc entirely capable of performing this function; in fact,
there are times when their process observations will be more readily ac-
cepted than those of the therapists. What is important is that they not
engage in this function for defensive reasons-for example, to avoid the
patient role or in any other way to distance themselves from or elevate
themselves above the other members.
Thus far in this discussion I have, for pedagogical reasons, overstated
two fundamental points that I must now qualify. Those points are: (1)
the here-and-now approach is an ahistoric one, and (2) there is a sharp
distinction between here-and-now experience and here-and-now
process illumination.
Strictly speaking, an ahistoric approach is an impossibility: every
process comment refers to an act already belonging to the past. (Sartre
once said, "Introspection is retrospection.") Not only does process com-
mentary involve behavior that has just transpired, but it frequently
refers to cycles of behavior or repetitive acts that have occurred in the
group over weeks or months. Thus, the past events of the therapy group
are a part of the here-and-now and an integral part of the data on which
process commentary is based.
Often it is helpful to ask patients to review their past experiences in
the group. If a patient feels that she is exploited every time she trusts
someone or reveals herself, I often inquire about her history of experi-
encing that feeling in this group. Other patients. depending upon the
relevant issues, may be encouraged to discuss such experiences as the
times they have felt most close to others, most angry, most accepted, or
most ignored.
My qualification of the ahistoric approach goes even further. ~o
 56 TH E Y A LO M RE A DER

group can maintain a total here-and-now approach. There will be fre-

quent excursions into the "then-and-there"-that is, into personal his-
tory and into current life situations. In fact, these excursions are so
inevitable that one becomes curious when they do not occur. It is not
that the group doesn't deal with the past; it is what is done with the past:
the crucial task is not to uncover, to piece together, and to understand
the past, but to use the past for the help it offers in understanding (and
changing) the individual's mode of relating to the others in the present.

Summary
The effective use of the here-and-now focus requires two steps: ex-
perience in here-and-now and process illumination. The combination
of these two steps imbues an experiential group with compelling po-
tency.
The therapist has different tasks in each step. First, the group must
be plunged into the here-and-now experience; second, the group must
be helped to understand the process of the here-and-now experience:
that is, what the interaction conveys about the nature of the members'
relationships to one another.
The first step, here-and-now activation, becomes part of the group
norm structure; ultimately the group members will assist the therapist
in this chore.
The second step, process illumination, is more difficult. There are
powerful injunctions against process commentary in everyday social in-
tercourse which the therapist must overcome. The task of process com-
mentary, to a great extent, remains the responsibility of the therapist
and consists, as I will discuss shortly, of a wide and complex range of be-
havior-from labeling single behavioral acts, to juxtaposing several
acts, to combining acts over time into a pattern of behavior, to pointing
out the undesirable consequences of a patient's behavioral patterns, to
more complex inferential explanations or interpretations about the
meaning and motivation of such behavior.

Techniques of Here-and-Now Activation

Each therapist must develop techniques consonant with his or her style.
Indeed, therapists have a more important task than mastering a tech-
,!

J.
 The Therapist \Vorking in the Here-and-Now Si

nique: they must fully comprehend the strategy and theoretical founda-
tions upon which all effective technique must rest.
I suggest that you think here-and-now. When you grow accustomed
to thinking of the here-and-now, you automatically steer the group into
the here-and-now. Sometimes I feel like a shepherd herding a flock into
an ever-tightening circle. I head off errant strays-forays into personal
historical material, discussions of current life situations, intellectu-
alisms-and guide them back into the circle. Whenever an issue is
raised in the group, I think, "How can I relate this to the group's pri-
mary task? How can I make it come to life in the here-and-now?" I am
relentless in this effort, and I begin it in the veryfirst meeting of the group.
Consider a typical first meeting of a group. After a short, awkward
pause, the members generally introduce themselves and proceed, often
with help from the therapist, to tell something about their life problems,
why they have sought therapy, and perhaps, the type of distress they
suffer. I generally intervene at some convenient point well into the
meeting and remark to the effect that "We've done a great deal here to-
day so far. Each of you has shared a great deal about yourself, your pain,
your reasons for seeking help. But I have a hunch that something else is
also going on, and that is that you're sizing one another up, each arriv-
ing at some impressions of the other, each wondering how you'll fit in
with the others. I wonder now if we could spend some time discussing
what each of us has come up with thus far." Now this is no subtle, art-
ful, shaping statement: it is a heavy-handed, explicit directive. Yet I find
that most groups respond favorably to such clear guidelines.
The therapist moves the focus from outside to inside, from the ab-
stract to the specific, from the generic to the personal. If a patient de-
scribes a hostile confrontation with a spouse or roommate, the therapist
may, at some point, inquire, "If you were to be angry like that with any-
one in the group, with whom would it be?" or "With whom in the
group can you foresee getting into the same type of struggle?" If a pa-
tient comments that one of his problems is that he lies, or that he stereo-
types people, or that he manipulates groups, the therapist rnay inquire,
"What is the main lie you've told in the group thus far?" or "Can you
describe the way you've stereotyped some of us?" or "To what extent
have you manipulated the group thus far?"
If a patient complains of mysterious flashes of anger or suicidal coin-
 11
I

58 TH E Y ALO M R EA DE R

pulsions, the therapist may urge the patient to signal to the group the
very moment such feelings occur during the session, so that the group
can track down and relate these experiences to events in the session.
In each of these instances, the therapist can deepen interaction by en-
couraging further responses from the others. For example, "How do
you feel about the perception of your ridiculing him? Can you imagine
doing that? Do you, at times, feel judgmental in the group? Does this
resonate with feelings that you are indeed influential, angry, too tact-
ful?" Even simple techniques of asking patients to speak directly to one
another, to use second-person pronouns ("you") rather than third-
person pronouns, and to look at one another are very useful.
Easier said than done! These suggestions are not always heeded. To
some patients, they are threatening indeed, and the therapist must here,
as always, employ good timing and attempt to experience what the pa-
tient is experiencing. Search for methods that lessen the threat. Begin by
focusing on positive interaction: "Toward whom in the group do you
feel most warm?" "Who in the group is most like you?" or "Obviously,
there are some strong vibes, both positive and negative, going on be-
tween you and John. I wonder what you most envy about him? And
what parts of him do you find most difficult to accept?"
Sometimes it is easier for group members to work in tandem or in
small subgroups. For exam ple, if they learn that there is another mem-
ber with similar fears or concerns, then the subgroup of two (or more)
members can, with less threat, discuss their here-and-now concerns.'
Using the conditional and subjunctive tenses provides safety and
distance and often is miraculously facilitative. I use them frequently
when I encounter initial resistance. If, for example, a patient says, "I
don't have any response or feelings at all about Mary today. I'm just
feeling too numb and withdrawn," I often say something like, "If you
were not numb or withdrawn today, what might you feel about
Mary?" The patient generally answers readily: the once-removed posi-
tion affords a refuge and encourages the patient to answer honestly and
directly. Similarly, the therapist might inquire, "If you were to be an-
gry at someone in the group, at whom would it be?" or "If you were to
go on a date with Albert (another group member), what kind of experi-
ence might it he?" J;
The therapist must often give instruction in the art of requesting and I
 The Therapist Working in the Here-and-Now 59

offering feedback. One important principle to teach patients is to avoid

global questions and observations. Questions such as "A1n I boring? nor
"Do you like me ?" are not usually productive. A patient learns a great
deal more by asking, "What do I do that causes you to tune out?"
"When are you most and least attentive to me?" or "What parts of me
or aspects of rny behavior do you like least and most?" In the same vein,
feedback such as "You're OK," or "a nice guy" is far less useful than "I
feel closer to you when you're willing to be honest with your feelings,
like in last week's meeting when you said you were attracted to Mary
but feared she would scorn you. I feel most distant from you when
you're impersonal and start analyzing the meaning of every word said
to you, like you did early in the meeting today." (These comments, inci-
dentally, have equal applicability in individual therapy.)
Resistance occurs in 1nany forrns. Often it appears in the cunning
guise of total equality. Patients, especially in early meetings, often re-
spond to the therapist's here-and-now urgings by claiming that they feel
exactly the same toward all the group members: that is, they say that
they feel equally warm toward all the members, or no anger toward
any, or equally influenced or threatened by all. Do not be misled. Such
claims are never true. Guided by your sense of timing, push the inquiry
further and help members to differentiate one from the other. Eventu-
ally they will disclose that they do have slight differences of feeling to-
ward some of the members. These slight differences are important and
are often the vestibule to full interactional participation. I explore the
slight differences (no one ever said they had to be enormous); sometimes
I suggest that the patient hold up a magnifying glass to these differences
and describe what he or she then sees and feels. Often resistance is
deeply ingrained, and considerable ingenuity is required, as in the fol-
lowing case study.

Claudia resisted participation 011 a here-and-now level for months. Keep

in mind that resistance is not usually conscious obstinacy but more often
stemsfrom sources outside of awareness. Sometimes the here-and-now task is
so unfamiliar and uncomfortableto the patient that it fr not unlike learning
a new language; one has to attend with maximal concentration in order not
to slip back into one's habitual remoteness.
Claudia's typical mode of relating to the group was to describe Jome
 60 TH E Y A LO M R EA DER

pressing current life problem, often one of such crisis proportions that the
group members felt trapped. First, they felt compelled to deal immediately
with the preciseproblem Claudia presented; second, they had to tread cau-
tiously because she explicitlyinformed them that she needed all her resources
to cope with the crisis and could not affordto be shaken up by interpersonal
confrontation. "Don't push me right now," she might say, "I'm just barely
hanging 011." Effortsto alter this pattern were unsuccessful, and the group
membersfelt discouraged in dealing with Claudia. They cringed when she
brought in problems to the meeting.
One day she opened the group with a typical gambit. After weeks of
searchingshe had obtained a new job, but she was convinced that she was go-
ing to fail and be dismissed. The group dutifully, but warily, investigated the
situation. The investigation met with many of the familiar, treacherous ob-
stacles that generally block the path of work on outside problems. There
seemed to be no objective evidence that Claudia was failing at work, She
seemed, if anything, to be trying too hard, working eighty hours a week. The
evidence, Claudia insisted, simply could not be appreciated by anyone not
there at work with her: the glances of her supervisor, the subtle innuendoes,
the air of dissatisfaction toward her, the general ambiance in the office, the
failure to live up to her (self-imposedand unrealistic) sales goals. Could
Claudia be believed? She was a highly unreliable observer;she always down-
graded herself and minimized her accomplishments and strengths.
The therapist moved the entire transaction into the here-and-now by ask-
ing, "Claudia, it's hardfor us to determine whether you are, in[act.failing at
your job. But let me ask you another question: What grade do you think you
deservefor your work in the group, and what do each of the others get?"
Claudia, not unexpectedly, awarded herself a "D" and staked her claim
for at least eight more years in the group. She awarded all the other members
substantially superior grades. The therapist replied by awarding Claudia a
"R"for her work in the group and then went on to point out the reasons:her
commitment to the group, perfect attendance, willingness to help others,
great effortsto work despite anxiety and often disabling depression.
Claudia laughed it off; she tried to brush off the incident as a gag or a
therapeuticploy. Rut the therapistheldfirm and insistedthat he was entirely
serious. Claudia then insisted that the therapist was wrong, and pointed out
his many failings in the group (one of which was, ironically, the avoidance of

'i
 The Therapist Working in the Here-and-Now 61

the here-and-now). However, Claudia's disagreement with the therapist was

incompatible with her long-held, frequently voiced, total confidencein the
therapist. (Claudia had often invalidated the feedback of other members in
the group by claiming that she trusted no one's judgment except the thera-
pist's.)

The intervention was enormously useful and transferred the process

of Claudia's evaluation of herself from a secret chamber lined with the
distorting mirrors of her self-perception to the open, vital arena of the
group. No longer was it necessary for the members to accept Claudia's
perception of her boss's glares and subtle innuendoes. The boss (the
therapist) was there in the group. The transaction, in its entirety, was
entirely visible to the group.
I never cease to be awed by the rich, subterranean lode of data that
exists in every group and in every meeting. Beneath each sentiment ex-
pressed there are layers of invisible, unvoiced ones. But how to tap these
riches? Sometimes after a long silence in a meeting, I express this very
thought: "There is so much information that could be valuable to us all
today if only we could excavate it. I wonder if we could, each of us, tell
the group about some thoughts that occurred to us in this silence, which
we thought of saying but didn't." The exercise is more effective, inci-
dentally, if you participate personally, even start it going. For example,
"I've been feeling on edge in the silence, wanting to break it, not want-
ing to waste time, but on the other hand feeling irritated that it always
has to be me doing this work for the group." Or, "I've been feeling torn
between wanting to get back to the struggle between you and me, Mike.
I feel uncomfortable with this much tension and anger, but I don't
know yet how to help understand and resolve it."
When I feel there has been a particularly great deal unsaid in a meet-
ing, I have often used, with success, a technique such as this: "It's now
six o'clock and we still have half an hour left, but I wonder if you each
would imagine that it's already six-thirty and that you're on your way
home. What disappointments would you have about the meeting to-
d ay. ?"
Many of the observations the therapist makes may be highly inferen-
tial. Objective accuracy is not the issue; as long as you persistently direct
 62 THE y A L () ~1 RE A DE R

the group from the nonrelevant, from the then-and-there, to the here-
and-now, you are operationally correct. If a group spends time in an un-
productive meeting discussing dull, boring parties, and the therapist
wonders aloud if the members are indirectly referring to the present
group session, there is no way of determining with any certainty
whether they in fact are. Correctness in this instance must be defined
relativistically and pragmatically. By shifting the group's attention from
then-and-there to here-and-now material, the therapist performs a ser-
vice to the group-a service that, consistently reinforced, will ultimately
result in a cohesive, interactional atmosphere maximally conducive to
therapy. Following this model, the effectiveness of an intervention
should be gauged by its success in focusing the group on itself.
Often, when activating the group, the therapist performs two simul-
taneous acts: steers the group into the here-and-now and, at the same
time, intcr rupts the content flow in the group. Not infrequently, some
members will resent or feel rejected by the interruption, and the thera-
pist must attend to these feelings for they, too, are part of the here-and-
now. This consideration often makes it difficult for the therapist to
intervene. Early in our socialization process we learn not to interrupt,
not to change the subject abruptly. Furthermore, there are times in the
group when everyone seems keenly interested in the topic under discus-
sion. Even though the therapist is certain that the group is not working,
it is not easy to buck the group current. Social psychological small group
research strongly documents the compelling force of group pressure. To
take a stand opposite to the perceived consensus of the group requires
considerable courage and conviction.
My experience is that the therapist faced with this type of dilemma
can increase the patient's receptivity by expressing both sets of feelings
to the group. For example, "Mary, I feel very uncomfortable as you talk.
I'm having a couple of strong feelings. One is that you're into something
that is very important and painful for you, and the other is that Ben [a
new member J has heen trying hard to get into the group for the last few
meetings and the group seems unwelcoming, This didn't happen when
other new members entered the group. Why do you think it's happen-
ing now?" Or, "Warren, I had two reactions as you started talking. The
first is that I'm delighted you feel comfortable enough now in the group
 The Therapist \Vorking in the Here-and-Now 63

to participate, but the other is that it's going to be hard for the group to
respond to what you're saying because it's very abstract and far removed
from you personally. I'd be much more interested in how you've been
feeling about the group these past few weeks. Which meetings, which
issues, have you been most tuned in to? What reactions have you had to
the various members?"
There are, of course, many more activating procedures. But my goal
in this chapter is not to offer a compendium of techniques. Quite the
contrary. I describe techniques only to illuminate the underlying princi-
ple of here-and-now activation. These techniques, or group gimmicks,
are servants, not masters. To use them injudiciously, to fill voids, to jazz
up the group, to acquiesce to the members' demands that the leader
lead, is seductive but not constructive for the group.
Group research offers corroborative evidence. In one group project,
the activating techniques (structured exercises) of sixteen different lead-
ers were studied and correlated with outcome.' There were two impor-
tant relevant findings:

1. The more structured exercises the leader used, the more compe-
tent did members (at the end of the thirty-hour group) deem the leader
to be.
2. The more structured exercises used by the leader, the less positive

were the results (measured at a six-month follow-up).

In other words, members desire leaders who lead, who offer consid-
erable structure and guidance. They equate a large number of struc-
tured exercises with competence. Yet this is a confusion of form and
substance: too much structure, too many activating techniques, is coun-
terproductive.
Overall, group leader activity correlates with outcome in a curvilin-
ear fashion (too much or too little activity led to unsuccessful outcome).
Too little leader activity results in a floundering group. Too much acti-
vation by a leader results in a dependent group that persists in looking
to the leader to supply too rnuch.
Remember that sheer acceleration of interaction is not the purpose of
these techniques. The therapist who moves too quickly-using gi1n-
 ,..
64 THE Y A LO M R EA DER

micks to make interactions, emotional expression, and self-disclosure

too easy-misses the whole point. Resistance, fear, guardedness, dis-
trust-in short, everything that impedes the development of satisfying
interpersonal relations-must be permitted expression. The goal is to
create not a slick-functioning, streamlined social organization, but one
that functions well enough and engenders sufficient trust for the un-
folding of each member's social microcosm. Working through the resis-
tances to change is the key to the production of change. Thus, the
therapist wants to go not around obstacles but through them. Ormont
puts it nicely when he points out that though we urge patients to engage
deeply in the here-and-now, we expect them to fail, to default on their
contract. In fact, we want them to default because we hope, through the
nature of their failure, to identify, and ultimately dispel, each member's
particular resistances to intimacy-including each member's resistance
style (for example, detachment, fighting, diverting, self-absorption, dis-
trust) and each member's underlying fears of intimacy (for example, im-
pulsivity, abandonment, merger, vulnerability ).3

Techniques of Process Illumination

As soon as patients have been successfully steered into a here-and-now
interactional pattern, the group therapist must attend to turning this in-
teraction to therapeutic advantage. This task is complex and consists of
several stages:

1. Patients must first recognize what they are doing with other peo-
ple (ranging from simple acts to complex patterns unfolding over a long
time).
2. They must then appreciate the impact of this behavior on others

and how it influences others' opinion of them, and consequently the im-
pact of the behavior on their own self-regard.
3. They must decide whether they are satisfied with their habitual ..,-
!

interpersonal style.
4. They must exercise the will to change.

Even when therapists have helped patients transform intent into de- 'II
cision and decision into action, their task is not complete. They must

l
 The Therapist \Vorking in the Here-and-Now 65

then help solidify change and transfer it from the group setting into pa-
tients' larger lives.
Each of these stages may be facilitated by some specific cognitive in-
put by the therapist, and I will describe each step in turn. First, how-
ever, I must discuss several prior and basic considerations: How does
the therapist recognize process? How can the therapist help the mem-
bers to assume a process orientation? How can the therapist increase the
receptivity of the patient to his or her process commentary?

Recognition of Process
Before therapists can help patients understand process, they themselves
must obviously learn to recognize it. The experienced therapist does
this naturally and effortlessly, observing the group proceedings from
a perspective that permits a continuous view of the process underlying
the content of the group discussion. This difference in perspective is
the major difference in role between the patient and the therapist in the
group.

Consider a group meeting in which a patient, Karen, discloses much

heavy, deeply personal material. The group is moved by her account and de-
votes much time to listening, to helping her elaborate more fully, and to of-
fering her support. The group therapist shares in these activities but
entertains many other thoughts as well. For example, the therapist may won-
der why, of all the members, it is invariably Karen who reveals first and
most. Why does Karen so often put hersel] in the role of the group patient
whom all the members must nurse? Why must she always display herself as
vulnerable? And why today? And that last meeting! So much conflict! After
such a meeting, one might have expected Karen to be angry. Instead, she
shows her throat. Is she avoiding giving expression to her rage?

At the end of a session in another group, Jay, a young, rather fragile pa-
tient, had, amid considerable emotional upheaval, revealed that he was
gay-his veryfint step out of the closet. At the next meeting the group urged
him to continue. He attempted to do so but, overcome with emotion, blocked
and hesitated. Just then, with indecent alacrity, Vic,ky filled the gap, saying,
"Well, if no one else is going to talk, I have a problem."
 ,.
66 T H E YA LO M RE A DER

Vick),, an aggressiveforty-year-old cabdriver, who sought therapy be-

cause of social loneliness and bitterness, proceeded to discuss in endless detail
a complex situation involving an unwelcome visiting aunt. For the experi-
enced, process-oriented therapist, the phrase "I have a problem" is a double
cntendre. Far more trenchantly than her words, Vick),'s behavior says, "I
have a problem," and her problem is manifest in her insensitivityto jay, who,
after months of silence, had finally mustered the courage to speak.

It is not easy to tell the beginning therapist how to recognize process;

the acquisition of this perspective is one of the major tasks in your edu-
cation. And it is an interminable task: throughout your career, you learn
to penetrate ever more deeply into the substratum of group discourse.
This deeper vision increases the keenness of a therapist's interest in the
meeting. Generally, beginning students who observe meetings find
them far Jess meaningful, complex, and interesting than does the expe-
rienced therapist.
Certain guidelines, though, may facilitate the neophyte therapist's
recognition of process. Note the simple nonverbal sense data available.'
Who chooses to sit where? Which members sit together? Who chooses
to sit close to the therapist? Far away? Who sits near the door? Who
comes to the meeting on time? Who is habitually late? Who looks at
whom when speaking? Do some members, while speaking to another
member, look at the therapist? If so, then they are relating not to one
another but instead to the therapist through their speech to the others.
Who looks at his watch? Who slouches in her seat? Who yawns? Do
the members pull their chairs away from the center at the same time as
they are verbally professing great interest in the group? Are coats kept
on? When in a single meeting or in the sequence of meetings are they
removed? How quickly do the group members enter the room? How
do they leave it?
Sometimes the process is clarified by attending not only to what is said
but to what is omitted: the female patient who offers suggestions, advice,
or feedback to the male patients but never to the other women in the
group; the group that never confronts or questions the therapist; the
topics (for example, the taboo trio: sex, money, death) that are never i'

broached; the patient who is never attacked; the one who is never sup-
 The Therapist Working in the Here-and-Now 67

ported; the one who never supports or inquires-all these omissions are
part of the transactional process of the group.

In one group, for example, Sonia stated that she felt others disliked her.
When asked who, she selected Eric, a detached, aloof man who habitually re-
lated only to those people who could be of use to him. Eric immediately bris-
tled, "Why me? Tell me one thing I've said to you that makes you pick me."
Sonia stated, "That's exactly the point. You have no usefor me. You've never
said anything to me. lVot a question, 1101 a greeting. Nothing. I just don't ex-
istfor you." Eric, much later, when completing therapy, cited this incident as
a particularly pou/erful and illuminating instruction.

Physiologists commonly study the function of a hormone by remov-

ing the endocrine gland that manufactures it and observing the changes
in the hormone-deficient organism. Similarly, in group therapy, we may
learn a great deal about the role of a particular member by observing the
here-and-now process of the group when that member is absent. For ex-
ample, if the absent member is aggressive and competitive, the group
may feel liberated. Other patients, who had felt threatened or restricted
in the missing member's presence, may suddenly blossom into activity.
If, on the other hand, the group has depended on the missing member to
carry the burden of self-disclosure or to coax other members into speak-
ing, then it will feel helpless and threatened when that member is absent.
Often this absence e1ucidates interpersonal feelings that previously were
entirely out of the group members' awareness, and the therapist may,
with profit, encourage the group to discuss these feelings toward the ab-
sent member both at that time and later in his or her presence.
Similarly, a rich supply of data about feelings toward the therapist
often emerges in a meeting in which the leader is absent. One leader led
an experiential training group of mental health professionals composed
of one woman and twelve men. The woman, though she habitually
took the chair closest to the door, felt reasonably comfortable in the
group until a leaderless meeting was scheduled when the therapist was
out of town. At that rneeting the group discussed sexual feelings and ex-
periences far more blatantly than ever before, and the woman had terri-
fying fantasies of the group locking the door and raping her. She
 68 TH E YA LO !-.1 R EA D ER

realized how the therapist's presence had offered her safety against fears
of unrestrained sexual behavior by the other members and against the
emergence of her own sexual fantasies. (She realized, too, the meaning
of her occupying the seat nearest the door!)
Search in every possible way to understand the relationship messages
in any communication. Look for incongruence between verbal and non-
verbal behavior. Be especially curious when there is something arrhyth-
mic about a transaction: when, for example, the intensity of a response
seems disproportionate to the stimulus statement; or when a response
seems to be off target or to make no sense. At these times look for sev-
eral possibilities: for example, parataxic distortion (the responder is
experiencing the sender unrealistically), or metacommunications (the re-
sponder is responding, accurately, not to the manifest content but to an-
other level of communication), or displacement (the responder is reacting
not to the current transaction but to feelings stemming from previous
transactions).

Common Group Tensions

Remember that certain tensions are always present, to some degree,
in every therapy group. Consider, for example, such tensions as the
struggle for dominance, the antagonism between mutually supportive
feelings and sibling rivalrous ones, between greed and selfless efforts to
help the other, between the desire to immerse oneself in the comforting
waters of the group and the fear of losing one's precious individuality,
between the wish to get better and the wish to stay in the group, be-
tween the wish that others improve and the fear of being left behind.
Sometimes these tensions are quiescent for months until some event
wakens them and they erupt into plain view.
Do not forget these tensions. They are always there, always fueling
the hidden motors of group interaction. The knowledge of these ten-
sions often informs the therapist's recognition of process. Consider, for
example, one of the most powerful covert sources of group tension: the
struggle for dominance. Earlier in this chapter, I described an interven-
tion where the therapist, in an effort to steer a patient into the here-and-
now, gave her a grade for her work in the group. The intervention was
effective for that particular patient. Yet that was not the end of the . I
 The Therapist Working in the Here-and-Now 69

story: there were later repercussions on the rest of the group. In the next
meeting, two patients asked the therapist to clarify some remark he had
made to them at a previous meeting, The remarks had been so support-
ive in nature and so straightforwardly phrased that the therapist was
puzzled at the request for clarification. Deeper investigation revealed
that the two patients, and later others, too, were requesting grades from
the therapist.

In another experiential group of mental health professionals at several

levels of training, the leader was deeply impressed at the group skills of Stew-
art, one of the youngest, most inexperienced members. The leader expressed
his fantasy that Stewart was a plant, that he could not possibly be just begin-
ning his training, since he conducted himself like a veteran with ten years'
group experience. The comment evoked a flood of tensions. It was not easily
[orgoucn by the group and.for months to come, was periodically revived and
angrily discussed. With his comment, the therapist placed the kiss of death 011
Stewart's brow, since thereafter the group systematically challenged and de-
skilled him. It is likely that the therapist who makes a positive evaluation of
one member will evoke feelings of sibling rivalry.

The struggle for dominance fluctuates in intensity throughout the

group. It is much in evidence at the beginning of the group as members
jockey for position in the pecking order. Once the hierarchy is estab-
lished, the issue may become quiescent, with periodic flare-ups: for ex-
ample, when some member, as part of his or her therapeutic work,
begins to grow in assertiveness and to challenge the established order.
When new members enter the group, especially aggressive members
who do not know their place, who do not respectfully search out and
honor the rules of the group, you may be certain that the struggle for
dominance will rise to the surface.

In one group a veteran member, Betty, u/as much threatened by the en-
trance of a new, aggressive u/oman, Rena. A few meetings later, when Betty
discussed some important material concerning her inability to assert herself,
Rena attempted to help by commenting that she, herself, used to be like that,
and then she presented various methods she had used to overcome it. Rena re-
assured Betty that if she continued to talk about it openly in the group she,
 THE YA L0!--1 READER

too, would gain considerable confidence. Betty's response was silent fury of
such magnitude that several meetings passed before she could discuss and
work through her feelings. To the uninformed observer, Betty's response
would appear puzzling; but in the light of Betty's seniority in the group and
Rena's vigorous challenge to that seniority, her response was entirely pre-
dictable. She responded not to Rena's manifest offer of help but instead to
Rena's metacommunication: "I'm more advanced than you, more mature,
more knowledgeable about the process of psychotherapy, and more pou/erful
in this group despite your longer presence here."

Process Commentary: A Theoretical Overview

It is not easy to discuss, in a systematic way, the actual practice of
process illumination. How can one propose crisp, basic guidelines for a
procedure of such complexity and range, such delicate timing, so many
linguistic nuances? I am tern pted to beg the question by claiming that
herein lies the art of psychotherapy: it will come as you gain experience;
you cannot, in a systematic way, come to it. To a degree, I believe this to
be so. Yet I also believe that it is possible to blaze crude trails, to provide
the clinician with general principles that will accelerate education with-
out limiting the scope of artistry.
The approach [ take in this section closely parallels the approach I
use to clarify the basic therapeutic factors in group therapy. Here the is-
sue is not how group therapy helps but how process illumination leads
to change. The issue is complex and requires considerable attention, but
the length of this discussion should not suggest that the interpretive
function of the therapist takes precedence over other tasks.
First, let me proceed to view in a dispassionate manner the entire
range of interpretive comments. I ask of each the simplistic but basic
question, "How does this interpretation, this process-illuminating com-
ment, help a patient to change?" Such an approach, consistently fol-
lowed, reveals a set of basic operational patterns.
I hegin by considering a series of process comments that a therapist
made to a male patient over several months of group therapy:

I. You are interrupting me.

2. Your voice is tight, and your fists are clenched.
 The Therapist Working in the Here-and-Now 71

3. Whenever you talk to me, you take issue with me.

+ When you do that, I feel threatened and sometimes frightened.
5. I think you feel very competitive with me and are trying to de-
value me.
6. I've noticed that you've done the same thing with all the men in
the group. Even when they try to a pp roach you helpfully, you strike out
at them. Consequently, they see you as hostile and threatening .
.7· In the three meetings when there were no women present in the
group, you were more approachable.
8. I think you're so concerned about your sexual attractiveness to
women that you view men only as competitors. Yau deprive yourself of
the opportunity of ever getting close to a man.
9. Even though you always seem to spar with me, there seems to be
another side to it. You often stay after the group to have a word with
me; you frequently look at me in the group. And there's that dream you
described three weeks ago about the two of us fighting and then falling
to the ground in an embrace. l think you very much want to be close to
me, but somehow you 've got closeness and homosexuality entangled
and you keep pushing me away.
10. You are lonely here and feel unwanted and uncared for. That
rekindles so many of your bad feelings of unworthiness.
r t , What's happened in the group now is that you've distanced your-
self, estranged yourself, from all the men here. Are you satisfied with
that? (Remember that one of your major goals when you started the
group was to find out why you haven't had any close men friends and to
do something about that.)

Note, first of all, that the comments form a progression: they start
with simple observations of single acts and proceed to a description of
feelings evoked by an act, to observations about several acts over a pe-
riod of time, to the juxtaposition of different acts, to speculations about
the patient's intentions and motivations, to comments about the unfor-
tunate repercussions of his behavior, to the inclusion of rnore inferential
data (dreams, subtle gestures), to calling attention to the similarity be-
tween the patient's behavioral patterns in the here-and-now and in his
outside social world.
In this progression, the comments become more inferential. They
 72 THE YALOM READER

begin with sense-data observations and gradually shift to complex gen-

eralizations based on sequences of behavior, interpersonal patterns, fan-
tasy, and dream material. As the comments become more complex and
more inferential, their author becomes more removed from the other
person-in short, more a therapist process-commentator. Members of-
ten make some of the earlier statements to one another but rarely make
the ones at the end of the sequence.
There is, incidentally, an exceptionally sharp barrier between com-
ments 4 and 5. The first four statements issue from the experience of the
commentator. They are the commentator's observations and feelings;
the patient can devalue or ignore them but cannot deny them, disagree
with them, or take them away from the commentator. The fifth state-
ment ("I think you feel very competitive with me and are trying to de-
value me") is much more likely to evoke defensiveness and to close
down constructive interactional flow. This genre of comment is intru-
sive; it is a guess about the other's intention and motivation and is often
rejected unless an important trusting, supportive relationship has been
previously established. If members in a young group make many "type
5'' comments to one another, they are not likely to develop a construc-
tive therapeutic climate.'
But how does this series (or any series of process comments) help the
patient change? In making these process comments, the group therapist
initiates change by escorting the patient through the following sequence:

1. Here is what your behavior is like. Through feedback and later

through self-observation, members learn to see themselves as seen by
others.
2. Here is how your behavior makes others feel. Members learn ,•
about the impact of their behavior on the feelings of other members.
3. Here is how your behavior influences the opinions others have of -r
you. Members learn that, as a result of their behavior, others value
I.
them, dislike them, find them unpleasant, respect them, avoid them,
and so on.
4. Here is how your behavior influences your opinion of yourself.
Building on the information gathered in the first three steps, patients
formulate self-evaluations; they make judgments about their self-worth
 The Therapist \Vorking in the Here-and-Now 73

and their lovability, (Recall Sullivan's aphorism that the self-concept is

largely constructed from reflected self-appraisals.)

Once this sequence has been developed and is fully understood by

the patient, once patients have a deep understanding that their behavior
is not in their own best interests, that relationships to others and to
themselves are a result of their own actions, then they have come to a
crucial point in therapy: they have entered the antechamber of change.
The therapist is now in a position co pose a question that initiates the
real crunch of therapy. The question, presented in a number of ways by
the therapist but rarely in direct form, is: Are you satisfied with the
world you have created? This is what you do to others, to others' opin-
ion of you, and to your opinion of yourself-are you satisfied with your
actions?
When the inevitable negative answer arr ives, the therapist embarks
on a many-layered effort to transform a sense of personal dissatisfaction
into a decision to change and then into the act of change. In one way or
another, the therapist's interpretive remarks are designed to encourage
the act of change. Only a few psychotherapy theoreticians (for example,
Otto Rank, Rollo May, Silvano Arieti, Leslie Farber, Allen Wheelis,
and myself)" include the concept of will in their formulations, yet it is, I
believe, implicit in most interpretive systems. I discuss the role of will in
psychotherapy in great detail elsewhere, and I refer interested readers to
that publication.' For now, broad brush strokes are sufficient.
The intrapsychic agency that initiates an act, that transforms inten-
tion and decision into action, is will. Will is the primary responsible
mover within the individual, Although modern analytic metapsychol-
ogy has chosen to emphasize the irresponsible movers of our behavior
(that is, unconscious motivations and drives},' it is difficult to do with-
out the idea of will in our understanding of change. \Ve cannot bypass it
under the assumption that it is too nebulous and too elusive, and conse-
quently consign it to the black box of the mental apparatus, to which the
therapist has no access.
Knowingly or unknowingly, every therapist assumes that each pa-
tient possesses the capacity to change through willful choice. The thera-
pist, using a variety of strategies and tactics, attempts to escort the
 74 THE Y ALOM READER

patient to a crossroads where he or she can choose, choose willfully in

the best interests of his or her own integrity. The therapist's task is not
to create will or to infuse it into the patient. That, of course, you cannot
do. What you can do is to help remove encumbrances from the bound
or stifled will of the patient.
The concept of will provides a useful construct for understanding
the procedure of process illumination. The interpretive remarks of the
therapist can all be viewed in terms of how they bear on the patient's
will. The most common and simplistic therapeutic approach is exhorta-
rive: "Your behavior is, as you yourself now know, counter to your best
interests. You are not satisfied. This is not what you want for yourself.
Damn it, change!"
The expectation that the patient will change is simply an extension
of the moral philosophical belief that if one knows the good (that is,
what is, in the deepest sense, in one's best interest), one will act accord-
ingly. In the words of St. Thomas Aquinas: "Man, insofar as he acts
wilJf ully, acts according to some irnagined good. "!I And, indeed, for
some individuals this knowledge and this exhortation are sufficient to
produce therapeutic change.
However, patients with significant and well-entrenched psy-
chopathology generally need much more than exhortation. The thera-
pist, through interpretive comments, then proceeds to exercise one of
several other options that help patients to disencumber their will. The
therapist's goal is to guide patients to a point where they accept one, sev-
eral, or all of the following basic prernises:

1. Only I can change the world I have created for myself

2. There is no danger in change.

3. To attain what I really want, I must change.

+ ] can change; I am potent.

Each of these premises, if fully accepted by a patient, can be a power-

ful stimulant to willful action. Each exerts its influence in a different
way. Though 1 will discuss each in turn, I do not wish to imply a se-
quential pattern. Each, depending on the need of the patient and the
style of the therapist, may be effective independently of the others.
r The Therapist Working in the Here-and-Now 75

"Only I can change the world I have created for myself."

Behind the simple group therapy sequence I have described (seeing
one's own behavior and appreciating its impact on others and on one-
self), there is a mighty overarching concept, one whose shadow touches
every part of the therapeutic process. That concept is responsibility.
Though it is rarely discussed explicitly, it is woven into the fabric of
most psychotherapeutic systems. Responsibility has 1nany meanings-
legal, religious, ethical. I use it in the sense that a person is "responsible
for" by being the "basis of/ the "cause of," the "author of' something.
One of the most fascinating aspects of group therapy is that everyone
is born again, born together in the group. Each member starts off on an
equal footing. In the view of the others {and, if the therapist does a good
job, in the view of oneself), each gradually scoops out and shapes a life
space in the group. Each member, in the deepest sense of the concept, is
responsible for this space and for the sequence of events that will occur
to him or her in the group. The patient, having truly come to appreciate
this responsibility, must then accept, too, that there is no hope for
change unless he or she changes. Others cannot bring change, nor can
change bring itself. One is responsible for one's past and present life in
the group (as well as in the outside world) and similarly and totally re-
sponsible for one's future. ·
Thus, the therapist helps the patient to understand that the interper-
sonal world is arranged in a generally predictable and orderly fashion,
that it is not that the patient cannot change but that he or she will not
change, that the patient bears the responsibility for the creation of his or
her world, and therefore the responsibility for its transmutation.

"There is no danger in change."

These efforts may not be enough. The therapist may tug at the ther-
apeutic cord and learn that patients, even after being thus enlightened,
still make no significant therapeutic movement. In this case, therapists
apply additional therapeutic leverage by helping patients face the para-
dox of continuing to act contrary to their basic interests. In a number of
ways therapists must pose the question, "How come? Why do you con-
tinue to defeat yourself?"
 76 T HE Y :\ LO :VI R EA DE R

A common method of explaining "How come?" is to assume that

there are obstacles to the patient's exercising willful choice, obstacles
that prevent patients from seriously considering a1tering their behavior.
The presence of the obstacle is generally inferred; the therapist makes
an "as if" assumption: "You behave as if you feel there were some con-
siderable danger that would befall you if you were to change. You fear
to act otherwise for fear that some calamity will befall you." The thera-
pist helps the patient clarify the nature of the imagined danger, and
then proceeds, in several ways, to detoxify, to disconfirm the reality of
this danger.
The patient's reason may be enlisted as an ally. The process of identi-
fying and naming the fantasized danger n1ay, in itself, enable one to un-
derstand how far removed one's fears are from reality. Another
approach is to encourage the patient, in carefully calibrated doses, to
cornrnit the dreaded act in the group. The fantasized calamity does not,
of course, ensue, and the dread is gradually extinguished.
For example, suppose a patient avoids any aggressive behavior be-
cause at a deep level he fears that he has a dammed-up reservoir of
homicidal fury and must be constantly vigilant lest he unleash it and
eventually face retribution from others. An appropriate therapeutic
strategy is to help the patient express aggression in small doses in the
group: pique at being interrupted, irritation at members who are habit-
ually late, anger at the therapist for charging him money, and so on.
Gradually, the patient is helped to relate openly to the other members
and to demythologize himself as a homicidal being. Although the lan-
guage and the view of human nature are different, this is precisely the
same approach to change used in systematic desensitization-a major
technique of behavior therapy.

"To attain what I realty want, I must change."

Another explanatory approach used by n1any therapists to deal with
a patient who persists in behaving counter to his or her best interests is
to consider the payoffs of that patient's behavior. Though the behavior
of the patient sabotages n1any of his or her mature needs and goals, at
the same rime it satisfies another set of needs and goals. In other words,
the patient has conflicting motivations that cannot be simultaneously
r The Therapist Working in the Here-and-Now 77
satisfied. For example, a male patient may wish to establish mature het-
erosexual relationships; but at another, often unconscious, level, he may
wish to be nurtured, to be cradled endlessly, to assuage castration anxi-
ety by a maternal identification, or, to use an existential vocabulary, to
be sheltered from the terrifying freedom of adulthood.
Obviously, the patient cannot satisfy both sets of wishes: he cannot
establish an adult heterosexual relationship with a woman if he also says
(and much more loudly). "Take care of me, protect me, nurse me, let
me be a part of you."
It is important to clarify this paradox for the patient. The therapist
tries to help the patient understand the nature of his conflicting desires,
to choose between them, to relinquish those that cannot be fulfilled ex-
cept at enormous cost to his integrity and autonomy. Once the patient
realizes what he really wants (as an adult), and that his behavior is de-
signed to fulfill opposing growth-retarding needs, he gradually con-
cludes: To attain what I really want, I must change.

"I can change; I am potent."

Perhaps the major therapeutic approach to the question, "How
come?" ("How come you act in \-vays counter to your best interests?") is
to offer explanation, to attribute meaning to the patient's behavior. The
therapist says, in effect, "You behave in certain fashions because . . . , "
and the "because" clause generally invokes motivational factors outside
the patient's awareness. It is true that the previous two options I have
discussed also proffer explanation but-and I will clarify this shortly-
the purpose of the explanation (the nature of the leverage exerted on
will) is quite different in each of these approaches.
What type of explanation does the therapist offer the patient? And
which explanations are correct, and which incorrect? Which "deep"?
Which "superficial"? It is at this juncture that the great meta psycholog-
ical controversies of the field arise, since the nature of therapists' expla-
nations are a function of the ideological school to which they belong. I
think we can sidestep the ideological struggle by keeping a fixed gaze
on the function of the interpretation, on the relationship between expla-
._ nation and the final product: change. After all, our goal is change. Self-
... knowledge, derepression, analysis of transference, and self-actualization
 78 TH E YA LO M R EA DE R

all are worthwhile, enlightened pursuits; all are related to change, pre-
ludes to change, cousins and companions to it; and yet they are not syn-
onyrnous with change.
Explanation provides a system by which we can order the events in
our lives into some coherent and predictable pattern. To name some-
thing, to place it into a logical (or paralogical) causal sequence, is to ex-
perience it as being under our control. No longer is our behavior or our
internal experience frightening, inchoate, out of control; instead, we be-
have (or have a particular inner experience) because .... The "because"
offers us mastery (or a sense of mastery that, phenomenologically, is tan-
tamount to mastery), It offers us freedom and effectance. As we move
from a position of being motivated by unknown forces to a position of
identifying and controlling these forces, we move from a passive, reac-
tive posture to an active, acting, changing posture.
If we accept this basic premise-that a major function of explanation
in psychotherapy is to provide the patient with a sense of personal mas-
tery-it follows that the value of an explanation should be measured by
this criterion. To the extent that it offers a sense of potency, a causal ex-
planation is valid, correct, or "true." Such a definition of truth is com-
pletely relativistic and pragmatic. It argues that no explanatory system
has hegemony or exclusive rights, that no sys tern is the correct one.
Therapists 1nay offer the patient any of several interpretations to
clarify the same issue; each n1ay be made from a different frame of ref-
erence, and each may be "true." Freudian, interpersonal object rela-
tions, self psychology, existential, transactional analytic, Jungian, gestalt,
transpersonal, cognitive, behavioral explanations-all of these may be
true simultaneously. None, despite vehement claims to the contrary,
have sole rights to the truth. After all, they are all based on imaginary,
as-if structures. They all say, "You are behaving (or feeling) as if such
and such a thing were true." The superego, the id, the ego; the arche-
types; the masculine protest; the internalized objects; the self object; the
grandiose self and the omnipotent object; the parent, child, and adult
ego state-none of these really exists. They are all fictions, all psycho-
logical constructs created for semantic convenience. They justify their
existence only by virtue of their explanatory powers.
Do we therefore abandon our attempts to make precise, thoughtful
interpretations? Not at all. We only recognize the purpose and function
' The Therapist Working in the Hcrc-and-Xow 79

of the interpretation. Sarne may be superior to others. not because they

are deeper but because they have more explanatory power, are rnore
credible. provide more mastery. and are therefore more useful. Obvi-
ously, interpretations must be tailored to the recipient. In general. they
are more effective if they make sense, if they are logically consistent
with sound supporting arguments. if they are bolstered by empirical ob-
servation, if they are consonant with a patient's frame of reference, if
they "feel" right. if they somehow "click" with the internal experience
of the patient, and if they can be generalized and applied to rnany anal-
ogous situations in the life of the patient. Higher order interpretations
generally offer a novel explanation to the patient for some large pattern
of behavior (as opposed to a single trait or act). The novelty of the thera-
pist's explanation sterns from his or her unusual frame of reference,
which permits an original synthesis of data. Indeed. often the data is
material that has been generally overlooked by the patient or is out of
his or her awareness.
If pushed, to what extent am I willinj; to defend this relativistic the-
sis? When I present this position to students, they respond with such
questions as: Does that mean that an astrological explanation is also
valid in psychotherapy? These questions make me uneasy, but I have to
respond affirmatively. If an astrological or shamanistic or magical ex-
planation enhances a sense of mastery and leads to inner personal
change, then it is a valid explanation. There is much evidence from
cross-cultural psychiatric research to support this position; the explana-
tion must be consistent with the values and with the frame of reference
of the human community in which the patient dwells. In most primitive
cultures, it is often only the magical or the religious explanation that is
acceptable, and hence valid and effective.'" Psychoanalytic revisionists
make an analogous point and argue that reconstr uctive attempts to cap-
ture historical "truth" are futile; it is far more important to the process
of change to construct plausible, meaningful, personal narratives."
An interpretation, even the most elegant one, has no benefit if the
.. patient does not hear it. Therapists should take pains to review their ev-
idence with the patient and present the explanation clearly. (If they can-
.. not, it is likely that the explanation is rickety or that they thernsel ves do
\ not understand it. The reason is not, as has been claimed, that the thera-
I
pist is speaking directly to the patient's unconscious.)
 80 THE Y ALOM READER

Do not always expect the patient to accept an interpretation. Some-

times the patient hears the same interpretation many times until one r
day it seems to "click." Why does it click that one day? Perhaps the pa- I

tient just came across some corroborating data from new events in the I
environment or from the surfacing in fantasy or dreams of some previ-
ously unconscious material. Sometimes a patient will accept from an-
other member an interpretation that he or she would not accept from
II
I:
the therapist. (Patients are clearly capable of making interpretations as I

useful as those of the therapists, and members are receptive to these in-
terpretations provided the other member has accepted the patient role
and does not offer interpretations to acquire prestige, power, or a fa-
vored position with the leader.)
The interpretation will not click until the patient's relationship to
the therapist is just right. For example, a patient who feels threatened
and competitive with the therapist is unlikely to be helped by any inter-
pretation (except one that clarifies the transference). Even the most
thoughtful interpretation will fail because the patient may feel defeated
or humiliated by the proof of the therapist's superior perccptivity. An
interpretation becomes maximally effective only when it is delivered in
a context of acceptance and trust.
'
i

CHAPTER 3

Group Therapy with

Specialized Groups
Hospitalized Patients, Patients Addicted to
Alcohol, the Terminally Ill,
the Bereaved

INTRODUCTION

Earlier I addressed the problem of writing a textbook that could be re-

sponsive to the enormous variety of highly specialized therapy groups.
My first basic strategy was to delineate the therapeutic factors common
to all groups. My second strategic decision was to forgo any attempt to
I
I describe therapeutic procedures appropriate for each of the specialized
groups. Because the number of specialized groups has proliferated so
greatly, it is no longer possible to address each type separately. Even if
that were possible, it would not represent good pedagogy. A far better
approach, it seemed to me, would be to teach, in great depth, a proto-
typic form of group therapy and then offer students a set of principles to
enable them to adapt this standard group approach to any specialized
clinical situation.
 82 T H E YA LO M R E A DE R

I selected as the prototypic group the intensive long-term heteroge-

neous outpatient group {that is, a group consisting of members with a
wide variety of clinical complaints meeting for approximately six months
or more and attempting not only to ameliorate symptoms but to change
personality or modes of interpersonal relating). Even though the contem-
porary field is dominated by briefer groups with more limited goals, I se-
lected this group as my model for several reasons: it is a venerable group
and has generated a considerable body of research and clinical reflec-
tion; furthermore, the therapy required to lead this group is sophisticated
and complex. Students who become adept clinicians in such groups will
be well positioned to fashion a therapeutic approach for any clinical
population.
When attempting to design an appropriate therapy for a specialized
population, the clinician's first step is to appraise all relevant aspects of
the clinical situation: for example, the nature of the patients' problems,
the patients' motivation, the time frame available (length and frequency
of meetings, overall duration of therapy), the availability and training of
co-therapists, physical surroundings, and the availability for collabora-
tion of concurrent individual therapists. Once the treatment environment
is appraised, the clinician must then differentiate between immutable
and arbitrary conditions. Next the therapist must set about influencing
arbitrary restraints so as to create the optimal conditions for therapy. Fol-
lowing that the therapist must set therapy goals which are realistic and
achievable within the existing clinical constraints. Finally the therapist
11
must modify his or her standard therapy techniques to achieve what is I

possible.
The specialized groups described in the following selections-groups
of hospitalized psychiatric patients, alcoholics, individuals with cancer,
the spousally bereaved-demonstrate the process of customizing therapy
to fit the demands of the clinical situation. The first selection-about
groups on the psychiatric hospital ward-describes this process most
explicitly.
'
l Group Therapy with Specialized Groups

PART I

GROUP THERAPY \VITH

HOSPITALIZED PATIENTS
There are few situations more inhospitable to the therapy group than
the psychiatric inpatient setting. During 1ny tenure as medical director
of the Stanford University Hospital psychiatric ward, I led a daily in pa-
tient group for fi,·e years and became highly sensitized to the logistical
difficulties faced by the group therapist. For starters, let me mention
that over a five-year period I rarely had the identical group for two
straight days (in other words, at least one member had been discharged
or a new member admitted), and I almost never had the same group for
three straight days. Obviously the traditional practice of building group
cohesiveness over a period of weeks and months was no longer perti-
nent. A new approach had to be devised. During this time I visited
many other hospital group programs, experimented with a number of
treatment models, conducted process and outcome research on the
groups, and ultimately wrote the book from which this selection is
taken, Inpatient Group Psychotherapy.
The inpatient therapy group is of importance not only because it re-
quires such radical modification of technique but also because it repre-
I
sents, numerically, the most significant form of specialized group.
Every day tens of thousands of hospitalized psychiatric patients attend a
variety of groups offered by most psychiatric wards in the country.
The selections from Inpatient Group Psychotherapy summarize as-
pects of the environment-the clinical facts of life--of the inpatient
ward that have particular relevance for the group therapist, and then
proceed to discuss the strategies and techniques of leadership that are
consonant with that environment. Finally I describe the beginning
phases of a group designed for higher level inpatients.
 84 THE Y ALOM READER

Clinical Setting of the InpatientGroup '

The contemporary acute psychiatric ward is a radically different clinical set- '
ting and demands a radical modification of group therapy technique. Let me
begin this discussion by examining the stark clinical facts of life that the
inpatient group therapist must face:

1: There is considerable patient turnover. The average length of

stay is one to three weeks. There is generally a new patient in the
group almost every meeting.

2: Many patients attend the group meeting just for a single meeting
or two. There is no time to work on termination. Some member
terminates almost every meeting, and a focus on termination
would consume all the group time.

3: There is great heterogeneity of psychopathology: patients with

psychosis, neurosis, characterological disturbance, substance
abuse, adolescent problems, major affective disorders, and
anorexia nervosa are all present in the same group.

4: All the patients are acutely uncomfortable; they strive toward res-
olution of psychosis or acute despair rather than toward personal
growth or self-understanding. As soon as a patient is out of an
acute crisis, he or she is discharged. .,
I
I
5: There are many unmotivated patients in the group: they may be
psychologically unsophisticated; they do not want to be there;
they may not agree that they need therapy; they often are not pay-
ing for therapy; they may have little curiosity about themselves.

6: The therapist has no time to prepare or screen patients.

7: The therapist often has no control over group composition.

8· There is little therapist stability. Many of the therapists have .ro-

tating schedules and generally cannot attend all of the meetings
of the group.

9: Patients see their therapist in other roles throughout the day on

the ward,
r Group Therapy with Specialized Groups 85

10: Group therapy is only one of many therapies in which the patient
participates; some of these ocher therapies are with some of the
same patients in the group and often with the same therapist.

11: There is often little sense of cohesion in the group; not enough
time exists for members to learn to care for or trust one another.

12: There is not time for gradual recognition of subtle interpersonal

patterns, or for "working through," and no opportunity to focus
on transfer of learning to the situation at home.

Strategies and Techniques of Leadership

Inpatient clinical exigencies demand that group therapists modify their
approach toward such structural issues as composition, frequency, dura-
tion and size of meetings, goals of therapy, extragroup socializing, and
confidentiality.
Let us now examine the implications of these clinical facts of life for
the inpatient group therapist's basic strategy. The strategies and tech-
niques discussed here are generally applicable to all forms of inpatient
group therapy.

The Single-Session Time Frame

Outpatient group therapists have a longitudinal time frame: they
build cohesiveness over many sessions.
On the inpatient unit, the rapid turnover of group membership, the
brief duration of hospitalization, and the changing composition from
one meeting to the next all dictate a fundamental shift in the therapist's
time frame. Rarely does the group have two consecutive sessions with
identical membership. Indeed, many members will attend only a single
session.
.1
Inpatient group therapists cannot work within a longitudinal time
frame; instead, they must consider the life of the group to last a single ses-
sion. This necessity suggests that they must attempt to do as much effec-
... tive work as possible for as many patients as possible during each group
I
session. The single-session time frame dictates that inpatient group
therapists strive for efficiency. They have no time to build the group, no
 86 TH E YA LO ~1 RE A DE}{

time to let things develop, no time for gradual working through. What-
ever they are going to do, they must do in one session, and they must do
it quickly.
These considerations demand a high level of activity-far higher than
is common or appropriate in long-term outpatient group psychother-
apy. Inpatient group therapists must structure and activate the group;
they must call on members; they must actively support members; they
must interact personally with patients. There is no place in inpatient
group therapy for the passive, inactive therapist.

Structure
Nor is there a place in inpatient group psychotherapy for the nondi-
rectivc leader] Many outpatient group therapists prefer to provide rela-
tively little structure to the procedure of therapy; instead, one permits
the group members to search for their own direction, and one studies
the varying responses of the group members to the ambiguity of the
therapy situation. Rut, as we ha vc seen, the time fr a inc of the in patient
group therapist docs not permit this luxury.
The outpatient group therapist also can depend upon a stable group
membership to provide a durable norm skeleton for the group. But, as I
also have discussed, the inpatient group therapist cannot depend on that
source of structure; instead, the therapist himself must provide a norm
structure.
Furthermore, the nature of the psychopathology confronting the in-
Ii
patient group psychotherapist demands structure. The vast majority of
patients on an inpatient unit are confused, frightened, and disorga-
nized; they crave and require some externally imposed structure. The
last thing a confused patient needs is to be thrust into an enigmatic,
u
anxiety-provoking situation. Numerous clinical observers have noted II
that confused patients feel deeply threatened by being placed on wards
that thernsclves appear confused.
Keep in mind the experience of a confused patient who enters a psy-
chiatric unit for the first time: he or she is surrounded by large numbers
of deeply troubled, irrationally behaving patients; the new patient's
mental acuity may he obtunded by medication; he or she is introduced
to a bewilderingly large staff whose specific roles are often undifferenti-
 Group Therapy with Specialized Groups 87

ated; because n1any staff members are wearing street clothes, the new
patient may confuse them with patients; furthermore, since the staff is
often on a complex rotating schedule, the patient's sense of external con-
stancy becomes even further eroded.
An externally int posed structure is the first step to a sense of internal
structure. A patient's anxiety is relieved when he or she perceives a clear
external structure and is provided with some clear, firm expectations for
his or her own behavior.

Modesof Structure
Group leaders provide structure for the group by delineating clear
spatial and temporal boundaries; by adopting a lucid, decisive, but flexi-
ble personal style; by providing an explicit orientation and preparation
for the patient; and by developing a consistent, coherent group proce-
dure.
Spatial and Temporal Boundaries Consistent, well-delineated spa-
tial boundaries beget a sense of inner stability. It is important that the
group meet in a room of appropriate size-a room that provides corn-
fort but is not cavernous. I prefer to meet in a room that is largely filled
by the group circle. It is exceptionally important that the group meet in
a clearly delineated space, preferablyin a room that has a closed door. Be-
cause of space limitations, many groups have to meet in a very large
general activity room or in a hallway without clear demarcation. It is
my experience that such settings place these groups at a considerable
disadvantage, and it is preferable to find a room off the ward than to
meet in a space whose boundaries are incomplete or unclear.
The ideal seating arrangement for the group is a circle. Therapists
should avoid a seating arrangement in which any member of the group
cannot see every other member (for example, three or four patients sit-
ting in a row on a long couch). Such an arrangement will invariably dis-
courage the member-to-member interaction so vital to the therapy
group and will, instead, encourage the patients to address the therapist
1·
rather than each other.
I The therapist should endeavor to have as few interruptions in the
-
pr group's time as possible. AH late arrivals and premature departures of
members during a meeting should be discouraged. In the ideal situa-
 88 THE Y ALOM READER

tion, of course, all members are present at the beginning of the meeting,
and there are no interruptions whatsoever until its conclusion. Debrief-
ing interviews with patients make it clear that patients invariably resent
interruptions caused by latecomers. The therapist must model prompt-
ness and be on time for each meeting. The more disorganized patients
will often need reminding and escort service into the room. If patients
are napping, the staff should awaken them at least ten to fifteen minutes
prior to the meeting.
In higher level groups I have, for many years, preferred a policy of
not permitting latecomers (regardless of their excuse) to enter the ses-
sion. Once the door is closed, the group space is inviolable. Naturally
some resentment is experienced by members who come three or four
minutes late and are not allowed to enter, but the advantages far out-
weigh the disadvantages. The therapist demonstrates to the patients
that he or she values the group's time and wishes to make maximal use
of it. The great majority of the group members will appreciate the deci-
sion not to allow latecomers to enter, and the patient denied entrance
will sulk briefly but invariably be prompt the following day.
It is also desirable that the members of the meeting not leave early.
Dealing with early "bolters" is more complex than dealing with late-
comers, since highly anxious patients (especially those with claustropho-
bic tendencies) are likely to become more anxious if they perceive that
they will not be permitted to leave the room. Therefore, the therapist is
well advised simply to express the hope that members can stay the full
meeting. The therapist who, before a meeting starts, sees any clearly hy-
peractive and agitated patients should inquire whether they feel able to
sit in the group for the duration of the meeting. If the answer is no, the
therapist n1ay suggest that they not attend the group that day but, in-
stead, return the next day when they feel more settled. In lower level
groups patients may frequently have to leave early but should be sup-
ported for the time they have been able to remain in the group.
A prompt ending of the group is rarely problematic, since space de-
mands on most inpatient units are heavy, and the room is usually
needed for some other activity. On the whole, this limitation is for the
goo<l. Occasionally the end of a session may find the group in the midst
of a crucial issue which absolutely demands that the session be extended
 Group Therapy with Specialized Groups 89

for a few minutes. Generally, however, a prompt ending is as important

as a prompt beginning to create a sense of consistent structure for the
patients.
Personal Style The therapist's style of communication greatly con-
tributes to the amount of structure the group provides to patients.
Acutely troubled, frightened, and confused patients are reassured by a
therapist who is firm, explicit, and decisive yet who, at the same time,
shares with them the reasons for his or her actions.
In inpatient groups it is almost invariably an error for therapists to be
as nondirecrive in the face of some major, disruptive event as they might
be in an outpatient group. Patients are too frightened, too much in cri-
sis, too highly stressed to be able to deal effectively with such events.
They are reassured and experience the group environment as immea-
surably safer if the therapist is able to act firmly and decisively in such
instances. If, for example, a manic patient is veering out of control,
nothing is to be gained by allowing the patient to continue on that
course: he or she will not feel better as a result of the runaway behavior,
and the rest of the group will feel irritated at the patient and cheated of
their therapy time. The therapist's stance must be firm and decisive.
You may suggest to the manic patient that it is time to be quiet and to
work on learning to listen to others; or if the patient has insufficient in-
ner control, you may have to ask the patient to leave the group.
Patients will be much relieved by such firm intervention by the ther-
apist. Occasionally some patients might feel concerned or threatened by
a therapist's decisive behavior; but this response is often ameliorated by
a process discussion of the incident and of the therapist's response. Of-
ten it is good modeling for the therapist to comment on any of his or her
own contradictory feelings. For example, you may comment on having
felt uncomfortable at silencing a patient and concerned about having
thereby possibly hurt that patient, but mention also your strong feeling
that it was the best thing to do for the patient and for the group. It is of-
ten advisable to solicit feedback from the group. Do the group members
feel you are being too strict or too stern? Do they feel you as rejecting?
Do they have some relief when you intervene?
Therapists must feel assured that they have a coherent, cognitive
framework for the group's goals and procedures-a framework and an
 90 THE Y ALOM READER

assurance that they convey to the patients. It is not feasible or clinically

useful to be explicit about every benefit of the group format: some ther-
apeutic mechanisms are rendered less effective if made absolutely ex-
plicit (such as the raising of self-esteem by group acceptance).
Furthermore, some therapeutic factors (such as altruism and universal-
ity) require a degree of spontaneity and are less effective if explicitly or-
chestrated. N onerhcless, there are many benefits of the group that can
be lucidlv described. The leader who shares, in an understandable way,
the theoretical rationale underlying his or her actions, not only provides
useful structure to the patients but also enlists them as allies in the ther-
apeutic work.
Patients who have developed a clear picture of the group goals and
of the task necessary to approach them are more likely to invest them-
selves in the work of therapy. Research corroborates that patients report
high levels of satisfaction with a group session if they feel that the meet-
ing dealt with important, relevant issues and progressed toward clearly
formulated goals.
Orientation and Preparation The first minutes of the group pro-
vide an opportunity for the therapist to create considerable structure for
the session. The therapist provides an official beginning to the group
and launches the meeting on its way. It is a time to introduce, orient,
and prepare the new members for group therapy. Even if there are no
new members, it is a time nonetheless to restate briefly the goals of the
group and its procedure. The provision of external structure, as I have
stressed, promotes the acquisition of internal structure; and the begin-
ning of the group is the place to begin building that structure. If ob-
servers are viewing the group, the therapist should always so inform the
patients at the very outset of the meeting.
A typical orientation in a higher level group session where a new
member is present rnight begin with addressing the new member thus:
"John, I'm Irv Yalorn," and this is the afternoon therapy group
which meets daily for one hour and fifteen minutes beginning at two o'-
clock. My co-therapist is , and she will be here four of the five

*There is great variation around the country about how patients and thera-
pists address one another. In the informal climate of California, most group t
patients and therapists address one another by first name. ~
i
I
 Group Therapy with Specialized Groups 91

meetings for the next four weeks. On the fifth day another psychiatric
nurse will take her place. The purpose of this group is to help members
to understand their problems better and to learn more about the way
they communicate and relate to others. People come into the hospital
with many different kinds of important problems, but one thing that
most individuals have in common here is some unhappiness about the
way that some of their important relationships are going. There are, of
course, many other important problems that people have, but those are
best worked on in some of your other fonns of therapy. What groups do
best of all is to help people understand more about their relationships
with others. One of the ways that we will try to work on relationships is
to focus on them in this group and especially to focus on the relation-
ships that may go on between people in this room, The better your com-
munication becomes with each of the people here, the better will your
communication become with people in your outside life.
Hit's important to know that observers are present almost every day
to watch the group through this one-way mirror. [I point toward the
mirror and also toward the microphone, in an attempt to orient the pa-
tient as dearly as possible to his spatial surroundings.] The observers
will usually be medical students or other members of the ward staff. No
one else will be allowed to observe the group without my checking that
out with you before the group starts.
"We begin our meetings by going around the group and checking
with each person and asking each to say something about the kinds of
problems they're having in their lives that they'd like to try to work on
in the group. After the go-round we then try to work on as many of
these problems as possible. In the last ten minutes of the group, we stop
our discussion and check in with everyone here about how they feel
about the meeting and about the kinds of leftover feelings that should
be looked at before the group ends."
Such an introduction serves a number of functions: it provides some
temporal, spatial, and procedural structure; it breaks the ice of the meet-
ing; it serves as a formal beginning; and it also constitutes a brief prepa-
ration for group psychotherapy.
Group Therapy Preparation A compelling body of research litera-
ture demonstrates that if the patient is systematically prepared by the
therapist for group therapy, then the patient's course in the therapy
 92 THE YALO!\i1 READER

process will be facilitated. In long-term outpatient therapy groups, it is

standard practice for therapists to prepare a patient for the impending
group therapy experience in individual session(s) prior to the patient's
entry into the group.
In the hustle and bustle of inpatient work, there is no time for the
luxury of lengthy preparation. Consequently, group therapists have to
prepare patients for group therapy in any way possible during the brief
time available. It is often advisable for the therapist to share the task of
preparation and orientation with some of the members. The therapist
1nay, for example, ask one of the older members to tell the new mem-
ber(s) about the purpose and procedure of the group. The therapist then
may ask some of the other patients whether there are any additional
points they want to contribute; and if the therapist feels there are still
some points that have not been stated, he or she can then state them.
This approach increases not only the participation of members but also
their tendency to experience the meeting and the procedure of the meet-
ing as their own rather than something that is imposed upon them.
Patients who come frorn the lower socioeconomic levels of society,
and are unsophisticated about psychotherapy, particularly profit from
an intensive preparation. A researcher systematically prepared such pa-
tients admitted to an acute psychiatric ward and compared their
progress in the therapy group with similar patients who were not sys-
tematically prepared. Data from the first five group sessions demon-
strated that the prepared patients worked much more effectively: they
volunteered more, communicated more frequently, engaged in self-
exploration more frequently, initiated more statements in the group. II

One important function of the preparation is that it helps to elimi-

r
nate discrepancies in expectations between therapists and patients. A l~
.J

study of patient and staff expectations on one inpatient ward demon- 'I.)
strated that patients expected that the staff would approve of their seek-
ing advice, whereas the staff hoped instead for more self-direction on
Ii
the part of the patients. Such a discrepancy between the patients' and ii
I
the staff's expectations will invariably breed confusion and impede the I
forrnation of a therapeutic alliance. It is absolutely essential in short- J.I
term therapy that patients be given explicit procedural directions.
Explicit preparation for the group also reduces the patients' appre-
hension and makes it more possible for them to participate in the group
r

Group Therapy with Specialized Groups 93

without crippling anxiety. It is to be expected that patients will be anx-

ious in a therapy group. Individuals with lifelong disabilities in inter-
personal relationships will invariably be stressed by a therapy session
that urges them to discuss their relationships to others with great can-
dor. Most concur that a certain degree of anxiety is necessary for thera-
peutic growth; anxiety increases vigilance and motivation to work in the
group. But too much anxiety freezes the group work. Primary anxi-
ety-the anxiety stemming from a patient's psychological disorder-
will be an inevitable accompaniment of group work, and there is little
the leader can do to ameliorate it in the initial stages of the session. But
the leader can do a great deal to prevent secondary anxiety-anxiety
that stems from the patient's being thrown into an ambiguous therapy
. .
situation.
A Consistent, Coherent Group Procedure Clarity and structure are
so important that many clinicians prefer highly structured, explicitly
programmed groups. One ward has instituted a procedure in which
patients go through a series of "step groups," each of which is designed
to teach a specific set of behavioral skills. For example, the most ele-
mentary group emphasizes good eye contact, learning to listen and
understand others, and so on. The next step teaches patients to ask
open-ended questions, to make questions into statements, to reflect feel-
ings. The next step teaches learning to give and accept feedback, and to
self-disclose. Clinicians using such programs report that they are far
more effective than unstructured groups. My impression is that a heav-
ily structured approach is particularly indicated for groups of more
poorly functioning patients.
Structure is as important to a therapist as it is to the patients. Lead-
ing a group is anxiety provoking. The therapist is exposed to many
powerful and often primitive emotions. There are many patients vying
for the leader's sole attention; and the leader will inevitably disappoint
and frustrate some of them, who may then respond angrily and un-
gratefully. Group therapy with psychotic patients particularly is intrin-
sically anxiety provoking. The work is slow, often unrewarding, and
generally perplexing. Furthermore, group therapists are exposed. No
secret therapy sessions behind closed doors for them: their work is
painfully visible to large numbers of people.
One of the fabled definitions of psychotherapy is attributed to Harry
 94 THE YA L01J READER

Stack Sullivan: ''A situation in which two people meet together, one of
whom is less anxious than the other." The therapist who falls prey to
these rnany sources of anxiety 1nay violate Sullivan's law, become more
anxious than the patient, and, by definition, cease to be therapeutically
effective.
Ambiguity is as anxiety provoking for the therapist as for the pa-
tient, and the therapist's chief defense against the anxiety intrinsic to the
practice of psychotherapy is the sense of structure provided by a thera-
peutic model. It is less important which model than that there be a
model. By developing a cognitive framework that permits an ordering
of all the inchoate events of therapy, the therapist experiences a sense of
inner order and mastery-s-a sense that, if deeply felt, is automatically
conveyed to patients and generates in them a corresponding sense of
clarity and mastery.
Are there any disadvantages in providing structure? Indeed, there
are! Providing too much structure is as harmful as providing too little.
Although patients desire and require considerable structuring by the
therapist, excessive structure 1nay retard their therapeutic growth. If the
leader does everything for patients, they will do too little for themselves.
Thus, in the early stages of therapy, structure provides reassurance to
the frightened and confused patient; but persistent and rigid structure,
over the long run, can infantilize the patient and delay assumption of
autonorny.
Thus, group leaders face a dilemma. On the one hand, they must
provide structure; but, on the other hand, they must not provide so
much structure that patients will not learn to use their own resources.
The basic task of the therapist is to augment the advantages of structuring
the group and to minimize the disadvantages. There is a solution to this
dilcn1ma-the leader must structure the group in a fashion that facilitates
each patient's autonomous functioning.

Support
Short-term hospitalization is effective only if it is coupled with effec-
tive aftercare therapy. One of the major goals of the inpatient therapy
group progra m is to increase the desire in patients to continue therapy
after they have left the hospital. In fact, if the therapy group does noth-
 Group Therapy with Specialized Groups 95

ing else but encourage the patient to pursue post-hospital psychother-

apy, especially group psychotherapy, it will have been an effective inter-
vention.
Thus, it is imperative that patients perceive the therapy group as a
positive, supportive experience, one that they will wish to continue in
the future. The therapist must create in the group an atmosphere that is
perceived as constructive, warm, and supportive. Patients must feel safe
in the group. They must learn to trust the group. They must experience
the group as a place where they will be heard, accepted, and understood.
The inpatient therapy group is not the place for confrontations, criti-
cism, or the expression and examination of anger. There is considerable
clinical consensus that, if the inpatient therapy group is to accomplish its
goals, these sentiments must be avoided. There will be patients who
may need a certain degree of confrontation. For example, sociopathic or
manipulative individuals do not often profit from a therapeutic ap-
proach that is continuously supportive and empathic; but it is far better
that the group therapist "miss" these patients than run the risk of mak-
ing the group feel unsafe to the majority of patients.
A vast body of research literature demonstrates conclusively that,
both in individual and in group therapy, positive outcome is posi-
tively correlated with a supportive and empathic relationship with the
therapist.
Not only does considerable empirical evidence support the impor-
tance of a positive, nonjudgmental, accepting therapist-patient relation-
ship, but there are numerous retrospective views of psychotherapy in
which patients underscore the importance of a therapist's liking them,
valuing them, and noticing and reinforcing their positive characteristics.
In a therapy group situation, the therapist's personal support takes
on an added dimension. Not only does the therapist interact with his or
her own person upon each of the members of the group, but the thera-
pist's actions shape the norms (the code, or the unwritten rules) that in-
fluence how all the members behave. Therapists create norms in many
ways: they explicitly set certain rules, they reinforce certain types of be-
havior in the group and extinguish others (either through explicit dis-
agreement or discouragement or implicitly by inattention to certain
types of comment). But one of the most important modes through
 96 TH E Y ALO M R EA DER

which therapists shape the norms of the group is through their own be-
havior upon which patients pattern themselves.
Despite the enormously important role that "support" plays in the
ultimate outcome of psychotherapy, relatively little attention is given to
it in conceptualizations of psychotherapy or in training programs. Sup-
port is often taken for granted; it may be considered superficial; it is of-
ten assumed that "of course" therapists will be supportive to their
patients. Many therapists conclude that support is equivalent to paying
compliments, and that such a simple act hardly needs any detailed dis-
cussion in therapy training.
Support is not something that therapists "of course" provide. As a
matter of fact, many intensive training programs in psychotherapy un-
wittingly extinguish the therapist's natural proclivities to support the
patient. Therapists become pathology sniffers--experts in the detection
of weaknesses. In extreme form this tendency results in the therapist's
regarding positive qualities with suspicion: kindness, generosity, dili-
gence, moral responsibility-all may be approached in a reductionistic
fashion and be interpreted as psychopathology. Furthermore, therapists
are so sensitized to transferenrial and countertransferential issues that
they hold themselves back from engaging in basically human support-
ive behavior with their patients. I remember vividly a heated discussion
I heard twenty years ago in an analytic conference about the pros and
cons of the therapist's helping a patient (an old lady) on and off with her
overcoat! Therefore, learning how to give support in inpatient group
therapy often entails a degree of "unlearning" of professionally taught
postures and attitudes toward patients which obstruct the therapist's
natural human inclinations to provide support.

The Higher Level Inpatient Therapy Group:

A Working Model
Higher level groups are the most complex of the inpatient groups to
lead and require that the leader be trained in basic group therapy tech- \
niques. In this section I will describe one possible structure for a higher
level group. Keep in mind that this structure augments, but is not a re-
placement for, fundamental training in group therapy. The group may
l
[

I
~
 Group Therapy with Specialized Groups 97

be led either by a single therapist or by co-therapists. The co-therapy

format makes the group less demanding for the therapists, provides an
excellent medium for training neophyte therapists by pairing one with
an experienced therapist, and often is more fun for therapists. By no
means, however, is the co-therapy model a requirement; the group can
be led effectively by a single competent therapist.
One basic blueprint of a seventy-five-minute session is:

1. Orientation and preparation 3 to 5 minutes

2. Agenda go-round (each member formulates a 20 to 30 minutes
personal agenda for that meeting)
3. Work on the agendas (the group attempts to 20 to 35 minutes
"fill" as many agendas as possible)
4. Therapists' and observers' discussion of the 10 minures
meetings (if there are observers behind a one-way
mirror, they enter the room and, together with the
therapist, discuss the group in front of the patients)
5. The patients' response to the summary 10 minutes"
discussion

Orientation and Preparation

Earlier I presented a detailed illustrative example of the initial state-
ment that the therapist makes for each session. If there are new patients
present, as there usually are, the orientation must be more detailed than
if one is simply reminding the more experienced members of the basic
structure and purpose of the group.
The basic plan of the opening statement is to provide a basic orienta-
tion to the members, then to describe the purpose of the group, and fi-
nally, to clarify the procedure that the group will follow.
In the basic orientation statement, the therapist reminds the patient
about the time of the meeting, about its length, and about the presence

*'Only the first two phases of the blueprint are covered here. For a more ex-
haustive discussion, please refer to my book Inpatient Group Psychotherapy
(New York: Basic Books, 1983).
 98 TH E YA LO M RE A DER

of observers, if any, and n1ay review some basic ground rules of the
group (for example, the necessity of arriving punctually or rules about
smoking).
The purpose of the group must be presented to each patient in ex-
tremely lucid terms. New members are always anxious and often con-
fused, and the therapist cannot err in the direction of being too coherent
and too explicit. As the sample introduction indicates, the therapist t.
makes a. short statement about the importance of working on relation-
ships with other people and asserts that the investigation and improve-
merit of interpersonal relationships is what groups can do best and will
be the focus of this group. Furthermore, the therapist lets it be known
that the group will be able to be most effective by helping people under-
stand as much as they can about the relationships they have toward one
another in the room.
The therapist then outlines the basic procedure of the group, describ- r
ing briefly the five phases of the group I have just described and being
especially careful to inform new members of the presence of observers
in the room or behind the mirror who, toward the end of the session,
"viii discuss the meeting with the leader(s). The therapist then sets the
stage for the next step by commenting that each session begins with a
go-round, in which the therapist touches base with each person, asking
what he or she would like to work on in the group that day. The work
must be appropriate and able to be achieved in the therapy group time. t

This short statement about the agenda leaves new patients very per-
plexed and often anxious. The therapist does well simply to reassure
them and to let them know it is the therapist's job to help each person 1
ti

forn1ulate an agenda and that the group will begin by letting the new
patients participate last.

The Agenda Go-Round

It is important to launch a meeting with some structured vehicle that
permits the therapist to make some contact, however brief, with each
member in the group. In groups with a stable composition-e-for exam-
ple, long-term outpatient groups-the therapist has considerable infor-
mation at his or her disposal about each of the members of the group
and generally requires only a short time to determine the point of ur-
 Group Therapy with Specialized Groups 99

gency for a particular group session. In the rapid change of the inpatient
group, the therapist is often confronted with individuals about whom
he or she has little information. A structured ''go-round" allows the
therapist to scan the group quickly, to make contact with each person in
the room, and to obtain a bird's-eye view of the work possible for the
group that day.
Furthermore, a structured exercise at the onset of an inpatient meet-
ing conveys a clear tnessage to each patient that activity and participa-
tion by each is expected. If the therapist allows the group to start on its
own, there will almost invariably be a period of silence, confusion, ice-
hreaking ritualistic comments, and casting about for some useful or
convenient topic for conversation.
What type of initial structured go-round is preferable? Many options
exist. The most obvious one, used by many group leaders, is to ask each
patient to describe briefly why he or she is in the hospital. It rnay be ar-
gued that this form of go-round is a "no-nonsense" approach, since it fo-
cuses directly upon the life crisis and the ensuing decompensation that
brought the patient into the hospital.
But there are many disadvantages in such an opening gambit. For
one thing, a patient's perceived reasons for entering the hospital are of-
ten several steps removed from the work one can do in a therapy group.
Patients may be in the hospital because of substance abuse or because of
some external event (for example, the loss of a job, the malfeasance of
another, the loss of a lover) or because of some other externalized com-
plaint (for example, a psychosomatic ailment, ideas of reference, or hal-
lucinations) or because of some primary biological disturbance (such as
major affective disturbances). To concentrate on these reasons for ad-
mission emphasizes the then-and-there and makes it more difficult for
patients to use the resources of the group. Often the reasons for hospital-
ization are complex, and not infrequently most of a session may be con-
sumed in an investigation of the admission stories of the new members.
Furthermore, it becomes repetitious for older members to continue to
restate their reasons for entering.
Another commonly used initial go-round is for the therapist simply
to ask each patient to state something about the way he or she is feeling
that day. This tack accomplishes the task of touching base with each pa-
 100 THE Y ALOM READER

tient and obtaining a sense of the overall emotional state of the members
of the group, but it often steers the group into a cul-de-sac: it neither
provides a blueprint for the remainder of the meeting nor orients pa-
tients toward the changing of dysphoric feelings.
In my opinion, a highly effective way of beginning a meeting is to
ask each patient to formulate a brief personal agenda for the meeting.
The agenda identifies some area in which the patient desires change.
The agenda is most effective if it is both realistic and doable in the
group meeting that day. I urge the members to formulate an agenda
that focuses on interpersonal issues and, if possible, on those that in
some way relate to one or more members of the group meeting in that
session.
The very best agendas are those that reflect some issue that is of core
importance to the individual's functioning, that is interpersonal in na-
ture and may be worked on in the here-and-now of the group. Some ex-
amples of agendas that lead to useful, effective work in the group:

1: "My problem is trust. I feel if I open up and be honest about my-

self, other people, especially men, will ridicule me. I feel that way,
for example, about Mike and John [two other members of the
group that day]."

2: "I feel like other people consider me a nuisance. I think I talk too
much and want to find out if that's true."

3: "I put up a wall around myself. I want to approach others and

make friends, but I'm shy. Consequently, I stay alone in my room
all day. I feel I have some common interest with Joe and Helen
[two other members], but I'm scared to death to talk to them."
l.

Later in this discussion of the agenda go-round I will give many

other examples of agendas; but, for the moment, consider these three.
Each deals with a concern that is central to the individual speaking.
(:\"ote, however, that in none of these three instances was the problem
stated in the agenda the actual precipitating cause for hospitalization. ~I
The first patient was an anorexic; the second, a young alcoholic; and the
third had made a serious suicide atternpt.) Furthermore, each of these .
I,

three agendas expressed an interpersonal concern. Last, each had a

 Group Therapy with Specialized Groups 101

here-and-now component: that is, each concern could be examined

in the context of that patient's relationship with others in the group
that day.

The Advantages of the Agenda Go-Round

The major advantage of the agenda exercise is that it offers the ther-
apist an ideal solution to the dilemma of having either too much struc-
ture or too little. The exercise provides a structure for the meeting but
simultaneously encourages patients to assume autonomous behavior.
Each patient is urged to say, in effect, "Here is what I want to change
about myself. Here is what I choose to work on today."
The agenda provides the leader with a wide-angle-lens view of the
group work that can be done that day. He or she quickly makes an ap-
praisal of which patient wants to do what type of work and which goals
intersect with the goals of others. Furthermore, the agenda serves the
function of initiating interaction between members.
The agenda encourages patients to assume a more active posture in
psychotherapy. Often the agenda exercise is exceptionally useful in their
ongoing therapy once they leave the hospital. Patients are encouraged to
state their needs explicitly and straightforwardly-a particularly thera-
peutic exercise for those patients who habitually ask for help in indirect
and self-destructive ways-s-for example, through self-mutilation or
other self-destructive acts. (As I shall emphasize later, not all agendas
can or will be filled or even addressed during the meeting; but for many
patients, the formulation-not the completion-of the agenda is the
key therapeutic task.) The agenda task teaches patients to ask explicitly
for something for themselves. It helps them understand what therapy
can do and their responsibility for using or not using therapy. They re-
alize very clearly-and this is a point I shall discuss at length-that if
they formulate an inadequate agenda, they are unlikely to profit from
the meeting.

HelpingPatients to Formulate Their Agendas

The formulation of an agenda is not an effortless, automatic task.
Patients do not do it easily, and the therapist must devote considerable
effort to help them in this task.
For one thing, the great majority of patients have considerable diffi-
 102 THE Y ALOM READER

culty understanding precisely what the therapist wants and why. The
task must be explained to patients simply and lucidly. The therapist J
may give examples of possible agendas and painstakingly help each ~
member shape his or her own. The therapist must also explain to pa- I
tients why he or she wants an agenda by stating the advantages of the •
agenda format. r
Agenda formation requires three steps, and the therapist must escort /
most patients, especially in their first meeting, through each of the three
steps:

1: The patient must identify some important personal aspect that he

or she wishes to change. Moreover, the task must be realistic; that
is, the aspect must be amenable to change and appropriate for a
therapy group approach.

2: The patient must attempt to shape his or her complaint into in-
terpersonal terms,

3: The patient must transform that interpersonal complaint into one

that has here-and-now ramifications.

These remarks about agenda shaping may be made clearer by clini-

cal illustrations.
Consider a meeting in which a new woman member offers as her
agenda item: "I'm depressed and what I want to work on in this group
is getting over my depression." This agenda will lead to no useful work
in the group. First of all, it is unrealistic. The time frame for the agenda I
must be a single meeting; that is, the agenda must refer to a task that can
be accomplished in one session. This particular patient had been de-
I
pressed for years; how could a single therapy group meeting possibly al- I
leviate that depression? Furthermore, the agenda is too vague; it is not
specific and not consonant with the explicit activities of the group. I
Groups cannot work on "depression": there is no toehold; it is interper-
sonal problems, not symptoms, that constitute the currency of dynamic
psychotherapy.
When helping a patient transform an unrealistic agenda, such as this
one, into an appropriate working agenda, it is important to acknowl-
edge the importance of the patient's agenda. After all, in this patient's
 Group Therapy with Specialized Groups 103

experience it is her depression that is the key reason for her being in the
hospital. But the therapist must help the patient to obtain a more realis-
tic perspective on the therapy of the depression. For example, one might
say, "Being depressed is the pits, and of course you want to feel better.
That's the goal, and a very appropriate goal, for your entire course of
therapy. To alleviate your depression, however, weeks, even months, of
therapy will be required. The important task for today is, How to be-
gin? What can you work on in this group now? What groups can do
best is to help people understand what goes wrong in their relationships
with one another. What would you like to change in the way that you
live with or relate to other people? Your relationships to people, in a
way that may not yet be clear to you, are closely related to your depres-
sion. If you will begin to work on your ways of relating to others, I feel
strongly that ultimately, not in a day, you will begin to experience much
less pain in your life."
The therapist must acknowledge the patient's distress but try to
place it in the perspective of the work of the group. Thus, the therapist
might say, "This must feel devastating to you. I can see how the pain of
what has happened must dwarf everything else in your mind now and
make it hard to pay attention to other things. But distressing as your loss
of job and the problems of finding another must be, I do not see how the
group can specifically help you with that. It sounds like an issue you
could best work on in your individual therapy or in your work with a
vocational counselor or an occupational therapist. Let's see how this
group could help you. What could you work on here that might be
helpful to you?"
Most likely the patient will insist that he wants to work on the job
loss or might conclude that there is nothing the group can offer him.
The therapist's task at this time is to search for some interpersonal com-
ponent of the patient's problems. In such a situation I begin to sift
silently through a number of interpersonal hunches: "Does this man's
interpersonal style have anything to do with his losing his job? Or per-
haps his obsequious, self-denigrating manner creates obstacles in apply-
ing for and obtaining another job. He doesn't seem to acknowledge his
pain. I wonder what he does to get help for his feelings of distress. Does
he ever get any support from others? Can he ask for help? Who helps
him? He seems very down on himself. I wonder what it feels like for

l
 I 04 THE y A LO ~l R EADER

him to tell us about his failure. I wonder if there's someone in the group
he feels especially ashamed to tell."
By investigating some of these interpersonal leads, the therapist can
generally help a patient re1inquish an unrealistic agenda and arrive at
one appropriate to the group.
In this clinical example, Harvey, a paranoid schizophrenic crop
duster, was admitted to the hospital because of his bizarre, self-destruc-
rive behavior. He claimed that his only problem was vertigo (not a good
L
thing for a crop duster to havel), and declined to participate in the r
agenda task. His admission to the psychiatric ward was a mistake, Har-
vey claimed; he belonged on a medical ward.
The therapist responded, "It's unfortunate that you were admitted to
the wrong ward. But as Jong as you're here, why not take advantage of
what we've got to offer? You know, I often consider this ward a post-
graduate course in self-discovery. There are dozens of expensive courses
in the community in self-exploration or personal growth. You can never
learn too much about yourself. All of us keep learning and growing.
\Ve'\'e got expert instructors in this group. You're paying for it anyway,
it's all gra,·y. Why not take advantage of the opportunity?"
Harvey was disarmed by this approach. He opined that it made good
sense, and stated that he guessed he could work on why people so often
accused him of lecturing to them.
By using such strategic approaches, the therapist is able, without too
much difficulty, to help shape each patient's agenda into interpersonal
language. The interpersonal agendas vary widely, but the great major-
ity are expressed in one of the following formulations:

1. I'm lonely; there is no one in my life.

2. I want to communicate better with people.

3. I want to be able to express my feelings and not hold everything

inside.

+ I want to be able to assert myself, to say no, and not to feel

overpowered by others.

5. I want to be able to get closer to others and to make friends.

 Group Therapy with Specialized Groups 105

6. I want to be able to trust others, I've been hurt so often in my life.

7. I want some feedback about how I come across to others.

8. I want to he able to express my anger.

Transforming the interpersonal Agenda into a Hcrc-and-Nou/ Agenda

Recall that the agenda task consists of three steps: ( 1) identification of
a personal area that the patient wishes to change; (2) transformation of
the complaint into interpersonal terms; (3) statement of the agenda in
here-and-now terms.
The list of agendas I have just cited satisfied the first two criteria.
The therapist has one remaining task: to help members transform these
general interpersonal agendas into specific agendas involving other members
of the group.
Once this basic principle is grasped, the technical work is straightfor-
ward. Let us reconsider each of the eight agendas I have listed and ex-
amine some approaches the therapist may take to shape them into
here-and-now agendas.

1. I'm lonely; there is 110 one in my life.

"Can you think and talk about the way you are lonely here in the
hospital? From whom have you cut yourself off in this group? Perhaps
a good agenda might be to try to find out how and why you've made
yourself lonely here."

2. I want to communicate better with people.

"With whom in this room is your communication good? With

whom is it not entirely satisfactory? With whom here in this room
would you like to improve your communication? Is there some 'unfin-
ished business' between yourself and anyone else in this group?"

J I want to be able to expressmy feelings and not hold everything

inside.

r. "Would you be willing to express the feelings you have here in the
group today as they occur? For example, I wonder if you'd be willing to
 I 06 THE YA LO M RE A DER

describe some feelings you've had toward an issue or some person so far
today as we've been going around the room doing these agenda go-
rounds?"

4. I want to be able to assert myself, to say no, and not to feel oucrpoio-
ered by others.

"Would you be willing to try that today? Would you try to say one
thing that you'd ordinarily suppress? Would you select the people in the
group today that most overwhelm you, and see if you might be able to
explore some of your feelings about that? Would you like to ask some-
thing for yourself? How much time would you like for yourself later in
the group today?"

5. I want to be able to get closer to others and to make friends. f

"With whom here in this room would you like to get closer? I won- I
der whether a useful agenda might not be to try and explore what keeps
you a way from trying to get close to these people. Would you try some
different way of approaching them today? Would you like feedback
from them on how you create distance?"

6. I want to be able to trust others, I've been hurt so often in my life.

"Would you try to explore that with members of this group? Who in
this room do you particularly trust? Why? What is there about them?
Which people in the room might seem somewhat difficult for you to
trust? Why? What is there about them? What do you have to fear from
.)
anyone here in this group? In which ways do I threaten you? What do r
you have to fear fro in me?"
I
7- I want some feedback about how I come across to others. I:

r
"Why do you want the feedback? [Try to tie it in with some impor-
tant aspect of the patient's problems with living.] What aspect of your- r
self would you like some feedback about? From whom here in the
room do you especially want some feedback today?" :
II
8. I want to be able to express my anger.
I
Work on this particular agenda is delicate. It is advisable to steer
clear, so far as possible, of overt conflict in the group. One approach to
r
Group Therapy with Specialized Groups rn7

such an agenda is as follows: "Expressing anger is scary to an awful lot

of people and it may be too much to try and express a lot of anger here
in the group. However, one problem that n1any people have with anger
is that they let it build up inside of them until the sheer amount of it gets
to be very frightening. Perhaps one way you might be able to work on it
here is to try and let some of the negative feelings out while they' re still
in a stage of slight irritation or annoyance, before they build up to real
anger. I wonder, then, if you would try in the group today to express
slighter feelings of annoyance or irritation just as you first perceive
them to be forming. For example, would you be willing to talk about
some annoyance that you've had with me or with the way I've been
leading the group thus far today? Would it be all right with you if I
were to check back with you at other points during the group today to
see what annoyance you've experienced?"

The therapist's responses to each of these agendas are designed to guide

the patient into here-and-now exploration. Each response represents, of
course, only one of many possible interventions; and each therapist must
construct a repertoire of interventions that are consonant with his or her
personal style. Let us consider genera] strategies upon which specific
techniques must rest.
Help Guide Patients from the General to the Specific Help the
members be exceedingly specific with their complaints and with their
feelings toward other people. Interact with others. Address others ex-
plicitly and by name. Once a member is specific and names someone
else {for example, "I want to get closer to Mary, but I feel put off by
her"), then the stage is well set for the next phase of the meeting because
almost certainly Mary's interest will be kindled, and she will inquire of
that patient at some point in the meeting, "What do I do that puts you
off?"
Be Gentle but Persistent Nag the patients. Encourage, cajole, per-
suade them to formulate a workable agenda. This n1ay be mildly irritat-
ing to them, but in the long run it has a high yield. Repeatedly, in
debriefing research interviews, patients commented that, though they
may have been annoyed during a meeting, they ultimately appreciated
the persistence of the therapist. It is necessary to be gentle with patients
who are having a difficult time understanding the task. Supp1y agendas
 108 THE Y ALOM READER

for them, if necessary, in their first meeting or two. Avoid any com-
ments that might injure sensitive feelings.
One useful technique to decrease a patient's irritation is to allow him
or her to monitor the procedure. Check in with the patient and ask, on
more than one occasion, "Am I nagging you too much?" Or, "Am I
pressing you too hard?" Thus you allow the patient to have a sense of
controlling the interaction and of being able to terminate it when he or
she really wishes to.
Help Patients Differentiate One Another One of the most com-
mon modes of resistance to interacting with others is the reluctance to
differentiate one person from another. Thus, a woman patient may say
she feels isolated in life and yet will decline to differentiate the group
members sufficiently to say that she feels slightly closer to one person
than to another. As true interpersonal exploration and all the ensuing
interpersonal learning cannot really begin until individuals start to dif-
ferentiate one from the other, it is important to stress this task. The
therapist may underscore the problem and comment that the failure to
differentiate between people is another way of staying distant and unen-
gaged-preciscly the patterns patients are trying to change.
Strive for Some Commitment Even a very small commitment in
the agenda statement provides important therapeutic leverage. For ex-
ample, if one patient comments that he or she is intimidated by others,
obtain a commitment from this patient to name some of the people who
most and least intimidate him or her in the group. Or, if one patient
states an agenda of wanting to learn to express feelings, then attempt to
extract a commitment from that patient to express in this meeting at
least one or two feelings that he or she usually suppresses. Or, if one pa-
tient frames an agenda of wanting to learn how to ask for things for
herself, then attempt to extract a commitment that that patient will ask
for some specified amount of time (even three or four minutes) for her-
self in the group that day. Or, if one says that he wants to reveal more of
himself, obtain a commitment to disclose some personal data that the
group has not known before. Each of these commitments represents
"credit" in the bank upon which the therapist can draw later in theses-
sion.
Be Positive and Constructive Do not foment conflict in the group.
In the agenda go-round, therapists help to avoid conflict and facilitate
 Group Therapy with Specialized Groups 109

the development of a trusting, constructive atmosphere by starting with

positive feelings. If, for example, if a patient states that his problem cen-
ters on being unable to feel close to others, then the therapist best facili-
tates investigation of this area by beginning the exploration of the
positive side of the spectrum. Ask, for example, "With whom do you
feel most close in the group?'' or, "With whom is your communication
good?" Once safety has been established, you can gently move to the
more problematic areas with such questions as: "With whom do you ex-
perience some blocks in communication?" The general strategy consists
of starting on the far side of anger and cautiously inching up on it until
you find an optimal area for therapeutic work.
Transform Resistance into Agenda Work Not infrequently pa-
tients will seem unalterably resistant to the agenda task. They may be
too depressed, too demoralized, or too convinced that they cannot
change and would be better off dead. In such instances, it is always im-
portant to locate and ally oneself with the healthy part of the patient, the
part that wants to live. One of the advantages of making the higher
level group optional is that the therapist can always assume that the part
of the patient that decided to come to the group that day is striving for
growth.
The agenda go-round may be construed as an exercise in helping in-
dividuals to get their needs met. By accentuating that aspect of the
agenda, the therapist circumvents resistance and forges a therapeutic al-
liance. Exhortations to "ask for something for yourself," "get your own
needs met," "be more selfish," or "learn to value yourself and take care
of yourself more" are basically highly supportive to the patient. They all
suggest that the therapist feels strongly that the patient is worthwhile
and deserving of care and attention. Therefore, agenda pressure by the
therapist need not evoke defensiveness. Rarely will patients object to be-
ing considered too selfless, too unselfish, or too giving. Nor will patients
take umbrage at a therapist who exhorts them to ask for more for them-
selves.
Occasiona1ly the resistance stems from problems in the therapeutic
relationship. For example, a patient may resist the agenda task as part of
his or her overall struggle to defeat the therapist. Such trends are rela-
tively easy to determine and generally will be reflected in the patient's
posture toward many therapeutic activities in the ward. If the conflict is
 110 THEY ALOM READER

considerable, you may first have to clarify the patient-therapist relation-

ship. The therapist is, you may point out, easy to defeat, but the patient's
is a Pyrrhic victory: its losses far outweigh its gains. Why be an adver-
sary? After all, you, the therapist, are there to help. Why and whence
the conflict?
"Final Product" Agendas: Clinical Examples
Fully formed agendas vary widely in detail, general content, and
form; and it is neither possible nor necessary to present an exhaustive
list of them. Representative agendas drawn from group meetings may,
however, illustrate the texture of a workable agenda:

1: "Rick talked about being gay in the group yesterday, and I have a
lot of feelings about that which I didn't share."

2: "Would you [addressing the men in the group] still talk to me

and care about me if I didn't have my eye makeup on?"

3: "I've been annoyed about Steve's [another member of the group]

'hyper' behavior. I'm afraid that I hurt his feelings when I men-
tioned it this morning."

4: "I want to know how my rocking affects everyone in the group."

5: "I've been told I'm not real. Yesterday you two [pointing out two
members of the groupl said you could take me for one of the staff.
I want to find out what that's all about."

6: "I've got to find out why I'm so scared to talk in groups, especially
in front of people !designating three members] my own age."

7: "In a group this morning someone told me that I blend into the
woodwork. Is that the way you see me, too? If so, I want to work
on that."

8: "I want to be able to deal with my anger toward the men in the
,,
group.

9: "I need to learn how to talk about my sexual feelings in front of

other people."
 Group Therapy with Specialized Groups 111

10: "People think I'n1 weird because I'm phobic about touching any-
thing. I felt really bad about being laughed at yesterday for play-
ing cards with gloves on. I want to explain to everyone what it's
like to have these kinds of fears."

11: "I said some crazy things in the community meeting this morning
and I'm very upset about having talked like that. What do you all
here feel about me after this morning?"

12: "I want to know whether there's something about me or the way
I behave that would make a man want to rape me."

These are "final product" agendas. They have been fully processed
and shaped by the therapist and are far different from what patients
started out with. For example, the last three agendas were offered by
patients who had each been in the group for over twelve meetings, Each
agenda is the product of considerable therapeutic evolution. The last
agenda was formulated by a patient who, during her first several meet-
ings, declined to talk at all about the fact that she had been raped. Fi-
nally, after learning to trust the group and hearing other patients talk
about having been sexually assaulted, she was willing to discuss that
and, only with much therapeutic work, was able finally in this agenda
item to confront the possibility that she, unlike most rape victims, may
unwittingly have played some significant role in what had happened to
her.

Resistance to the Agenda Task: ResponsibilityAssumption

Earlier I remarked that forming an agenda is difficult for patients
simply on a cognitive level. Many patients have difficulty comprehend-
ing the relevance and the mechanics of the task, and thus far I have con-
centrated on methods the therapist can use to help overcome these
cognitive difficulties. But there is a second reason that patients find the
agenda task troublesome; this reason has deeper roots and offers a more
obstinate impediment to therapy. The very nature of the agenda task
reaches deep into many patients' psychopathology and evokes fierce re-
sistance. Thus, despite the most lucid instructions, some patients may be
unable to comprehend the task, refuse to engage in it, develop consider-
 112 THE YALOM READER

able anxiety during it, or, for reasons that are unclear to them, be angry
at the entire exercise.
In order to formulate a coherent strategy to overcome this resistance,
the therapist requires some understanding of its source. At both a con-
scious and an unconscious level, patients balk at the agenda because the
task confronts them with "responsibility." The therapist who is to un-
derstand fully the nature of the resistance must understand the concept
of responsibility-the subtext of the agenda task.
Responsibility refers to "authorship." To be aware of one's responsi-
bility means to be aware of creating one's own self, destiny, life predica-
ment, feelings, and, if such be the case, one's own suffering.
The individual avoids facing responsibility because awareness of
one's responsibility is deeply frightening. Consider its implications. If it
is true that it is we, ourselves, who give the world significance, who cre-
ate, through our own choices, our lives and our destinies, if it is true that
there are no external references whatsoever and that there is no grand
design in the universe, then it is also true that the world is not al ways as
it had seemed to us. Instead of a world design around us and solid
ground beneath us, we have to face the utter loneliness of self-creation
and the terror of groundlessness.
There are many clinical modes that patients use to avoid knowledge
of responsibility: one may displace responsibility for one's life upon oth-
ers through externalization, placing the blame for what has gone wrong
upon some external figure or force; one may deny responsibility by con-
sidering oneself as an "innocent victim" of events that one has oneself
(unwittingly) set into motion; one may deny responsibility by being
temporarily "out of one's mind"; one may avoid autonomous behavior
and choice in different ways; one may behave in a way that elicits "tak-
ing over" behavior from others; one may develop a compulsive disorder
in which one experiences one's actions as out of one's control.
An important initial step in the therapy of patients with all of these
clinical disorders is to help them appreciate the individual's role in cre-
ating his or her own distress. In fact, if a patient will not accept such re-
sponsibility and persists in blaming others, either other individuals or
other forces, for his or her dysphoria, no effective therapy is possible.
Consequently, responsibility assumption is a crucial first step in therapy,
 Group Therapy with Specialized Groups 113

but it is a step that meets much resistance: at an unconscious level, the

patient resists responsibility awareness because of anxiety about ground-
lessness that invariably accompanies full awareness of responsibility.
There is another source of anxiety in responsibility assumption. If
patients become aware that they are responsible for their current life
predicaments, they also veer close to appreciating the extent to which
they have been responsible for the course of their past lives as well. For
many patients that awareness incurs considerable pain: as one looks
back upon the wreckage of one's life, upon all one's unfulfilled poten-
tial, all of the possibilities never examined or taken, then one becomes
flooded with guilt-not guilt in its traditional sense, which is related to
what one has done to others, but guilt from an existential sense, which
refers to what one has done to one's own life.
Thus, the simple act of forming an agenda is not so simple after all; it
confronts patients with issues that have roots steeped in anxiety, roots
reaching down to the very foundations of their existence. Consider the
steps a patient must take in the proper formation of the agenda.

Realizing That There Is Something about Oneself One Must Change

It is an extraordinarily important step for a patient to realize that
there is something about himself or herself that he or she must change.
Indeed, for some patients who externalize to an extensive degree, it is
an entirely sufficient goal of the acute inpatient psychotherapy group.
Patients who regard their problems as "out there"-that is, unfair treat-
ment by employers, abandonment by a treacherous mate, or victimiza-
tion by fate---cannot begin the change process until they come to terms
with their own personal role in their life predicament. Otherwise, why
change? It would make more sense for therapy to be directed toward
changing not oneself but the offending other party. As long as patients
remain in an externalizing mode, the psychological help that they can
accept is limited to such modes as commiseration, support, problem
solving, advice, and suggestions.
Hospitalized patients who externalize considerably constitute a rela-
tively large percentage of the inpatient population. They represent such
diverse clinical entities as psychophysiological disorders, paranoid disor-
ders, involuntarily hospitalization, and substance abuse.

l
 r14 THE YALOM READER

Identifying Some Specific Aspect of Oneself

One Would Like to Change
The identification of some specific piece of work is an important fo-
cusing task for each patient. Many patients are so demoralized and so
overwhelmed by the shambles of their lives that they despair of change.
To force oneself to identify a starting point, to commit oneself to a dis-
crete task, often inspires hope and combats confusion.

Communicating One's Wishesto Others

It is an exceedingly important step for patients to learn to communi-
cate their wishes to others, and one that addresses a very important facet
of n1any patients' psychopathology. It brings home to them that others
cannot read their mind; that others cannot know their wishes automati-
cally; that they have to state their wishes aloud or those wishes wil1
never be known, much less gratified.
The awareness that one must communicate one's wishes is impor-
tant because it leads to the insight (distasteful though it may be) that we
are truly alone, that there is no omniscient servant looking over us, that
we will not change unless we change ourselves. The agenda format
brings this insight home via another route as well: patients, after attend-
ing many meetings, gradually comprehend that, if they do not formu-
late an agenda, they will derive little benefit from the meeting. After
even a couple of meetings, patients know perfectly well what type of
agenda gets attention and results in effective work. At some level of
awareness, the agenda initiates an internal dialogue in which patients t

are forced to come to grips with their unwillingness to change. I

!
Agenda work with a depressed woman patient il1ustrates some of
~
these issues. She felt defeated and self-con tern ptuous and stated the fol-
lowing agenda: "I feel like an absolute failure. Today what I want from l·1
the group is simply support. I need lots of strokes from people."
The therapist urged her to stretch farther: "What kind of strokes
would you like? What would you like to hear them say to you?"
Now, of course, this line of questioning is highly irritating. It's an-
noying to be required to state what positive things one wants people to
say to one spontaneously. The patient's reply reflected exasperation. She
snapped, "If I have to tell them what to say, then it doesn't count!"
 Group Therapy with Specialized Groups 115

Yet at another level it counts very much that the patient not only ex-
pressed her pain but identified precisely what would make her feel bet-
ter. This is a giant stride on the road to learning how to become her own
mother and father-and, for this patient as for a substantial number of
others, that is the major goal of psychotherapy.

Agenda Formation: The Completion of the Task

There is tremendous variation in the types of agenda formulated by
members. The agendas are a function of many factors, including the
composition of the group that day, its stability, and its size. If the group
is relatively stable, and all the members present have formulated agen-
das in previous meetings, the agenda go-round n1ay be completed
quickly. By no means does this indicate that the members will use the
same agenda every day. Occasionally an individual will work on the
same agenda for several days in a row, but generally agendas will
change to some degree: an individual may change focus because of the
presence of different members in the group or because the previous
day's work opened up different vistas. If there are many new members
in a meeting, the agenda go-round will consume much more time. If the
group is large, less time will have to be spent on each agenda.
A well-conducted agenda go-round results in a banquet of clinical
material which should launch the group into productive use of the re-
maining time. Consider the following meeting of nine patients:
In approximately twenty-five minutes, an energetic, supportive ther-
apist helped the members formulate these "finished" agendas:

1: "I was a battered child. I've got a lot of feelings about that I
haven't worked out. I've never talked about that with other peo-
ple, and I would like the group to try and help me talk about it."

2: "I have some unfinished business with you [the group leader] left
over from yesterday's meeting, and I'd like to talk about that to-
day. "

3: "I've got to learn how to identify my feelings. I think I've got to

do it alone, but I want to try to talk about feelings that come up
during the meeting."
 116 THE Y ALOM READER

+ "I've got to learn how to take more risks with others and assert
myself more, especially with the other men here."

5: "I'm feeling \'cry vulnerable and hurt, and I want to work on that
in the group. I'd like to be able to tell all the people in the group
about all the various ways I hurt."

6: "I've got some strong feelings about a conversation I had earlier

with Mike [another patient in the group] this morning, and I'd
like to try to work on those."

T "I don't have the energy to state an agenda today." The therapist
pressed her by asking a question that is usually effective: "If you
were to have the energy to state an agenda, what do you think it
would be?" The patient went on to say, "I think I'd like to ask for
feedback from the other people in the group, especially from the
men, since I usually seem to antagonize men for some reason."

8: "I want to talk about the feelings I have about my physical ap-
pearance. It's got to do with my size. I'n1 so big and tall that
everyone seems to feel they can lean on rne for help."

9: A new patient: "I'm in the hospital because my psychiatrist [a

woman] left town for a few weeks. I'm in love with her and I
want to n1arry her, and I'd like to work on that in the group."
The therapist inquired about how the group could help him, be-
cause, after all, his psychiatrist wasn't present in the group. Was it
possible to work on something more relevant to the group? The
patient then stated that he was developing somewhat similar feel-
ings toward one of the women in the group and perhaps he could
talk about those feelings.

With this beginning the therapist should have no difficulty leading a

rich and productive group meeting. There is so much material that
therapists must focus their energy on addressing as many agendas as
possible.
 Group Therapy with Specialized Groups 117

PART 2

GROUP THERAPY WITH PATIENTS

ADDICTED TO ALCOHOL

The group treatment of alcoholics is daunting. Traditional group ap-

proaches have long proven so ineffective that most professional group
leaders have abandoned attempts to lead such groups. Obviously, a
highly specialized approach is required for this population. The follow-
ing article describes my attempt to employ a disciplined group inter-
actional approach with alcoholics. It is a tricky matter to use a
here-and-now approach with alcoholic patients: the intensity of the fo-
cus invariably arouses anxiety, and alcoholics often respond to anxiety
by turning back to alcohol. Consequently, it was necessary-and this is
the heart of the article-to develop a series of techniques that would
diminish anxiety but still permit the group to maintain an interactional
focus. Some of these techniques, for example, writing a candid summary
of the session and mailing it to the members before the next meeting,
proved so useful that I incorporated them into my work with many other
types of groups. "Group Therapy and Alcoholism" has had a long, active
life and has been reprinted and distributed numerous times to classesof
alcoholic counselors.

Group Therapy and Alcoholism

(excerpted from An. of the 1V.Y. Acad. of Sciences, 233:85-103, 1974)

I have occasiona11y attempted to treat alcoholics in therapy groups com-

posed of patients with a wide variety of problems, and like most group
therapists, I have ended up discouraged, resolving each time to leave al-
coholics to Alcoholics Anonymous. Recently, however, with the encour-
agement of the National Institute of Alcohol Abuse and Alcoholism, I
 118 THE YALOM RE:\DER

decided to make a very earnest attempt to apply my group skills to the

therapy of alcoholic patients. Although there is a vast literature on the
treatment of alcoholics in groups, there have been few, if any, systematic
attempts to utilize dynamic interactional group therapy methods with
alcoholic patients. In this paper I shall describe my efforts to apply some
basic principles of interactional group therapy to the treatment of the al-
coholic patient.
I planned to conduct the alcoholic therapy group as a complement to
and not a substitute for Alcoholics Anonymous. The task of the therapy
group, as I conceptualized it, was not to help individuals attain sobriety
but to help them work through the underlying personality conflicts that
produce the alcoholic compulsion. I specifically planned to focus on the
interpersonal pathology that underlies all maladaptive behavior, includ-
ing alcoholism. The group's task was to help members overcome feel-
ings of self-contempt, loneliness, alienation, and disengagement; to
understand and alter abrasive, maladaptive, self-defeating styles of self-
presentation; and to help members involve themselves meaningfully in
the peopled world.

Structure of the Group

The Initial Interview The usual purpose of individual interviews
before a patient begins group therapy is twofold: first, the therapist at-
tempts to arrive at a decision as to whether a specific patient is a suitable
candidate for group therapy in general and for the specific group the
therapist is leading. Second, he attempts to prepare the patient for the
group therapy experience which lies ahead. My co-therapist and I had
decided in advance to accept all coiners, and therefore made no effort to
screen patients. Indeed, we suspended our ordinary clinical judgment
and accepted some patients whom we would never have considered
suitable for a therapy group.
There is ample evidence to indicate that proper pregroup orientation
leads to greater patient satisfaction, increased group cohesiveness, and
an increased level of interpersonal exploration. We attempted to make
the initial interview the beginning of therapy both by conveying to the
patient that it was his responsibility to decide what changes he would
like to make in himself, as well as by modeling the honesty and candor
 Group Therapy with Specialized Groups 119

that we expected of everyone in the group. For example, I told them

quite openly that I had had a great deal of experience in group therapy
but relatively little experience with alcoholic patients. Since the group
experience would benefit both the patients and myself, there was to be a
two-way contract. I would provide what group therapy skills I had,
while they would enlighten me on the problems of alcoholism. My co-
therapist, who was a professionally trained therapist as well as a recov-
ered alcoholic and an active AA member, helped enormously to bridge
the gap between the alcoholic patients and myself, the nonalcoholic pro-
fessional.
We interviewed and accepted eight patients. Three of the patients
had long-term sobriety (from one to three years); two had shorter term
sobriety (from four to twelve months); one patient had sobriety for only
about one month; and two patients were actively drinking. One patient,
who was desperately ill and drinking very heavily, came to a single
meeting. He was replaced in three to four weeks by another member,
who was also an active drinker. At the beginning of their group experi-
ence, all but three members were actively involved in AA. As the group
progressed the other members began to participate occasionally in AA.
Certain important issues a rose <luring the initial interviews. These
may be most clearly illustrated by briefly presenting two examples:
Ken, a 50-year-old divorced musician, had been sober for two years
after having been an extremely heavy drinker for the previous five. He
was an exceedingly active member of AA, attending approximately five
meetings a week and totally orienting his very limited social life around
AA. He had considerable difficulty in formulating any goals for himself
in therapy, insisting that he had achieved considerable tranquillity and
comfort in the life he had shaped for himself. He insisted that he desired
no personal changes and had no urgent problems upon which he
wanted to work. We suspected that he viewed this group as one more
AA-like meeting to fill his lonely life. We would never have accepted
Ken for an ordinary therapy group: his level of denial was extraordinar-
ily high, but seemed to be an effective defense. We doubted whether we
could offer him anything better than his defense mechanisms, which
apparently provided him with unshakable tranquillity. We worr icd too
that without this mechanism of denial. Ken might sink into a serious
 I 20 THE Y A LO M R EA D ER

depression; yet it was not possible to engage Ken in serious therapeutic

work without undermining denial. My co-therapist's immediate re-
sponse to me was "Leave him be. Let's not rock this boat." We decided
to express these concerns quite candidly to Ken and warn him that,
were he to go into the group, he might experience more discomfort than
he had for years.
Another, quite different problem was personified by Donna. Donna
had had several years of sobriety and was an active, militant AA mem-
ber. Her career goal was to become a professional counselor for alco-
holics. We distrusted her reasons for entering the group. She stated that
she wanted to learn something about professional psychotherapeutic
methods which would be helpful to her in her work, but she also explic-
itly stated that she hated psychiatrists and psychologists and regarded us
in many ways as "murderers" of alcoholics. This sentiment was so
strong that I had good reason to believe she wanted to come into the
group to act as a type of policeman or watchdog to protect the other pa-
tients from me. When I insisted that she describe some area in which
she wished to change, she evaded me by the rather ingenious ploy of
stating that her chief problem was her extreme distrust of professionals.
Perhaps, she said, through her work in the group, she might be able to
overcome this mistrust. I had a strong sense of being conned, but I
squelched my doubts and decided, on an experimental basis, to accept
her also. Ultimately this proved unwise: she attended approximately
eight or nine sessions and then finally left the group. Not only was she
unbcnefi.ted, but she clearly fettered the group by parroting AA slogans,
refusing to reveal herself, and constantly challenging and undermin-
ing the therapists. It was only afterwards that we found out that one of
her chief reasons for continuing in the group was her strong sexual feel-
ings toward one of the other members, whom she had known previ-
ously in AA.
Another patient, Bill, not only was actively drinking but was in a
stage of severe deterioration (had no money, no home) and was ap-
proaching some serious physical complications of his drinking. Again,
we had little hope of helping Bill in the group, but I had hoped that af-
ter starting him in the group we might be able to steer him into AA. He
was much too sick, however, attended only one meeting, and shortly
thereafter was hospitalized by his physician.
r

Group Therapy with Specialized Groups 121

The other patients had a wide range of problems: low self-esteem,

loneliness, depression, inability to find work, and a constant struggle
with the desire to drink. Many were extremely nonintrospective, con-
ceptualized their problems concretely, and expected advice or solutions
from other members and especially from the therapists. They were re-
moved from their feelings, denying, circumstantial, fragile, dependent,
restricted interpersonally, and unable to deal with the feelings that were
aroused during the meeting. Perhaps I would have considered only one
or two at most of the eight patients as suitable for the typical outpatient
groups operating in our clinic. It was truly a challenge of the first mag-
nitude.
The early meetings were so labored, tense, and circumstantial that I
used them as contrast groups for my group therapy students. By observ-
ing and contrasting the alcohol therapy group and an outpatient neu-
rotic therapy group, they could arrive at a clearer picture of honest
interpersonal exploration and a dedicated here-and-now orientation.
However, by the sixteenth meeting the alcoholic group had changed so
much that this type of comparison was no longer possible. The group
became intense, hard working, and intcractional. I could not possibly
have imagined at the onset that this group would have progressed to
such a level in the short space of fifteen meetings. Let me now describe
some of the methods by which this transformation occurred.
Strategy and Tactics of the Group Leader Many of the techniques
that I used in this group were similar to those that I use in all my group
therapy. However, because of the very unusual types of problems pre-
sented by this group of alcoholic patients, a number of very specific in-
terventional techniques were required, which I shall describe in context.
We structured the initial session much more than usua I by suggest-
ing that the members go around the room and discuss aloud their thera-
peutic contract, that is, the goals that each of them had in therapy. From
the very first moment of the life of the group, we began to guide mem-
bers in a variety of ways to interact directly with other members of the
group and to explore these interactions. For example, I pointed out to
one member that he was speaking to Ken but looking at me, and I sug-
gested that the group members look directly at one another when they
speak. I pointed out that when one member would speak to Dave he
would impersonalize the transaction by avoiding the second person pro-
 I 22 T H E YA LO M RE AO ER

noun "you" and referring to him instead by name or by the third person
pronoun. We tried to direct members into an immediate focus, reiterat-
ing our belief that the group as a whole could not fully appreciate issues
and persons outside the group, despite their crucial importance for indi-
vidual group members. We urged them to talk about how they felt to-
ward the people within the group. A typical question: "Ted, to whom
do you feel closest in the group, to whom do you feel most distant?" It is
best always to word questions in as nonthreatening a way as possible.
For example, I do not ask the members of the group whom they dislike
most of all but instead inquire about those aspects of each person they
find it most difficult to accept. We focus at first on more positive aspects
of their relationships. We are relentless in noting when the group seems
to be moving away from the here-and-now.
The leader should strive to transfer the responsibility of the content
and direction of the meetings onto the members, In other words the
therapist should aim to help the group become self-monitoring. If they
discuss sorne abstract, intellectualized issue, it generally doesn't take
very long to observe that rnany of the members are not so intensely in-
volved as they are when speaking about themselves. In these situations I
usually ask certain people about their reactions at that specific moment;
how do they feel about what's happening in the group? Generally some
members will comment that they feel less engaged at that moment than
previously. I try to help them understand which material seems to be
most relevant and important for them. One rnethod of doing this is via
videotape playback. Each meeting was videotaped and began with a
ten-minute playback of important segments of the previous meeting.
\Ve ask the group to identify which sections of the meeting seem to be
most involved or most important and what sections are least so.
Whenever there is the slightest hint that members of the group are
being talked about, it is 1ny reflex as a leader to help the members be
specific, to name names. For example, the group was discussing the fact
that Bill, an intoxicated member present in the first meeting, was quite
disruptive. One of the members said she didn't mind a drunk in the
group; in fact she felt the group needed a disruptive influence because
things were ordinarily too peaceful and kind in the group. My response
at this point was to ask her, .. Who in this room are the ringleaders of the
 Group Therapy with Specialized Groups 123

peace and calm movement?" When she mentioned two members, the
others agreed that these two were al ways kind and understanding, and
that at times it was difficult to know if they ever had negative feelings.
As early as the fifth meeting, the self-monitoring process began to
take hold. By that time, when a member indicated he wanted to talk
about an article he had read in the newspaper that he considered rele-
vant to his condition, members in the group started to chuckle at his
penchant for moving things away from a personal level, and they effec-
tively prevented him from distancing the group.
It is important for the leader to supply cognitive bridges for the
members so that they appreciate the rationale of the here-and-now ori-
entation. In this particular instance one of the members asked why we
wanted him to show anger. What good does destructive behavior ever
do? He described the cruelty of his father, how he was brutalized as a
child, and how he decided early to eliminate anger from his life. We
provided a cognitive bridge by recalling for him that his original goals
in the group consisted largely of his desire to be able to assert himself
and to prevent others from exploiting him. We noted that he avoided
any type of anger to the point that any form of self-assertive behavior
was stifled. He did not accept this interpretation and responded with,
"Well, may I ask you a question then?" I immediately pointed out that
he was repeating the pattern: Why, of all the people in the group, was it
only he who had to ask permission to ask a question? It was quite obvi-
ous that everyone was free to say what he or she wished in the group.
He then became annoyed with me and said that he was not sure he
could trust me and demanded to know what was in this for me. I re-
sponded openly by telling him about my desire to help the members of
the group while learning more about alcoholism, and I confessed to en-
joying certain benefits from a government grant on alcoholism. I also let
him know that as a result of his confronting me, I felt closer to him; his
approaching me, even in anger, had decreased the distance between us.
Another example of here-and-now training: One member was silent
and obviously uncomfortable in a meeting. She had, since the group be-
gan, found it very hard to share personal feelings in the group. When I
asked her about her present state of mind, she said, as she always did,
that she was experiencing some diffuse apprehension and anxiety. Usu-
 1 24 TH E Y ALO M R EADER

ally this ended the discussion, but in one meeting we escorted her into
the here-and-now by saying, "Joan, I know that you're experiencing
your fear now as generalized and diffuse, but let us help you make it
more specific. If you were going to be afraid of anyone in the group,
who would it be? Who in the group frightens you the most or has the
most potential for frightening?" This soon moved Joan into an ex-
trcmely important area for her, that is, her fear of the therapist and of
one of the other members who, because of previous group therapy expe-
rience, appeared more sophisticated than the others. Joan was enabled
to discuss her great investment of pride in her intellect and her desper-
ate fear of looking stupid, of saying the wrong thing, and of being
judged adversely.
At one point, Ted, who was extremely impersonal and "intellectual-
ized," commented that he really didn't know Sally very well. My re-
sponse at this juncture was to ask, "Ted, could you try to think of a
question which you could ask Sally that might help you know her better
or feel closer to her?" Thus, in a number of ways we gradually made it
clear to the members that the group was an experimental society-a so-
ciety which had a time-limited but deep intimacy, and furthermore a
society which dispensed with the normal rules of social etiquette and
encouraged members to ask questions of one another that they would
never drcarn of asking in conventional social intercourse.
Another member's problems were demonstrated by his behavior
during the sessions. He was always left out of the group and would
never ask for help for himself, and consequently the therapists found
themselves searching for ways to give him the floor. When we asked
about his past or his current life crises, he could discuss these problems
hut would not personally relate to anyone in the group. When he de-
scribed how his domineering mother and sister ruled his life, we at-
tern ptcd to relate this to the present session by asking, "Of all the
women in the group, who could you imagine dominating you like your
mother or your sister?" By helping him to interact in this manner with
other members, we brought his past and his outside world to life within
the group. W c were careful to reinforce him or other members making
their first forays into the here-and-now by such direct statements as t
"that sounds good" or "it's good to hear you be so direct."
 Group Therapy with Specialized Groups 125

Obviously we are asking something quite different of the members

than is requested by AA, which not only does not encourage direct in-
teraction but implicitly discourages it. Our relationship to AA, then, is a
complex one; we encourage joint membership, yet we work on very dif-
ferent operational models. Indeed, we expend much effort helping
members unlearn the ritualized AA models of group interaction.
The Group Dilemma The first half-dozen meetings were spent in
this interactional training procedure. During this phase the group
moved relatively slowly and the members required considerable explicit
training. Additional factors impeded the pace of the group. For exam-
ple, the group was unlike the typical outpatient therapy group in that an
unceasing staccato of crises seemed to be beating on the door. At almost
every meeting some member was facing an important life crisis. One
patient lost his business and considered filing for bankruptcy; another
was fired from her job; another was enmeshed in a complicated, explo-
sive, extramarital affair; two had episodes of extreme marital discord,
and another patient's brother died suddenly. The drinking members
each went on a binge, during which they phoned to report they were too
ill to come to the meeting; we urged them to attend, but they were so
distracted and tremulous they could scarcely contain themselves. Al-
most every meeting began with a crisis report, and the therapists grew
concerned by the evolving group norm, which predicated that a mem-
ber could ask for the group's attention only if he had a major crisis to
present; indeed some members seemed forced into silence by this infor-
mal rule. The therapists dealt with this development vigorously by
commenting explicitly on what was happening in the group and by fac-
ing the members with the decision of whether they wanted a crisis in-
tervention group, whether they wished to forgo other kinds of work,
and whether they wished members not in crisis to remain silent about
moderate nondramatic discomfort.
After considerable evolution the group gradually assumed a work-
oriented posture. By the twelfth meeting, however, another major de-
velopment occurred; it became very clear that the group was facing a
difficult dilemma, which can best be appreciated in this description of a
pivotal meeting.
In the two or three previous meetings, one member, Arlene. had be-
 126 TH E Y A LO i\f R E :\ D ER

come increasingly hostile and dominating. She began to shut out other
members, became competitive with one of the therapists, and on a num-
ber of occasions presented such long monologues about her personal
difficulties that she consumed 50 percent of the group time. In the last
meeting she was "working" (as a therapist) with one of the members on
some traumatic events in that member's past. When a couple of the men
tried to contribute to the discussion, she cut them both off and made it
explicit that she considered their contributions to be irrelevant and un-
helpful. In the week between meetings, one of these men, Ken (the
member who professed tranquillity and a two-year sobriety before the
group began), called to say he had decided to leave the group. He had
been feeling consistently "uptight" since the last meeting when he had
been put down by Arlene, and he felt he had nothing to offer to anyone
in the group; for the first time in two years he was experiencing the type
of discomfort that in the past had led to drinking. He said that he sim-
ply couldn't afford to have that degree of anxiety; he wasn't going to
permit the group to push him into alcohol. Ted, the other man who had
been attacked by Arlene, was similarly affected and stated that he had
been terribly anxious all week long and that if he ever went home from
the group feeling like that again, he would never return. Another mem-
ber's sister called to say that he had been out on a binge, and when we
called him, he said that he was too shaky and too ill to return to the
group the next week. \Ve encouraged him and Ken to return. In that
particular mcetirijz, the two men, with the help of the therapists, faced
the source of their anxiety, that is, their anger toward Arlene and her
extrerne hostility toward them. They did this with much trepidation
since both of them were individuals who found it extraordinarily diffi-
cult to express anger. After an extremely tempestuous meeting, the two
men felt better, hut Arlene went home and for the first time in approxi-
mutely six weeks she began drinking again. When she reported this to
the group the next week, the two men were overwhelmed with guilt at
ha Ying been responsible for Arlene's drinking, and so things went,
This sequence of events was enough to make the therapists realize
the group had reached a crisis point and required some drastic interven-
tion. \Ve decided to change our tactics and to move into a much more
structured format, which I shall describe shortly. It became clear that
 Group Therapy with Specialized Groups 127

we had the option of leaving certain members with their pregroup

defenses of avoidance, suppression, and denial, which provided tran-
quillity hut resulted in a massive restriction of intra personal and inter-
personal exploration, or of helping them 1110\'c into a self-exploratory
posture, which would disturb tranquillity and possibly even cause
"eruptions" of drinking, but which might permit them to attain a richer
life. This dilemma posed itself more starkly for the A£-\ members than
for the drinking non-AA members, who had so little stability that their
psychological risk was not as great. As the tension level rose in the
group, we were forced to find a number of different ways to moderate
the amount of anxiety present. I believe that conflict and anxiety are ab-
solutely essential if change is to occur in the group therapeutic process.
The dilemma, however, is that the alcoholic patients in the group are
capable of tolerating only small degrees of anxiety before resorting to
old, well-ingrained patterns of anxiety relief, especially alcohol and
avoidance (leaving the group).

Anxiety-Reducing Tactics
The group had a dual attitude toward the professional leader: both
distrust for the nonalcoholic professional and extreme dependency. I
decided to make use of this attitude by imposing considerable structure
on the group. It was my long-term strategy to build into the structure a
method by which they could recognize and alter some of their unrealis-
tic expectations of the leader.
Agenda In a number of ways the therapists began to provide more
explicit leadership. We started the particular crisis meeting that I have
just described by putting an agenda on the blackboard and telling the
group that, regardless of whatever else we discussed that day, we con-
sidered it imperative to cover these issues: ( 1) Ken's anxiety and his de-
sire to leave the group; (2) Ted's similar anxiety; (3) Arlene's anger and
domination of the group and the response this generated in other rnern-
bers; (4) Sally's recent alcoholic lapse and the persistent avoidance of this
subject by the rest of the group; (5) the competition between Arlene and
the co-therapist.
For the next several months we began every session in a similar fash-
ion. As the group moved on to a new level of functioning, the need for
 128 TH E Y A LO M R EA D F. R

an agenda became less; however, without question it proved to be an ex-

trernely valuable structuring technique during the time of crisis. Exam-
ples of agenda items from other meetings were: leftover feelings from
the last meeting between X and Y; the death of one member's brother,
which he had not been willing to discuss in the group; secrets shared by
some members in extragroup meetings; the tendency of the group
members not to ask a specific member about his current drinking;
undiscussed sexual feelings; and the leader's concerns that the previous
meeting had been too rough on a certain person.
Didactic Instruction A structuring device which we used with con-
siderable success was an occasional didactic interlude. We began to go to
the blackboard once or twice during a meeting to clarify in diagram-
matic form some aspect of the dynamics that were occurring in the
group. For example, I sketched out the series of interactions beginning
with Arlene's castigation of Ken and Ted, which resulted in their anger
at her, which quickly changed into anxiety and then into a desire to
leave the group. With our prompting, this anger and anxiety was ex-
pressed but resulted in Arlene's resumption of drinking, which then re-
sulted in even greater anxiety and guilt on their part. The clarification
of this sequence helped them to understand the dilemma more clearly
and helped Arlene understand the bind in which she placed Ken and
Ted. We tried to pose alternatives; for example, Ken had two tradi-
tional ways of dealing with anxiety-s-ro relieve the anxiety by drinking
or to avoid anger- and anxiety-provoking incidents by withdrawal. Al-
though the second method, the one he had been using for the past cou-
ple of years, operated satisfactorily, he paid a rather heavy price for his
avoidance; the price was isolation, since he increasingly tended to avoid
intimate relationships with other people lest they led to discomfort. We
then suggested an alternative for Ken: to face, even temporarily, the
anger and to express it under the tempered, optimal conditions in the
group.
On another occasion Allen, who had good reason to be annoyed with
Ted, said to him, "I understand your feelings; three years ago I was in
the same place . . . " At that point several members grinned and we
stopped Allen by asking whether he knew why they had grinned. In re-
sponse to his bafflement, the therapists sketched out Allen's interaction
 Group Therapy with Specialized Groups 129

on the blackboard, noting that he transmitted, at the same time, two op-
posing messages. The first message was one of concern; he was gen-
uinely trying to be helpful to the other. The second, and the one that
prompted the grinning, was "You're three years behind me," or "I'm
better and significantly more mature than you."
Another diagram related to iritrapersonal functioning. One rnernber
of the group described the despair she felt when sober: during those pe-
riods she would become more aware of all the things that she was not
doing in life, and she would grow increasingly hateful of herself. When
we explored the expectations she had for herself, it was quite obvious
that they were extraordinarily unrealistic. She wanted to make major
social changes in the structure of the country, acts that have been impos-
sible even for a Cabinet officer. I diagrammed Karen Hor ney's schema
of the real and the idealized selves and underscored the extensive
"shoulds" she placed on herself. Her idealized image was a highly unre-
alistic and unattainable one, and yet whenever she noted the discrep-
ancy between what she was and what she demanded she should be, she
responded with self-hatred. In the past she responded by turning to al-
cohol (which blunted her awareness of the discrepancy between her real
and idealized selves) to attempt to diminish the pain of self-intolerance
caused by placing tyrannical demands upon herself. We suggested that
another method might be to explore and to reappraise the highly unre-
alistic nature of her idealized image. It turned out that this same schema
was applicable to several of the other members. A caveat: the therapist
must not confuse the means with the end. The means is simply to re-
duce anxiety by providing some type of cognitive structuring so the pa-
tient may participate, without crippling anxiety, in the intensive group
experience and benefit from one or several of the mechanisms of change
described above. Too often zealots of any specific system take it too seri-
ously, forget the universal mechanisms of change, and expend their en-
ergy on converting patients to their conceptual framework.
Summaries for Patients The most successful method we found to
modulate the anxiety of the group was the dictated summary. After
each group therapy meeting, it is my practice to dictate an extremely de-
tailed summary of the meeting for my own research interests. When the
alcohol therapy group appeared to be going into crisis, I decided on a
 I 30 TH E y A LO ~f R EA DER

forrn of feedback that I have never attempted before (and to the best of
n1y knowledge has not been reported by other group therapists}. I de-
cided to use a special summary, similar but not identical to my own
summary, which I then distributed to the patients before the next meet-
ing. For the first couple of weeks, the patients came fifteen to twenty
minutes early to read the summary immediately before the session.
They soon began to value the summary so much that they asked to
receive it earlier in the week to have more time to digest it; I then be-
gan mailing the suinmary approximately three to four days before the
meeting. The general structure of the summary is a three- to five-page
<louble-spaced narrative of the meeting. I tried to present an objective
account of the meeting and to review each person's contributions to it.
The su1n1nary gives therapists a medium to convey an enormous
amount of information to the patients. They can make editorial com-
ments or present feelings or opinions about events in the group. These
may be restatements of comments they made in the group, observations
that they di<l not feel it timely to report during the meeting, or after-
thoughts. The su1nmary 1nay be used to reinforce certain kinds of be-
havior. For example, when Ken expressed anger in the group, we
pointed out how pleased we and the other members were to see him ex-
press himself so freely. We often expressed our concern over specific
events: for example, after one meeting that had been particularly upset-
ting for one of the members, we wondered in the summary if he would
choose to miss the next meeting or even terminate therapy. Such predic-
tions were usually reassuring and often prevented impulsive antithera-
peutic decisions. We supported individuals in need of support. For
example, Arlene, who came under considerable attack for her abrasive-
ness, was praised in the sumn1ary for her risk taking, which, although
soliciting much anger, was nonetheless very helpful to the group; if
everyone could be as honest as Arlene, we pointed out, the group would
move rnore quickly. The summary made explicit certain important im-
plicit themes, such as the members' reluctance to ask Wayne whether or
not he was still drinking, because of their sensitivity to his intense
shame. \Ve pointed out the dilemma for the group: that they did not
wish to embarrass or threaten Wayne, but that if they continued to pro-
tect him, they would isolate him and prevent him from benefiting from
the group.
 Group Therapy with Specialized Groups 131

\Ve attempted to increase cohesiveness by indicating in the sumn1ary

similarities between members of the group. We made guesses why cer-
tain silent members were blocking. We openly discussed some of the
dilemmas we as therapists faced, such as the group dilemma. that
is, that although it was necessary for conflict to develop, we were
distressed when members confessed they were driven to the point of
wanting to take a drink. We repeated some of the more didactic inter-
pretations made in the meeting so the members would have time to as-
similate them the second time around. \Ve wondered whether or not
certain people were being ignored. \Ve expressed our concern about
people who were not present at the meeting. \Ve wondered about the
previously good relationship between two members, which seerned to
be going sour. \Ve attempted to take some of the sting out of attacks on
certain members. We tried to present some of the interpretations in a
lighthearted way so that they could be more easily accepted.
There are times when we hesitate to make an interpretation to a pa-
tient during a particular session because he seems so fragile; however,
we find it feasible to make the interpretation in the surnrnary, where we
speak openly of the reasons for having avoided the issue during the
meeting. For example, when Arlene (who had been drinking during
the week and was very shaky) made an effort to clarify exactly what she
had said the previous week but did so by once again cutting off the
other members and taking up too much time, we felt it would have
been poor timing to point this out in the group. However, the su1nmary
provided an excellent opportunity to make that kind of statement. Our
written formulations increased the security of the members, convincing
them that someone really knew what was going on in the meeting;
someone appeared to be in charge of this seemingly runaway wild beast
of a group. By specifying which of the meetings or sections of meetings
we considered good or poor, we used the summaries to help the group
learn to monitor itself.
An important use of the summary was to help the rnernbers of the
group view the leaders more realistically. I talked about my feelings of
helplessness when certain members expected me to be able to see
through everything and to provide a near-magical solution. As the
meetings progressed, I gradually became more self-disclosing in the
summary. For example, when discussing how the group was dealing
 I 32 TH E Y A LO ;'.1 RE A DE R

with the concept of assuming responsibility for themselves, I noted that

this is a stance difficult for anyone, certainly for myself, to assume com-
pletely. I disclosed my uneasiness in feeling that I am the only one heard
when in fact there are others who are making equally helpful com-
ments. I acknowledged how choked up and helpless I felt when one of
the members was talking about her own personal crisis. Gradually it
came about that the summaries for the patients resembled more closely
the summaries I dictated for myself and my co-workers. This, of course,
is a reflection of increased therapist self-disclosure. In a sense, then, the
summary represents a rather subtle technique for dealing with a depen-
dent group. It provides the therapist an opportunity to satisfy depen-
dency needs and yet at the same time avoid infantilization of the group.
He uses the group's overvaluation of him to plunge them into a more
autonomous, independent form of group structure. After we started to
use these structures, there were no further complaints about therapists
who remained mysterious, did not answer questions, or never explained
things to patients. At the same time the patients were increasingly able
to challenge the therapists. Furthermore, the summaries helped patients
assume the self-reflection that is so important for the interactional
group therapy experience.
We have had considerable patient testimony about the value of the
summaries, Members appreciated the work spent in preparing them,
and some would reread them several times during the week. Members
brought the summaries to the meeting to discuss parts they didn't fully
understand or agree with. On a number of occasions members be-
gan the meeting by following up issues or hunches expressed in the
sumrnarv.,
Video Playback Video playback is a structuring technique that,
like others described earlier, has the potential to reduce anxiety. Every
meeting was videotaped, and we started the following meeting by
showing portions of the previous week's interaction. We tried several
different formats. At times we played a section of the tape that we con-
sidered particularly important and then asked people to discuss what
rhey were feeling but not saying during that session. At other times we
would play particularly significant sections in which some patient was
behaving in a way that we wished to reinforce. Or we played a section
 Group Therapy with Specialized Groups 133

of the tape that we thought might help a patient view himself more ac-
curately. At other times we selected a few sections (a total of approxi-
mately 15 minutes) and played them at the start of the meeting, without
inviting comment from any of the patients during the playing. \Ve
never found an ideal format and, compared to the dictated summaries,
the video playback provided only a modest amount of help for the
group. It is an expensive procedure and n1ay create distraction if the
cameras or cameramen are visible or noisy.
An example of a constructive use of the playback occurred during a
meeting when Mary was extremely upset about a turbulent love affair.
When pressed by the group, she began to cry and suddenly ran out, not
to return until the following week. Next meeting, we viewed the scene
of her running avvay and the group's discussion of her after she had left.
She had exited because of shame at her tears; she was convinced people
would consider her stupid or silly for crying and even more so for run-
ning out of the meeting. It was a potent and constructive experience for
her to observe herself and the other members discussing her after she
had left. She was surprised and moved by their understanding and em-
pathy. Another member who had probably been drinking spoke with
noticeably slurred speech during a meeting, yet no one felt comfortable
enough to comment upon it. We played that section back in the group
and wondered what they were hearing then and what had prevented
them from being honest with one another earlier. On a couple of occa-
sions members came to view the whole tape of a meeting that they had
missed so they could stay abreast of the group. One member, Arlene,
came in on two occasions to review an entire meeting so that she would
get a clearer idea of her behavior that had aroused so much antagonism,

Special Problem.f
Subgrouping Subgrouping, or extragroup socializing, may compli-
cate the process of any therapy group, and is especially problematic in
the group therapy of alcoholic patients. Most group therapists attempt
either to discourage patients from meeting outside the group or to make
it as clear as possible that it is important for patients to share with the
rest of the group significant information obtained outside the group
about other members. If such information is not shared it is likely that
 I 34 T H E Y A LO :vt R E A D E R

important subgroups will form, which may defeat the purpose of the
primary therapy group.
Two basic principles provide useful guidelines. The first is that a
subgroup can either strengthen or weaken the primary group, depend-
ing upon the subgroup's function and its norms. If the function of the
subgroup overlaps that of the primary group and the norms conflict
with the primary group norms, then it will weaken the larger group
and be a disintegrative influence.
The second principle is that there is a distinction between primary
task and secondary gratification in psychotherapy. The primary task in
therapy is the fulfi1lrnent of the patient's implicit or explicit goals, such
as relief of anguish and change of behavior. Secondary gratifications, of
course, occur in all therapy formats, but they are especially marked in
group therapy and may take 111any forms. For example, there is an in-
herent pleasure which derives from being dominant or influential, pop-
ular or admired, helpful to the others, or favored by the therapist. When
the secondary gain becomes so marked that the patient loses sight of the
primary task, then therapeutic work comes to a standstill and it is in-
cumbent upon the therapist to intervene appropriately.
The members of the alcoholic group had an enormous amount of ex-
tragroup contact. They saw one another frequently at AA meetings or
AA social functions. Some of the rnembers had had a long-term rela-
tionship with one another before entering the group. A couple of them
had sponsored other members of the group during their first contacts
with AA. They regularly met after the group for lunch and frequently
exchanged phone calls during the week. Two members of the group
who were not AA members were often excluded from much of the out-
side socializing and gradually became irritated at their exclusion. Com-
plications arose when some members who were closely involved with
one another felt uneasy about discussing information confided in extra-
group discussions. To do so would, in their opinion, "betray" the other
individual, Furthermore, members often formed impressions of others
from their observations outside the group or from information learned
from other people about a specific member. They refrained from bring-
ing up this material in the group because that too would have consti-
tuted a betrayal. This is an example of how a small group, either a dyad

Ir
 Group Therapy with Specialized Groups 135

or triad, develops norms that conflict with the norms of the larger
group. Members sense a stronger loyalty to the dyad or triad than they
do to the primary group itself. The group suffers because important and
very relevant information is withheld and unavailable for the work of
the group. Because of his fear of betraying secrets and jeopardizing his
friendship, a member does not speak to his friend in the group, and the
two friends are of little value to each other in the therapeutic work. The
secondary gratification that steins frmn friendship or companionship
outside the group thus takes precedence over the primary task of ther-
apy. The other members of the group usually become aware of extra-
group contact between members and sense that secrets are being kept.
The result is a global inhibition and lack of trust in the group process.
There was much information that members chose not to share with
the group. For example, one knew that another member, during a pe-
riod of heavy drinking, was also becoming addicted to Demerol; an-
other knew that one of the members was involved in an extremely
destructive extramarital relationship; two patients knew that one
woman in the group had received an obscene phone call from one of the
men in the group approximately a year before starting the group.
It is important that the therapist make as explicit as possible the fact
that the members must, themselves, assume the responsibility for bring-
ing up all pertinent information to the group. My experience has been
that this is a much wiser course of action than any attempt to preYent
extragroup socializing. Patients will inevitably meet outside of the
group, and one does well not to lay down rules that will inevitably be
broken and which patients will then attempt to conceal from the thera-
pist and the rest of the group. Furthermore, it is helpful if the therapist
explains why it is important for members to share this information
in the group. \Ve do this in our preparatory interviews and again, as
the situation arises, both during the group and in the post-group
summanes.
The Drinking Patient The actively drinking member presented a
major problem. It is more difficult to cope with drinking than with
other forms of acting out, such as promiscuity or stealing, because the
patient who comes into a therapy session intoxicated is in an altered
state of mind, which makes it unlikely that he will be able to under-
 I 36 T H E YA LO ~i RE AD ER

stand the feedback from others or to retain the experience. This, of

course, makes the members extremely discouraged, since they recognize
the futility of working with the inebriated patient and at the same time
-
they cannot avoid dealing with him in the group. The drinking patient
r
arouses "twelfth step call" reflexes from experienced AA members, who
are strongly motivated to support and assist the drinking member and
yet at the same time are aware that this "twelfth step reflex" is not the
most effective way of involving themselves in the therapy process. In the
AA tradition a "slip" is an extremely important event: it is an indelible
entry into the record of the member and henceforth the AA member
who has slipped at least once must always present himself as such. Con-
sequently group members feel extraordinarily concerned and guilty
should they perceive themselves as in any \vay having been responsible
for the slip.
The problems surrounding a drinking member were exemplified in
the case of Arlene who, as described, was criticized by some of the
group and then came to the following meeting intoxicated. Her abra-
sive, maladaptive behavior vvas magnified; she monopolized the group,
did not listen to other members, was contemptuous of several members,
and refused to allow others to console her. Although it was obvious that
she had been drinking, she patently denied it and in a long rambling
monologue rationalized how useful alcohol was for her as an antide-
pressant. Despite the great sophistication and familiarity of the other
members with alcohol, they accepted her statements and attempted to
console her. Only after an hour of "punishment" did they first become
discouraged and then openly confrontative, ordering Arlene to allow
others to talk. They then refused to accept her rationalizations for
drinking and absolved themselves of guilt when they learned that she
had taken herself off Antabuse in preparation for drinking even before
their attack at the previous meeting. Although this seemed like a disas-
trous meeting for Arlene, it eventually turned out to be a very signifi-
cant incident in her therapy. She stopped drinking after leaving the
meeting and as soon as possible resumed taking Antabuse. The meeting
served as a "bortoming-our" point, and with the help of the summary
and the videotape playback, she arrived at a penetrating awareness of
the destructive nature of alcohol for her. She later stated that she real- 1
I

i
 Group Therapy with Specialized Groups 137

ized she had no right to inflict this kind of punishment on a group of

well-intentioned people. The sunnnary helped her to retain and under-
stand the comments made to her during the group, which she would
have otherwise forgotten. As she put it, it provided her with a living
record of the effects alcohol could have on herself and on her relation-
ships with others. She has decided that when she is stronger she will see
the whole meeting over again on videotape and asked us to save the tape
for her.
The most thorny problem for the group was their feelings of respon-
sibility for causing another to drink. \Ve eventually effected some reso-
lution of this issue within the larger context of personal responsibility.
We helped members to realize that no one could make them drink; in
the final analysis it was their responsibility and they could only allow
someone to make them drink. No one could control them: they could
only choose to allow others to control them. It was also important for
the group members to make the distinction between short-term and
long-term concerns. Immediate support is gratifying and is good to give
and good to receive; but an even more substantial way of showing con-
cern is to be more honest and direct with one's negative as well as one's
positive feelings toward another. This is a long-term concern which, al-
though somewhat unpleasant at first, may ultimately be more valuable
to the other. For members to believe this, however, considerable faith in
the therapist and in the therapeutic modality must be established.

Results
It is premature to comment on the results for each patient; this type
of group therapy has ambitious goals and is a long-term process. With
regard to some parameters the endeavor to establish a working therapy
group has been "successful." The group has navigated past numerous
dangerous shoals which have threatened to destroy it on several occa-
sions. Despite many factors that we suspected would limit our success
(no selection of patients, inclusion of many patients who appeared to be
extremely high risks for group therapy, an infrequent, once-a-week for-
mat, some actively drinking members), the group developed into an ef-
fective working therapy group with high cohesion and excellent
attendance.
 -•

138 THE YALOM READER

PART 3

GROUP THERAPY WITH

THE TERMINALLY ILL

Introduction
In recent years groups for patients facing life-threatening illness have be-
come commonplace. Thousands of patients with cancer, AIDS, heart dis- ,
ease, and kidney disease attend support groups. Many publications, lay ~
and professional, describe the groups; groups for breast cancer patients ~
•
have had considerable national TV coverage. The article I reproduce I

here, "Group Therapy with the Terminally Ill," which I coauthored with
Carlos Greaves, a psychiatric resident at the time, first appeared in the
American Journal of Psychiatry (April 1977); it is, to the best of my
knowledge, the first published description of a group for cancer patients.
During the late 1960s I grew increasingly interested in exploring exis-
tential sources of anxiety. These phenomena are deep, repressed, and
difficult to discern in everyday psychotherapy patients, and gradually I
turned to working with cancer patients whose illness forced them to con-
front more openly the issues of death, isolation, freedom, and meaning in
life. After seeing a number of patients in a one-to-one setting, I met Katie
Weers, a remarkable woman with advanced breast cancer, who acted as
adviser and teacher to me. With her assistance I organized a group for
patients with advanced cancer which first met in 1972. Meetings were
held weekly in the psychiatric outpatient clinic with occasional meetings
in the bedroom of a patient too ill to leave home. Most meetings were at-
tended by four to seven patients. When the group grew larger, we broke
it into two sections and had a joint session for the final fifteen minutes to
review the events of both meetings. Over the first four years forty patients
 Group Therapy with Specialized Groups 139

attended the group and twelve patients died. From its onset the group at-
tracted considerable attention from students-professional caregivers
from many disciplines-who observed the meetings through two-way
mirrors. The group members welcomed observers: they felt they had
learned much about life from their illness and they desired an opportu-
nity to teach. Our clinical impression was that the group offered enor-
mous support to the members and markedly improved their quality of
life. Soon Dr. David Spiegel joined me in this work, and we formed other
groups, which we based on the paradigm of the original cancer group
and studied more systematically. Many years later Or. Spiegel found that
these supportive/expressive groups not only offered breast cancer pa-
tients valuable support but actually increased their survival time. His
finding resulted in a flurry of new research and new applications of sup-
port groups for cancer patients.

Group Therapy with the Terminally Ill

with Carlos Greaves, A1.D.
(excerpted from the Am.]. of Psychiatry, 134:4, Ap 1997, pp. 396-400)

During the past four years we have employed a group therapy for-
mat in the care of dying patients. Initially we assumed that the group
members would profit from continued close contact with others facing
the same tragic experience. We thought that sharing, open communica-
tion, and the opportunity to be helpful to others would be an antidote to
the bitter isolation so many dying patients experience.
A second reason for organizing a therapy group for terminally ill pa-
tients was the conviction that such a group could teach us much about
everyday psychotherapy with the living. Although it is common knowl-
edge that a serious confrontation with death often triggers a profound
reappraisal of one's basic relationship with oneself, others, and the
world, it is uncommon for a concentrated contemplation of death to en-
ter the psychotherapeutic dialogue. One important reason for this is that
the psychotherapist's basic theories of anxiety (and hence his/her chief
consideration in psychotherapy) rest not on the bedrock of the dread of
nonbeing but on such derivative phenomena as separation, castration,
 140 THE YA LO J\iI RE A DER

and loss of ego boundaries. Another reason issues from the magnitude
of the threat. Most psychotherapy patients and most therapists will not
stare at death very long before they lower the blinds of denial. Psy-
chotherapy groups occasionally deal with death when prodded by such
stimuli as the death of someone dose to one of the members or the de-
parture of one of the members from the group. However, the focus is
rarely sustained for more than a single session; depression, avoidance,
and denial soon obstruct the work.
These considerations prodded us to organize a group of patients
with terminal illnesses-patients who are so close to death that contin-
ual denial is not possible. We hoped to help them if we could, to learn
from them, and to apply what we learned to the everyday therapy of the
living.

Description of the Group

Four years ago, with the aid of a patient with metastatic cancer, we
began a group for patients with metastatic carcinoma (breast carcinoma
in most cases). Since then the group has met weekly for 90 minutes. The
patients are all fuJly aware of the nature and prognosis of their illness.
Our experience is that it is best to exclude patients who exhibit massive
denial of their illness and its implications. We also exclude patients
whose cancer has been contained and who have excellent prognoses. It
is an open group; members come as often as their physical condition
permits and as long as they continue to profit from the experience.

Course of the Group: Modes of Help

The therapeutic factor of altruism played an important role in the
group. Not only did the patients help one another in quid pro quo
(giving-receiving) fashion, but altruism, the act of giving, was intrinsi-
cally valuable to the members. As in any therapy group, the members
themselves were the prime agents of help. In this group that fact took on
an added dimension, since terminally ill patients are so imbued with a
sense of powerlessness and uselessness. They dread nothing so much as
helpless immobility, being not only personally burdensome but without
value to another. Consequently, learning that they had much to offer
others irnhued many of the members with a renewed sense of worth.
 Group Therapy with Specialized Groups 141

Furthermore, being helpful to others brings patients out of a morbid

self-absorption which, for many, had stripped life of its meaning. The
more they are able to move out of themselves, to extend themselves to
others, the more they experience a sense of fulfillment.
Members are able to be helpful in a number of ways. They telephone
and visit members who are in despair. They share books and coping
techniques that have been useful to them. For example, one of the mern-
bers taught other members in the group the meditation techniques that
had been useful to her in dealing with pain.
Another mode of offering help (and thus helping oneself) is to teach
by sharing one's experiences with others. (The patients often thought
before joining the group, "We are teachers but the students will not lis-
ten.") The patients are very willing to speak to medical students and to
permit observation of the meetings through a one-way mirror. There is
rarely a meeting without observers (for example, nurses, physical thera-
pists, medical students, psychologists, oncologists, radiotherapists).
These patients are especially desirous of reaching and influencing
the medical profession because, almost without exception, they have a
complex and ambivalent set of feelings toward their doctors. At first,
much anger was evident; in fact, the group's initial cohesiveness re-
sulted at least in part from a common bond of enmity toward the med-
ical profession. Some of this enmity was justified, some was irrational.
Both types of anger were dealt with: the irrational by understanding
and working through, the realistic by ventilation and development of
adaptive coping strategies.
The irrational anger stems from the doctors' failure to meet ex-
tremely unrealistic demands. At deep, unconscious levels the members
expected the doctors to be all-knowing and all-protecting. They put
their faith in the doctor to the same degree that their ancestors had
placed their faith in the hands of the priest. And, of course, the doctor
could not be the ultimate rescuer. Patients are forced to confront lirnits
and finiteness, and the ensuing anger and dread is often displaced to the
physician.
However, much anger is justified. The surgeons and oncologists ei-
ther lack the time or arrange their schedules in such a way that they
cannot provide the kinds of support and information the patients crave.
 . I

142 THE YAL0'.\1 READER

The patients felt their physicians were too impersonal and too authori-
tarian. They resented not being kept fully informed and being excluded
from important decisions regarding their own treatment. Many patients
reported that physicians withdrew emotionally from them when metas-
tasis occurred. They felt abandoned just at the time when they needed
the most support.
Patients learn from one another what they can and cannot expect
from their doctors. They co1nparc notes and role-play methods of ask-
ing doctors questions. They come to grips with how much they really
want to know-were the physicians concealing information, or were
the patients asking questions in such a way that the physicians were
merely complying with their wishes to avoid gaining the information
they ostensibly wanted?
Over time it became abundantly clear in the group that the patients
had a strong need for a sustaining relationship when their illness was no
longer deemed curable and that 1nany had physicians who were so
threatened or discouraged that they could not provide the sheer pres-
ence the patients required. Presence was the overriding need and the
chief commodity provided by the group. Almost without exception, pa-
tients facing death feel cut off and shunned by the living. We agree with
Kubler-Ross that the question is not whether to tell the patient that
his/her disease is one that has no cure, but how to tell the patient. The
living, by a multitude of signals, always let the patient know that the ill-
ness is terminal. Nurses, paramedical personnel, and physicians cue the
patient, often in the most subtle \Vays-a hushed shrinking away, a ten-
dency to be less intimate, a slightly greater physical distance. One mern-
ber commented that her doctor always ended his meetings with her by
giving her a gentle pat on her fanny. When he became more solemn
and, instead of patting her, shook her hand, she recognized the serious-
ness of her illness for the first time.
Not only are patients isolated because they are shunned by the living,
but they increase their isolation by their reluctance to discuss their most
central concerns with others. They fear that friends will be frightened
and avoid them; they are reluctant to burden and depress their families
further.
It became apparent that the most basic anxiety of many group mern-
 Group Therapy with Specialized Groups q3

hers was not so much a fear of dying, of finiteness and non being, but
fear of the absolute utter loneliness that accompanies death. Obviously,
basic existential loneliness cannot be allayed or taken awav; it can only
' ' J

be appreciated and, in a curious way, shared through the sharing of it.

The other kind of loneliness. secondary interpersonal loneliness that is a
function both of the shunning of the dying person and of his/her self-
imposed isolation, can be dealt with effectively in the group. First and
most important, the group offers an arena in which all concerns can be
aired and thoroughly discussed. There are no issues too deep or morbid
to be discussed openly in the group. These issues include physical con-
cerns (for example, loss of hair from chemotherapy, disfigurement from
mutilating surgery), fear of the actual act of dying, fear of pain, the pos-
sibility of afterlife, the fear of becoming a "vegetable." the desire to have
decision-making power concerning the time of death, euthanasia, the
"living will," funeral arrangements, and so on. These concerns are fore-
most in the minds of many patients. but they are unable to discuss them
with any living person. The group affords considerable relief by simply
allowing patients to share these thoughts.
In this group, as in all therapy groups, one becomes ever more cog-
nizant of the overarching need that people have for other people. The
group spends much time and does much effective work with the pa-
tients who, because of characterological style or particular methods of
coping with recent stress, have cut themselves off from others. For ex-
ample, one patient never asked for any personal help from the group.
For months she tended to speak in extremely concrete terms. When she
was asked about herself, she responded by gi,·ing a long summary of her
physical condition, her examinations by doctors, and her recent
chemotherapeutic regimen. The therapist helped this patient by repeat-
edly asking her, when she had finished talking about her physical self,
to respond again to the question, "How are you? How is the person feel-
ing to whom all of these things are happening?" Gradually, she became
more able to relate to others and to discuss her own needs. Although she
could not easily discuss her feelings, she once reported to the group a
dream of a poor injured kitten for whom she had wept. She was able to
accept the interpretation offered by group members that she was the
kitten and that she wept for herself. Later in the group she became
 .I

144 TH E Y ALO j\t R EADER

more open to discussion of all affect; she even reported, after attending
one member's funeral, the anger and fear that the sterility and imper-
sonality of the service had aroused in her.
Another member had planned a large dinner party and learned from
her physician that morning that her cancer had metastasized. Her chief
concern at that point was less a fear of death than of isolation and aban-
donment. She feared that her illness would cause her so much pain that
she would respond to it in a primitive, animalistic fashion and therefore
be shunned by others. She held her party and kept her illness secret
from friends. It was with much relief that she was able to discuss these
concerns in the group and to hear how other members with more ad-
vanced disease had experienced and dealt with pain.
Another member began the group in bitter isolation. She was a
widow who felt she had been isolated by all of her former friends and
abandoned by her only child. The group at first empathized with her,
and rnany members felt extremely angry toward her son, who had ap-
parently behaved in an extremely ungrateful manner. Gradually some
members became aware of the fact that neither the patient nor her son
acted independently but were instead locked together in dynamic inter-
action. The patient had for years (long before her cancer) been an em-
bittered and angry woman who had in effect driven her son away from
her. With the help of the group she became softer, more open and re-
sponsive to others. Her son reciprocated and she became even more
generous; eventually, before her death, she became a source of consider-
able strength for other members of the group.
A woman who was desperately ill with advanced leukemia came to
the group for only one session. She spent the entire meeting discussing
the fecklessness and coldness of her only child, a daughter, who was a
psychologist and "should have known better." One of the other patients
helped this woman appreciate the triviality of her charges against the
daughter and suggested that she make the most of her remaining time
by saying to her daughter, "You are the most important thing in the
world to me, and I want us to be close before I die." The patient died
only a few <lays after this meeting, but we learned from the nursing staff
that she had followed the group's advice and had a final, deeply fulfill-
ing meeting with her <laughter.
 Group Therapy with Specialized Groups q5

The Therapist in the Group

The presence offered by the therapy group must, of course, include
the therapist. One cannot effectively lead such a group by making a di-
chotomy between "us," the living therapists, and "them," the dying pa-
tients. Therapists lead effectively when they appreciate that it is "we"
who face death; the leaders are members who must share in the group's
anxiety. The anxiety that the leader must tolerate is considerable, and it
has been our experience that a period of several months' apprenticeship
is necessary for therapists to deal with their own dread of death so that
they can work effectively. \Ve found, for exam pie, that when the group
interaction was superficial, the therapists were often responsible. They
considered certain topics too threatening for the patients to discuss, but
ultimately they were protecting themselves. Given the opportunity, the
group was willing to plunge deeply and meaningfully into any area.
Sometimes the therapist proceeded with extreme caution because he
regarded the patient as too anguished to tolerate any additional anxiety.
Not infrequently this spawned an overly conservative approach that
merely enhanced the patient's sense of isolation. Victor Frankl once
suggested that Boyle's law of gaseous expansion in a physical space
could be applied to anxiety, in that anxiety expands to fill any space of-
fered to it. Many people who are relatively unburdened find that trivial
anxiety fills their life space completely. Thus, the absolute amount of
anxiety in the dying patient is often no greater than that of patients
facing a number of other life concerns. It seems that we get used to any-
thing, even to dying. At times the group provided a type of desensitiza-
tion experience, as patients repeatedly approached and palpated the
most frightening issues. Laughter that was neither diversionary nor
tension-spawned often occurred spontaneously. For example, during
one meeting a member spoke about a seemingly healthy neighbor who
had died suddenly during the night. One member stated that that was
most regrettable since the woman had had no time to prepare either
herself or her family for her death. Others disagreed, and one member
said that that was precisely the \Vay she would like to die, quipping,
"I've always loved surprises."
At the same time, however, the therapist must learn to respect denial
 146 THE Y ALOM READER

and to allow each patient to proceed at his/her own pace. Even though
all of the group members are aware of their diagnosis and prognosis,
they often shift their level of awareness, and the therapist renders the
most help by respecting the patient's decision regarding what he/she
chooses to know at that moment.
It is important to conceptualize the group as a group for living, not
for dying. For one thing, physicians are more inclined to refer patients
when the group's purpose is to improve the quality of life rather than to
focus on <lying. Even more important is the fact that an open confronta-
tion with death allows many patients to move into a mode of existence
that is richer than the one they experienced prior to their illness. Many
patients report dramatic shifts in life perspective. They are able to trivi-
alize the trivial, to assume a sense of control, to stop doing things they
do not wish to do, to communicate more openly with families and close
friends, and to live entirely in the present rather than in the future or
the past. Many report that facing and mastering some of their fear of
death dissolves many other fears, particularly fears of awkward inter- I
personal situations, rejection, or humiliation. We are not being ironic f
r
when we suggest that, in a grim fashion, cancer cures psychoneuroses.
As one's focus turns from the trivial diversions of life, a fuller apprecia-
tion of the elemental factors in existence may emerge: the changing sea-
sons, the falling leaves, the last spring, and especially, the loving of
others. ()ver and over we hear our patients say (and this is a most com-
pelling message for the psychotherapist), "Why did we have to wait till
nou/, till we are riddled with cancer, to learn how to value and appreci-
ate life?"
 Group Therapy with Specialized Groups 147

PART4

GROUP THERAPY WITH THE BEREAVED

Bereavement groups, both professionally led (sponsored by hospitals,
hospices, outpatient mental health agencies and churches) and self-help
groups, have proliferated over the past three decades.
How effective are they? Should public mental health policy offer
groups to all bereaved individuals? The existing research did not supply
an answer to this question because virtually every study used a self-
selected sample of bereaved individuals who sought help from profes-
sional caregivers or else responded to an invitation to join a research
project.
Hence, in the mid-1980s my colleague Morton Lieberman and I de-
signed a controlled study in which we offered a brief group experience
to an unselected population of spousally bereaved individuals. This re-
search had several goals: to develop appropriate specialized techniques
for a bereavement group leader, to understand in depth the important is-
sues faced by our members, to determine the outcome of a brief group
intervention, and finally to test an observation I had made in individual
therapy with the bereaved-namely, that an often forgotten facet of be-
reavement is that the death of the other confronts us with our own death
and that part of the work of mourning is to integrate this confrontation.
Several papers were generated by this research. One, devoted to out-
come, reported that although the groups were effective therapy groups, it
was not possible to recommend them as routine prophylactic mental
health practice because the control population also did extremely well:
bereavement, in the great majority of instances, is a self-limited process.1
Another paper documented that a significant number (approximately
one-third) of the bereaved spouses did experience an existential con-
frontation that resulted in unexpected personal growth. For these individ-
 148 THE Y ALOM READER

uals the end point of bereavement was not the reinstitution of function
but a new and deeper level of maturity.2 "Bereavement Groups: Tech-
niques and Themes," which I coauthored with Sophia Vinogradov, was
originally published in the International Journal of Group Psychotherapy
(October 1988). The excerpt presented here explores the therapeutic
techniques we employed in bereavement groups and clinical themes
emerging in these groups.
f

Bereavement Groups: Techniques and Themes

with Sophia Vinogradov, IvLD.
ilnternauonal ], of Group Therapy, 38:4, Oct 1988) I
t

The recently bereaved represent a large at-risk population, a fact in-

dicated by persuasive clinical and research evidence. Bereavement
'
r
i
groups constitute a particularly sensible approach to treating this popu- I
lation, as great numbers of clients may be reached in a systematic and r
cost-effective manner. Furthermore, the small group format specifically
addresses and ameliorates the intense social· isolation experienced by
most bereaved spouses. Such groups represent excellent preventative
mental health practice.
In this paper we will report on the technical and thematic considera-
tions of four bereavement groups that met weekly for eight sessions. We
contacted the spouses of all the patients who had died of cancer at two
medical settings (Stanford Medical Center and the Palo Alto Medical
Clinic) during a six-month time frame. Of the sample of 74 consecutive
I
subjects, 63 (84 percent) agreed to participate. Fifteen were randomly
assigned to a control condition: they were interviewed before the study,
and one year later, but did not take part in the groups.

Techniques
General Principles The general techniques we employed in the be-
reavernenr groups are those used by group therapists in most settings,
and consisted essentially of establishing norms, of encouraging process
review, and of making here-and-now interventions. In addition, since
the life of the group was limited to eight sessions, and since issues of sep-
 Group Therapy with Specialized Groups 149

a ration and loss were paramount for these members, we were careful to
function as group timekeepers and to remind members of the number
of remaining meetings.
First Meeting After introductions, we began the opening session
by briefly restating our expectations for the group. (We had already ori-
ented each member in the individual intake sessions.) We hoped that
the group would focus prirnarily on the future and would help each
member learn to move forward despite the loss, the pain, and the major
changes each had experienced. We stated, too, that although the group
would explore painful issues surrounding bereavement, we would en-
deavor to ensure that such discussion be safe and gentle.
At this point, we invited the members to describe their bereavement
and to share, in any way they chose, what they thought we should know
about their current life situation. This go-round was, without excep-
tion, a moving and important part of the first meeting. Some members
wept openly when describing the death of the spouse; others became
tearful in sympathy, especially when hearing about the loss of a young
spouse or about young children left without a parent. Invariably, the
members were self-revealing and spontaneous, and the therapists' only
task was to reaffirm the safety of the group by reminding members,
when necessary, that one might say as little or as much as one chose. If a
member became tearful, we might inquire, for example, if he or she
wished to stop or whether questions from others would be welcomed.
Early Meetings During the early meetings (sessions 2 to 4), the
group discussed in greater depth many of the themes identified in the
first meeting. If necessary, the therapists reminded the group of the
salient issues and launched the discussion. These sessions were charac-
terized by considerable energy and interaction, and members gave
much explicit positive testimony about the group. For example, in one
group, a young widow who had guiltily begun dating a man several
months earlier received a great deal of support from other group mern-
bers; after the third meeting, she decided to marry the man and thence-
forth credited the group for enabling her to make this important
decision. In all of the bereavement groups, members stated that they
looked forward eagerly to meetings and that between meetings they did
much thinking about each other.
 ·J

l 50 TH E y A L o ~1 R EA D ER

An important norm that we attempted to shape early in the life of

the groups was that the group accept responsibility for its own direction.
We noted in one group, for example, that our request during the first
meeting to have members list the expectations had not seemed produc-
tive or helpful, but no one had mentioned this. We raised questions
about group norms. Was there an unwritten rule not to criticize the
leaders? Does the group have the right to evaluate its own meetings?
This turned into a rather powerful intervention, as it evoked discus-
sion of a theme that was to recur in all of the bereavement groups: the
notion of "shoulds"-personal or perceived societal behavioral expecta-
tions. When we asked, "What are the 'shoulds' for behavior in this
group?" it led n1any members to reflect on the yoke of "shoulds" they
carry around in the outside life: One should grieve for a whole year, one
should quickly give away all of the spouse's belongings, one should not
be alone during the weekend. Identifying that invisible burden and rec-
ognizing their personal dominion over "shoulds" was a liberating expe-
rience for many members.
Seizing on this general theme, we took the opportunity to begin
some gentle here-and-now work by asking different members to iden-
tify their "shoulds'' for behavior in this group. For example, Mary, an
orderly and shy woman who had always subordinated herself to her
boisterous husband, felt concerned about taking up too much time in
the group whenever she spoke. In contrast, Bob, a gregarious, self-made
man, was burdened by the responsibility for keeping conversation going
in the group. And more than one person was concerned about losing
.1
control and sobbing in front of everyone in a meeting. We obtained I
feedback for each of these members and helped decatastrophize weep- i
L
ing: the box of Kleenex often made rounds <luring the meetings.
We were careful to spend time in these early sessions and in the sum- f
maries on process review. Not only did this allow us to examine unfin-
ished business or leftover feelings as early as the second meeting (for f
example, by asking what people had felt when they went home from
the first session), but it permitted us to begin identifying and clarifying r
themes that we saw emerging and th us to begin to establish an agenda
for later group work. t
By the fourth meeting, the groups had developed considerable cohe- I
 Group Therapy with Specialized Groups 151

siveness. Each individual member began to realize "I'm not alone."

(One member offered a foxhole analogy: "There may be a lot of heavy
bombardment and shelling going on out there, hut I'm comforted by
the presence of others in the foxhole who understand what I'm going
through.") Likewise, members began to appreciate the ubiquity of pain.
At the end of the second meeting, we asked members to bring in
photographs of themselves and their spouses-if possible, at least one
early picture (perhaps a wedding portrait) and also a more recent pic-
ture. In the third meeting, members showed their pictures to the group
and discussed them in any way they chose. \Ve gave no further instruc-
tions, other than to express the hope that this would permit each person
to be more fully known to the group.
The choice of pictures that were shown varied greatly. At one ex-
treme were the formal memorial pictures or ne\\'spaper clippings
brought in by widows who had idealized their husbands. At the other
extreme was the honeymoon picture taken on Coney Island in the
1940s, where an ebullient bride and her young groom posed behind
painted cardboard figures from the Old West. An 82-year-old widower
who had been mar ried for 53 years brought in five carefully chosen pic-
tures, one from each decade of his marriage. There were stiff black-
and-white photographs of young servicemen with their brides, favorite
pictures of a wife or husband dressed up for some special occasion, and
recent snapshots of families on vacation. Several people brought photos
with particular poignancy, in which the spouse "must have had the can-
cer already, but we didn't know it yet." And several brought pho-
tographs in which the spouse was clearly ill, "but fighting it." Some
members had a discussion with their children to help decide which pic-
tures to bring, while a couple of others repeatedly "forgot" to bring in
their pictures for several meetings.
The pictures not only increased the sense of group engagement, but
also served as a vehicle for self-disclosure. The t\VO members who ini-
tially forgot to bring in any photographs ultimately revealed through
them some important and heretofore hidden aspects of their spouse and
their marriage. One widower, who had found it difficult to tell the
group about his wife' s severe scoliosis, finally showed a photograph of
her and only then shared a great deal about how his wife's physical
 I 52 TH E y A LO M RE A DER

handicap had placed considerable restrictions upon their activities as a

couple. Another member, a young white man, had never mentioned to
the group that his wife was black and that being part of an interracial
couple had been a unique aspect of his marriage. Further, in the few
years prior to her death she had, to his great displeasure, grown obese; it
wasn't until he brought in pictures of her that this member was able to
discuss his difficult, complex feelings about his marriage. A third wid-
ower, a young man in his thirties who repeatedly missed meetings, was
very ambivalent about an affair he had started with his wife's best
friend immediately after his wife's death from breast cancer. It was not
until he showed the group a photograph of his wife together with her
friend that he felt able to discuss his situation openly.
No group can be successfully led simply by stringing together a se-
ries of structured exercises, and the picture-showing exercise is a case in
point. As powerful as it was, the success of this exercise varied widely.
In one group, the members spent the entire session sharing their feel-
ings about the photographs in great depth, while another group went
through the entire exercise somewhat mechanically in five minutes.
This latter group had, in general, been more reserved and, because of an
early dropout and initial attendance problems, had developed cohesion
more slowly. In retrospect, we should have waited until more trust de-
veloped in this group before introducing a task calling for such a high
level of disclosure.
Later Meetings By later meetings (sessions 5 to 7), the bereavement
groups were cohesive, bonded, and hard working. As leaders, our most
important task had become that of monitoring the time remaining in
the group and of anticipating termination. We consistently and explic-
itly reminded the group of its limited life span, noting after the fourth
session, for example, that the group was half over. We found it useful to
link time-marking with the concept of anticipated regret: "What re-
grets can you anticipate experiencing after this group is over? What
have you left unsaid or unasked? Would you be willing to act now to
avoid having those regrets later?" This powerful technique helped to
foster new behavior in the microcosm of the group and also stimulated
members to examine the more global issue of bereavement and regrets
in their outside lives. I·

I
I
 Group Therapy with Specialized Groups 153

The technique of "anticipated regret," combined with the impend-

ing end of the group, often provoked new self-disclosure, which now
began to reflect the less idealized, more problematic areas of individual
marriages: anger at the dead spouse and at oneself for things left unsaid
in the marriage; resentment over fixed, restrictive roles; guilt about new
or future relationships. For example, Nancy, a contentious wornan in
one of the groups, explicitly acknowledged her anger toward the insen-
sitivity of the widowers in the group who protested too much, she
thought, about the many single women who pursued them. Her anger
in the group permitted her to reexperie nce and to express her anger to-
ward her deceased husband for his neglect of her and for his relation-
ships with other women. John, a proud self-made man, became deeply
attached to the group, often referring to it as his family. At the final
meeting, he made a high-risk disclosure: that he was an orphan, and that
without his wife, the upcoming Christmas holidays were sure to evoke
painful memories of his childhood spent in orphanages and foster homes.
These sorts of revelations provided the opportunity for some gentle
here-and-now work in the group. As a general rule, group leaders can
enhance the group work by considering not only the content but the
process of deep self-disclosure-in other words, they can facilitate the
exploration of rnetadisclosures, or disclosure about the act of disclosure.
What was it like for John to reveal so much to us? What helped him de-
cide to trust us today? Why was he usually so reticent about his back-
ground? How did the others respond to his revelation? What feelings
did the men in group have when Nancy expressed anger toward them?
In this fashion, we encouraged members to think about their usual
mode of behaving in the group and to consider what part of their be-
havior might be shaped by preconceived expectations of other people's
reactions.
Many of the members, as we shall discuss shortly, expressed concerns
about their new identity as a widow or widower. They became a ware,
sometimes for the first time in 50 years, of being a single person, an "I"
rather than a "we." They had had to relinquish old familiar roles---of
husband or wife, of companion, of lover. We attempted to use some
structured exercises that would help members to clarify and to explore
this process. The first was a 30-minute exercise in meditative disidcnti-
 154 TH E YA LO M R EA OE R

fication (a method suggested to me by James Bugental).3 We asked each

member to write an answer to the question "Who are you?" on seven
cards, one answer per card (for example, answers might include "a
wife" or "a teacher" or "someone who loves music"). At our instruction,
members then arranged their seven cards from most peripheral to their
sense of identity to most central. We then asked the members to medi-
tate on each card, beginning with the most peripheral, and to imagine
giving up that attribute. We served as timekeepers and after two min-
utes signaled the members to move on to the next card. We completed
the exercise by reversing the procedure and reassuming each of these at-
tributes.
A second, simpler exercise, but with the same purpose, consisted of
asking members to pair up and then to spend several minutes having
one person in each dyad repeatedly ask the question "Who are you?"
while the other person supplied as many answers as possible. After sev-
eral minutes, the roles were reversed. As with all structured exercises,
the effectiveness of these two techniques was not in the tasks themselves
but in the feelings and thoughts evoked and subsequently expressed
during the discussion that followed each exercise.
In addition to concerns about their new identity, many members
were experiencing a crisis of life meaning. Marriage and the marital re-
lationship had heretofore supplied a major sense of purpose in life for
most group members. The loss of that relationship left many with a sense
of confusion and bewilderment about their values, goals, and life mis-
sions. We employed a simple structured exercise to focus the group's at-
tention upon this issue. During the sixth or seventh session, we set aside
15 minutes and asked each member to consider the things for which he
or she wished to be remembered and to compose his or her own obituary.
The obituaries were then read and discussed in the group.
Termination Groups have two tasks when termination approaches,
and the leaders must ensure that the group attends to each task. The first
is simply to deal with loss; this includes saying good-bye, acknowledging
the ending of the group, and facing other feelings evoked by termina-
tion. The second task is to anticipate and prevent regret-regret over
unfinished business and over work left undone in the group.
The first task-dealing with the termination of the group-raised
several issues for the bereaved spouses. With termination, many rnem-
 Group Therapy with Specialized Groups 155

hers became aware of the importance of intimacy. They experienced a

sense of relief from sharing their experiences with others during the
group sessions, and thus they became persuaded of the necessity of de-
veloping a nourishing source of friends and potential confidants in their
outside lives. For 1nany, of course, termination re-evoked feelings re-
lated to the loss of their husband or wife. W e reminded the group that
grieving consists of a long sequence in which the feelings of painful loss
must arise, again and again, be felt deeply, and then allowed to fade. To
avoid this cyclical resurfacing of pain and grief-through distracting ac-
tivity, through new relationships, or through workaholism or drugs-
would, in our view, only result in a delayed or distorted recovery.
The second task of termination-the anticipation and avoidance of
regret-is in fact a call to action and a call to the assumption of respon-
sibility. By urging members to leave no work undone and no feelings or
questions unexpressed, we urged them to take responsibility for making
themselves feel better in the future. This technique also kept the groups
working until the very last minute. Many members had considerable re-
gret that they had left important sentiments unexpressed in their mar-
riage. The group provided them with an opportunity to acknowledge
and to change that behavior.
Every group hates to die, and the bereavement groups were no ex-
ception. Members exchanged phone numbers and made plans for a re-
union or for continued leaderless meetings. In a therapy group, it is
appropriate for the leaders to interpret such reunions as denial and an
attempt to avoid the work of termination; in bereavement groups, how-
ever, there is evidence that long-term social involvement with other
members is salutary:' Consequently, we supported and encouraged
postrerrnination group meetings. All of the four groups had some subse-
quent socialization: one group scheduled a monthly evening meeting,
which continued for seven months, a second arranged several group
luncheons, and the others set up a reunion luncheon and occasional
meetings or phone contact between members.

Themes
The leaders of bereavement groups must he familiar not only with
specific therapeutic techniques, but also with the major problems in life
facing the bereaved. Only then can they help their members to identify,
 ••i•

I 56 TH E Y A LO ~1 R EA DER

explore, understand, and master the major tasks of bereavement. We

observed that certain themes emerged again and again in each of the be-
rcavcment groups, common threads that stood out against the more
complex background tapestry of the various idiosyncratic processes of
each group and each member. Before we examine these themes, let us
recall one common feature of our bereavement groups: every member's
spouse had died of cancer. Thus, the spouse's death had generally been
anticipated for at least several months, and in most cases, much antici-
patory grieving had occurred by the time of death.
A basic assumption of our approach was that two fundamental
stages occur during bereavement. The first-like the "fast pain" neu-
rologists describe-consists of initial shock, denial, and numbness, fol-
lowed by an acute sense of loss, a sharp, painful realization that one has
lost a partner and best friend. This is followed by a stage of "slow pain,"
a more insidious and resistant discomfort related to the series of en-
forced changes the bereaved spouse must undergo: changes in lifestyle,
in social role, in self-image. All of our group members had been be-
reaved from five to twelve months and were therefore struggling with
this second stage of bereavement and with its monumental implications
for their entire future life.
Loneliness and Aloneness Every bereaved individual suffers from
loneliness, and the members in our groups found themselves especially
impaired by the loss of the intimate moments they had been used to
sharing with their spouse. They noted that two levels of intimacy are
suddenly lost upon the spouse's death. First, the small, daily intimacies
of shared routines and private moments together disappear: one woman
spoke of how much she missed the "silly little activity" of eating dinner
in front of the TV and watching Monday Night Football with her hus-
band. Second, there is the loss of the more obvious larger intimacies: i.
family holidays, time spent with children and grandchildren, sexual and
romantic closeness. The loss of these latter activities is so self-evident I
J
that the bereaved person is in a sense prepared for them ahead of time, I
but it is the small moments that are not anticipated and it is there that t
the loneliness appears unexpectedly. Another group member, for exam-
ple, described her confrontation with a "5:00 to 7:00 syndrome," the
time of day she had picked her husband up at the train station after
I
•
 Group Therapy with Specialized Groups 157

work for the past fifteen years. C. S. Lewis gave an eloquent description
of this phenomenon: "It is just at those moments when I feel least sor-
row-getting into my morning hath is one of them-e-rhat H. rushes
upon my mind in her full realiry.?'
In making the transition from "we" to "I," group members also con-
fronted another kind of loneliness: that of no longer being the single
most important person in someone's life, nor of having a single signifi-
cant other with whom to share important experiences. For example, one
widower described his inability, when alone, to derive any pleasure
from a beautiful sunset or an entertaining movie; only in the prospect or
process of sharing the event ("Wait till I tell ... ") did the experience be-
come fully realized. It was as if the memory of experience could become
fastened to reality only if mediated through a significant other. Some
found it devastatingly painful to realize that no one was thinking of
them, observing them, a ware of their leaving or entering their house.
Other group members felt that much of their past history had died with
their spouses. After all, they had each lost the one person who knew
them over time, who shared the same memories.
Finally, being alone resulted in a radical change in social role for
most of the widows or widowers in our groups. Individuals who had
been part of a couple through most of adulthood were suddenly forced
to adapt to life as a single person. One woman spoke of going to a party
and with a flash realizing that she was single, that she could speak with
whomever she wanted, that she could decide to leave the party at any
time she pleased. The realization was bittersweet, for it was also clear
that there was no one looking out for her at the party and that ulti-
mately she would leave the party by herself.
This new single identity brought with it the sensation of being a fifth
wheel. The bereaved learn that it's a "couples world." TV programs,
travel excursions, restaurants, leisure activities are all oriented toward
the couple, not the single person. The bereaved at first are issued many
invitations to dinners and social functions, but gradually the invitations
decline; even couples who are old friends of the family appeared to
grow uncomfortable socializing with just one spouse. Many widows re-
ported that married couples experienced the presence of a single woman
as a threat to their marriage. Both widows and widowers found that
 158 THE YA LOM READER

others seemed awkward around them: friends didn't know what to say,
and do-gooders were often intrusive. One member spoke of writing a
book on her experiences entitled "Where Have All the People Gone?"
Freedom and Growth If the loss of the "we" results in loneliness
and disengagement from an established role and social network, the
emergence of the "I" carries with it an awareness of freedom and the po-
tential for change. Elsewhere we describe in detail the finding that ap-
proximately 25 percent of our subjects experience some type of personal
growth. Some group members derived a sense of inner strength from the
knowledge that they had faced deep loss and grief-and survived. Oth-
ers grew to respect themselves for the courage they displayed during the
illness and death of their spouses or in their ability to care for their chil-
dren during the bereavement. Still others dealt admirably with the expe-
rience of loneliness and change in social role we have described above
and gained strength from their ability to cope with such adversity.
Several widows also described a sense of liberation from a restrictive,
stunting marr iage. One woman marveled at the incredible feeling of in-
dependence and treedorn she felt in deciding what to watch on TV: she
could now watch all the PBS shows she wanted, something her husband
had never permitted. Others described a sense of being liberated from
schedules or tight routines. "I don't have to prepare full meals. I can
have popcorn for dinner!" Or, "I can come home anytime I wish." One
widower changed professions and took a job that his wife had always
said he couldn't handle well. Many of our group members began to take
first steps toward discovering their own autonomy and self-identity.
They started asking themselves, "What is it that I do? What do I en-
joy?" rather than "What should I be doing as a good wife?" or "What
should we do as a couple?" For those members who had been part of a
cou pie in which the deceased spouse had done all of the wishing or deci-
sion making in the family, there was a sudden new freedom of choice
that G11ne from having no one to please but oneself. Those members of a
couple who had been the audience to a spouse who had been the "appre-
ciator" (of art, music, natural beauty) had to undust and unpack long-
i
unused sensory organs. This new sense of self, exhilarating as it was, t
also carried a bittersweet tinge for most members. Although there were
several whose marriages had been so conflictual that they experienced
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 Group Therapy with Specialized Groups 159

unambivalent liberation, the overwhelming majority would have gladly

exchanged this newfound freedom for the resumption of their old life
with their spouse.
The Process of Change The host of new responsibilities and roles
forced upon the bereaved spouses obliged them to engage in behavior
that, for many, encouraged a process of personal change. Men suddenly
found themselves having to cook, clean, and care for a household;
women were confronted with many financial decisions or mechanical
repairs which their husbands used to manage. Many, for the first time,
had to face decisions alone. Even minor decisions, like the purchase of a
new toaster or television set, had far-reaching symbolic significance.
Some members made major changes in lifestyle. Four moved into new
homes, one to a new city, three began new jobs, and many embarked on
various home redecorating projects.
The process of change for many of the group members influenced
the decision to deal with the personal effects of the dead spouse. Painful
choices had to be made about the disposal of mementos, clothes, and
other personal belongings. For most of the widows and widowers, the
ability to face these choices and to dispose of personal effects implied an
acceptance of the spouse's death and acceptance of time's irreversibility.
For a few others, it felt like an act that dismissed or betrayed the past.
Not surprisingly, a whole range of behaviors and reactions occurred
around this process. Some group members made a clean break, moved
into a new house soon after their spouse's death, and disposed of most
personal items as quickly as possible. Others found the process painful,
but after several months, usually with the help of children, were able to
begin sorting through their spouse's belongings. Some derived special
comfort in giving away cherished items to another family member or to
a good friend who had known the spouse, while others experienced
deep pain at seeing others wear their spouse's clothes. Four members,
all with considerable unresolved grief, were completely unable to deal
with their spouse's personal effects. One had not changed a single item
in his house since his wife's funeral. Her favorite sheet music still stood
at the piano; her purse, with its complete contents, still hung from the
back of the same chair where she had placed it when she had come
home from the hospital to die, eight months earlier.
 1.
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160 TH E YA LO M RE A DER

Overall, members seemed to experience an inherent tension between

the process of change and a sense of devotion or love for the deceased
spouse. It was as if the very work of mourning, the letting go of one's
old life, the putting behind, the facing forward, the detaching of emo-
tional ties somehow represented a betrayal of the marital relationship.
The Theme of Time and Ritual Much group discussion centered
upon the proper length of time for the grieving process. Most members
wisely concluded that each person has his or her own rhythm to griev-
ing and recovery. Folk wisdom often posits one year as the proper time
for grief, and although members rejected any prescribed limits to grief,
many agreed that there was a kernel of truth in the one-year time
frame. Over the course of the first year of bereavement, they knew they
must face all of the major holidays and anniversaries without their
spouse. After passing once through this annual cycle successfully, many
described a sense of hope and survival: "If I made it through Christmas
or through all those memories associated with our wedding anniver-
sary, I can make it through anything." In addition, most members
agreed that the rituals of a funeral or scheduled services proved helpful
by providing structure and identifiable norms for behavior during the
first painful weeks of bereavement.
The Theme of New Relationships The formation of new relation-
ships was an important theme in all of the groups. Members wondered
when would be the proper time to begin seeking new relationships.
How would society view this behavior? How does one enter the single
world? The range of behavior among the members was very wide,
ranging from one young widower who had started an affair several
days after his wife's death to certain widows who declared that they
could not imagine ever getting involved with anyone else. Overall the
groups were deeply supportive to members who had formed new rela-
tionships and were effective in relieving guilt. Several members' re-
sponses to the issue of new relationships changed over the course of the
group. One quiet and traditional woman who had vehemently said she
could never be with another man announced at termination that she
had shifted her stance and had informed all her friends of her readiness
to begin dating.
The idea of loving someone new evoked a range of complex feelings
 Group Therapy with Specialized Groups 161

in our bereavement groups. Many people agreed that the desire for a
new intimate relationship signaled a kind of healing and a readiness to
move forward in life. Others felt that a new love relationship repre-
sented a betrayal of their marriage, as if loving someone new might
somehow diminish the love one had had for one's spouse. \Ve often
pointed out the fallacy of believing that love is a fixed commodity, of be-
lieving that only a specified amount of love is available for relationships.
Finally, there were several members, all widowers, who frantically
threw themselves into new romantic liaisons, as if trying to distract
themselves from the depth of their loss.
The issues of dating and relationships created a major line of cleav-
age between the men and women in our groups. Almost without excep-
tion, the men were far more driven to form new relationships and
seemed much less able to tolerate living alone. Seven of the ten men in
the study had re-paired before the end of the study (approximately one-
and-one-half years after bereavement), and two others were being ac-
tively pursued by women. The word "re-pair" is used here with double
entendre: though they paired quickly, we sensed that many of these
men had not truly repaired themselves. Some had formed relationships
so quickly-two within the first few weeks of bereavernenr-c-that they
had not yet accomplished the necessary work of mourning. In contrast,
of the twenty-six widows in the groups, only three had paired before the
end of the study. The- widows in general were hesitant to become ro-
mantically involved with someone new too soon and seemed anxious
about the idea of being pursued or, worse yet, being pursuers. The
change in social mores that permits women to be more aggressive in
dating was unsettling to many of the older widows, and many felt un-
certain about how to behave on even a simple dinner date. Because wid-
ows outnumber eligible widowers, and because widowers have
socioeconotnic advantages and often a greater potential for future par-
enthood, the widows in our group generally felt quite disadvantaged
and sometimes embittered as they faced future prospects for new rela-
tionships.
Existential Themes Some of our members expressed considerable
anger during group sessions. Often this anger was directed toward
physicians, particularly physicians who had missed the diagnosis or who
 162 THE Y ALO~I REA DER
l
had been insensitive to the needs of the patient or the family. Others
were aware of feeling angry toward their deceased spouse, generally be-
cause the spouse had shown persistent denial while ill or had refused to
express feelings openly in the final stages of life.
But there was also considerable anger that could not be focused-
anger at life, at destiny, at the unfairness of it all. Members became
painfully aware of the fragility of their assumptions and world views, as
they understood that the concept of justice, for example, is entirely hu-
man-made and human-serving. Many of the bereaved spouses reported
realizing for the first time that there is no justice out there in nature, no
rules that good will be rewarded and that working hard as a couple for
decades to ensure a comfortable retirement places no mandate upon life
to cooperate in such plans. Members struggled for some time with their
recognition of the existential facts of life-of the indifference of the uni-
verse, of the random and contingent world into which we are thrown,
of our own finiteness. For some, the dissolution of a belief in personal
omnipotence was a startling revelation. One very articulate young
woman described the experience of driving home from work and stop-
ping at a stoplight. She mused about what it would be like if her hus-
band were still alive; he could be crossing the street just in front of her.
She entered a familiar reverie in which she was certain that she could
will him back, that she could alter the past, and then suddenly reality
struck her with a terrible thud: she realized, and it was as though she re-
alized it for the first time, that time was irreversible, that all her wishing
and willing was not going to bring him back.
The death of the spouse confronted nearly all of the subjects with
their own mortaiity. A few members described increased fear-concern
about personal safety, fear of being alone, ghost fear, hypochondriacal
fears-but most used their increased awareness of personal death in a
positive way. They stated that an awareness of life's brevity meant that
they had to decide on what is important in life, what it means to seize
the moment, to live fully, to appreciate each present moment and not be
distracted by trivial concerns. Some described finally planning trips
they had always wanted to take; others began to indulge their children
and grandchildren, to buy things for themselves, to take up new hob-
bies. Now that they had learned the significance of words left unsaid or
 Group Therapy with Specialized Groups 163

pleasurable experiences missed, members expressed their newfound de-

sire to avoid future regrets and guilt for things not done or problems left
unsolved. The death of their spouses served in this manner to teach
them existential responsibility-that they, and only they, have ultimate
responsibility for their life and their happiness.

Conclusion
In our view, the groups were highly successful: the members were
deeply engaged, cohesion was high, n1any meetings were powerful, at-
tendance was excellent (approximately one person absent per meeting),
the groups displayed high levels of trust and self-disclosure, and only
two members dropped out of the groups. At the one-year follow-up all
but two members gave high testimonials to the group (one member, a
religious zealot, felt the groups were too secular, while the other had re-
married before the project began and considered many of the group
meetings irrelevant to her life situation).
In conclusion, we found that our most important role as group lead-
ers was to anticipate and facilitate a natural process of self-exploration
and change, either by staying out of the way of the free-flowing currents
of the bereavement groups or by serving as gentle midwives to themes
and concerns that emerged almost spontaneously during the course of
the group work. \Ve believe that if one is able to live with the living, one
can learn to live with the dead. Rather than dwelling on loss, pain, or
emotional catharsis, we found ourselves concentrating on growth, self-
knowledge, and existential responsibility. Rather than dealing with the
silence and loneliness of bereavement, we found ourselves working
where, in Tennyson's words, "the noise of life begins again."6
 PART II

EXISTENTIAL
PSYCHOTHERAPY
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 CHAPTER 4

The Four
Ultimate Concerns

INTRODUCTION

My text Existential Psychotherapy was four years in the writing. But be-
fore the writing I spent twice that long in the reading-all the while pro-
crastinating and doubting whether the project was within my ability. I
was jump-started one day while discussing my interminable reading pro-
gram with a friend, Alex Comfort, who was prodigiously adept at starting
and finishing books. (He wrote forty-five books, including novels; poetry;
works of philosophy, medicine, and gerontology; and the highly success-
ful Joy of Sex.) His advice was simple and liberating: "Stop reading; start
writing." I put penci I to paper (in those precomputer days) the very next
morning.
Existential Psychotherapy was a textbook for a course that did not yet
exist, delineating a professional discipline that was both amorphous and
controversial. The introduction to the book, part of which is included in
the following selection, gives an overview of the book that defines and
 168 THE YA LOM REA DER

discusses the field in terms of four deep, ever-present, and clinically rele-
vant ultimate concerns of human life.

EXISTENTIAL PSYCHOTHERAPY:
THE INTRODUCTION
Once, several years ago, some friends and I enrolled in a cooking class
taught by an Armenian matriarch and her aged servant. Since they
spoke no English and we no Armenian, communication was not easy.
She taught by demonstration; we watched (and diligently tried to quan-
tify her recipes) as she prepared an array of marvelous eggplant and
lamb dishes. But our recipes were imperfect; and, hard as we tried, we
could not duplicate her dishes. "What was it," I wondered, "that gave
her cooking that special touch?" The answer eluded me until one day,
when I was keeping a particularly keen watch on the kitchen proceed-
ings, I saw our teacher, with great dignity and deliberation, prepare a
dish. She handed it to her servant, who wordlessly carried it into the
kitchen to the oven and, without breaking stride, threw in handful after
handful of assorted spices and condiments. I am convinced that those
surreptitious "throw-ins" made all the difference.
That cooking class often comes to mind when I think about psy-
chotherapy, especially when I think about the critical ingredients of suc-
cessful therapy. Formal texts, journal articles, and lectures portray
therapy as precise and systematic, with carefully delineated stages,
strategic technical interventions, the methodical development and reso-
lution of transference, analysis of object relations, and a careful, rational
program of insight-offering interpretations. Yet I believe deeply that,
when no one is looking, the therapist throws in the "real thing."
But what are these "throw-ins," these elusive, off-the-record extras?
They exist outside of formal theory, they are not written about, they are
not explicitly taught. Therapists are often unaware of them; yet every
therapist knows that he or she cannot explain why n1any patients im-
prove. The critical ingredients are hard to describe, even harder to de-
fine. Indeed, is it possible to define and teach such qualities as
compassion, "presence," caring, extending oneself, touching the patient
at a profound level, or-that most elusive one of all-wisdom?
 The Four Ultimate Concerns 169

One of the first recorded cases of modern psychotherapy is highly il-

lustrative of how therapists selectively inattcnd to these extras.' (Later
descriptions of therapy are less useful in this regard because psychiatry
became so doctrinaire about the proper conduct of therapy that off-the-
record maneuvers were omitted from case reports.) In 1892, Sigmund
Freud successfully treated Fraulein Elisabeth von R., a young woman
who was suffering from psychogenic difficulties in walking. Freud ex-
plained his therapeutic success solely hy his technique of abreaction, of
de-repressing certain noxious wishes and thoughts. However, in study-
ing Freud's notes, one is struck by the vast number of his other thera-
peutic activities. For example, he sent Elisabeth to visit her sister's grave
and to pay a call upon a young man whom she found attractive. He
demonstrated a "friendly interest in her present circumstances": by
interacting with the family in the patient's behalf: he interviewed the
patient's mother and "begged" her to provide open channels of comrnu-
nication with the patient and to permit the patient to unburden her
mind periodically. Having learned [rom the mother that Elisabeth had
no possibility of marrying her dead sister's husband, he conveyed that
information to his patient. He helped untangle the family financial tan-
gle. At other times Freud urged Elisabeth to face with calmness the fact
that the future, for everyone, is inevitably uncertain. He repeatedly con-
soled her by assuring her that she was not responsible for unwanted
feelings, and pointed out that her degree of guilt and remorse for these
feelings was powerful evidence of her high moral character. Finally, af-
ter the termination of therapy, Freud, hearing that Elisabeth was going
to a private dance, procured an invitation so he could watch her "whirl
past in a lively dance." One cannot help but wonder what really helped
Fraulein von R. Freud's extras, I have no doubt, constituted powerful
interventions; to exclude them from theory is to court error.
It is my purpose in this book to propose and elucidate an approach to
psychotherapy-a theoretical structure and a series of techniques
emerging from that strucrure-c-which will provide a fr aruework for
many of the extras of therapy. The label for this approach, "existential
psychotherapy," defies succinct definition, for the underpinnings of the
existential orientation are not empirical but are deeply intuitive. I shall
begin by offering a formal definition, and then, throughout the rest of
this book, I shall elucidate that definition: Existential psychotherapy is a
 I 70 T HE Y /\ LO I\f R EA D ER

dynamic approach to therapy which focuses on concerns that are rooted in

the individual's existence.
It is n1y belief that the vast majority of experienced therapists, re-
gardless of their adherence to some other ideological school, employ
many of the existential insights I shall describe. The majority of thera-
pists realize, for example, that an apprehension of one's finiteness can
often catalyze a major inner shift of perspective, that it is the relation-
ship that heals, that patients are tormented by choice, that a therapist
must catalyze a patient's "will" to act, and that the majority of patients
are bedeviled by a lack of meaning in their lives.
But the existential approach is more than a subtle accent or an im-
plicit perspective that therapists unwittingly employ. Over the past sev-
eral years, when lecturing to psychotherapists on a variety of topics, I
have asked, "Who among you consider yourselves to be existentially ori-
ented?" A sizable proportion of the audience, generally over 50 percent,
respond affirmatively. But when these therapists are asked, .. What is the
existential approach?" they find it difficult to answer. The language
used by therapists to describe any therapeutic approach has never been
celebrated for its crispness or simple clarity; but, of all the therapy vo-
cabularies, none rivals the existential in vagueness and confusion. Ther-
apists associate the existential approach with such intrinsically imprecise
and apparently unrelated terms as "authenticity," "encounter," "respon-
sibility," "choice," "humanistic," "self-actualization," "centering,"
"Sartrean," and "Heideggerian"; and many mental health professionals
have long considered it a muddled, "soft," irrational, and romantic ori-
entation which, rather than being an "approach," offers a license for im-
provisation, for unclisci plined, woolly th era pis ts to "do their thing." I
hope to demonstrate that such conclusions are unwarranted, that the ex-
istential approach is a valuable, effective psychotherapeutic paradigm-
as rational, as coherent, and as systematic as any other.

Existential Therapy: A Dynamic Psychotherapy

Existential psychotherapy is a form of dynamic psychotherapy. "Dy-
narnic" is a term frequently used in the mental health field-as in "psy-
chodynamics"; and if one is to understand one of the basic features of the
 The Four Ultimate Concerns 171

existential approach, it is necessary to be clear about the meaning of dy-

namic therapy. "Dynamic" has both lay and technical meanings. In the
lay sense "dynamic" (deriving from the Greek dunasthl, "to have strength
or power") evokes energy and movement (a "dynamic" football player or
politician, "dynamo," "dynamite"): but this is not its technical sense for,
if it were, what therapist would own to being nondynamic-c-thar is,
slow, sluggish, stagnant, inert? No, the term has a specific technical use
that involves the concept of "force." Freud's major contribution to the
understanding of the human being is his dynamic model of mental func-
tioning-a model that posits that there are forces in conflict within the
individual, and that thought, emotion, and behavior, both adaptive and
psychopathological, are the resultant of these conflicting forces. Further-
more-and this is important-theseforces exist at varying levels of aware-
ness; some, indeed, are entirelv, unconscious.
The psychodynamics of an individual thus include the various un-
conscious and conscious forces, motives, and fears that operate within
him or her. The dynamic psychotherapies are therapies based upon this
dynamic model of mental functioning.
So far, so good. Existential therapy, as I shall describe it, fits comfort-
ably in the category of the dynamic therapies. But what if we ask,
Which forces (and fears and motives) are in conflict? What is the con-
tent of this internal conscious and unconscious struggle? It is at this
juncture that dynamic existential therapy parts company from the other
dynamic therapies. Existential therapy is based on a radically different
view of the specific forces, motives, and fears that interact in the indi-
vidual.
The precise nature of the deepest internal conflicts is never easy to
identify. The clinician working with a troubled patient is rarely able to
examine primal conflicts in pristine form. Instead, the patient harbors
an enormously complex set of concerns: the primary concerns are
deeply buried, encrusted with layer upon layer of repression, denial, dis-
placement, and symbolization. The clinical investigator must contend
with a clinical picture of many threads so matted together that disentan-
glement is difficult. To identify the primary conflicts, one must use
many avenues of access-deep reflection, dreams, nightmares, flashes
of profound experience and insight, psychotic utterances, and the study
 I
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172 THE YALOM READER

of children. I shall, in time, explore these avenues, but for now a stylized
schematic presentation may be helpful.

Existential Psychodynamics
The existential position emphasizes a conflict that flows from the indi-
vidual's confrontation with the givens of existence. And I mean by "givens"
of existence certain ultimate concerns, certain intrinsic properties that
are a part, and an inescapable part, of the human being's existence in the
world.
How does one discover the nature of these givens? In one sense the
task is not difficult. The method is deep personal reflection. The condi-
tions are simple: solitude, silence, time, and freedom from the everyday
distractions with which each of us fills his or her experiential world. If
we can brush away or "bracket" the everyday world, if we reflect deeply
upon our "situation" in the world, upon our existence, our boundaries,
our possibilities, if we arrive at the ground that underlies all other
ground, we invariably confront the givens of existence, the "deep struc-
tures," which I shall henceforth refer to as "ultimate concerns." This
process of reflection is often catalyzed by certain urgent experiences.
These "boundary," or "border," situations, as they are often referred
to, include such experiences as a confrontation with one's own death,
some major irreversible decision, or the collapse of some fundamental
meaning-providing schema.
This book deals with four ultimate concerns: death, freedom, isolation,
and meaninglessness. The individual's confrontation with each of these
facts of life constitutes the content of the existential dynamic conflict.
Death The most obvious, the most easily apprehended ultimate
concern is death. We exist now, but one day we shall cease to be. Death
will come, and there is no escape from it. It is a terrible truth, and we re-
spond to it with mortal terror. "Everything," in Spinoza's words, "en-
deavors to persist in its own being";' and a core existential conflict is the
tension between the awareness of the inevitability of death and the wish
to continue to be.
Freedom Another ultimate concern, a far less accessible one, is
freedom. Ordinarily we think of freedom as an unequivocally positive
concept. Throughout recorded history has not the human being

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 The Four Ultimate Concerns 173

yearned and striven for freedom? Yet freedom viewed from the per-
spective of ultimate ground is riveted to dread. In its existential sense
"freedom" refers to the absence of external structure. Contrary to eYery-
day experience, the human being does not enter (and leave) a well-struc-
tured universe that has an inherent design. Rather, the individual is
entirely responsible for-that is, is the author of-his or her own world,
life design, choices, and actions. "Freedom," in this sense, has a terrify-
ing implication: it means that beneath us there is no ground-nothing,
a void, an abyss. A key existential dynamic, then, is the clash between
our confrontation with groundlessness and our wish for ground and
structure.
Existential Isolation A third ultimate concern is isolation-not in-
terpersonal isolation with its attendant loneliness, or intrapersonal isola-
tion (isolation from parts of oneself), but a fundamental isolation-an
isolation both from creatures and from world-which cuts beneath
other isolation. No matter how close each of us becomes to another,
there remains a final, unbridgeable gap; each of us enters existence
alone and must depart from it alone. The existential conflict is thus the
tension between our awareness of our absolute isolation and our wish
for contact, for protection, our wish to be part of a larger whole.
Meaninglessness A fourth u1timate concern, or gi ven, of existence
is meaninglessness. If we must die, if we constitute our own world, if
each is ultimately alone in an indifferent universe, then what meaning
does life have? Why do we live? How shall we live? If there is no preor-
dained design for us, then each of us must construct our own meanings
in life. Yet can a meaning of one's own creation be sturdy enough to
bear one's life? This existential dynamic conflict stems from the
dilemma of a meaning-seeking creature who is thrown into a uni verse
that has no meaning.

The Existential Orientation:

Strange but Oddly Familiar
A great deal of my material on the ultimate concerns will appear
strange yet, in an odd way, familiar to the clinician. The material will
appear strange because the existential approach cuts across common cat-
 174 THE YALO~f READER

egories and clusters clinical observations in a novel manner. Further-

more, much of the vocabulary is different. Even if I avoid the jargon of
the professional philosopher and use commonsense terms to describe
existential concepts, the clinician will find the language psychologically
alien. Where is the psychotherapy lexicon that contains such terms as
"choice," "responsibility," "freedom," "existential isolation," "mortal-
ity," "purpose in life," "willing"? The medical library computers snick-
ered at me when I requested literature searches in these areas.
Yet the clinician will find in them much that is familiar. I believe
that the experienced clinician often operates implicitly within an exis-
tential framework: "in his bones" he appreciates a patient's concerns
and responds accordingly. That response is what I meant earlier by the
crucial "throw-ins." A major task of this book is to shift the therapist's
focus, to attend carefully to these vital concerns and to the therapeutic
transactions that occur on the periphery of formal therapy, and to place
them where they belong-in the center of the therapeutic arena.
Another familiar note is that the major existential concerns have
been recognized and discussed since the beginning of written thought,
and that their primacy has been recognized by an unbroken stream of
philosophers, theologians, and poets. That fact may offend our sense of
pride in modernism, our sense of an eternal spiral of progress; but from
another perspective, we may feel reassured to travel a well-worn path
trailing back into time, hewed by the wisest and the most thoughtful of
individuals.
These existential sources of dread are familiar, too, in that they are
the experience of the therapist as Everyman; they are by no means the
exclusive province of the psychologically troubled individual. Repeat-
edly, I shall stress that they are part of the human condition. How then,
one may ask, can a theory of psychopathology" rest on factors that are
experienced by every individual? The answer, of course, is that each
person experiences the stress of the human condition in highly individ-
ualized fashion.
In fact, only the universality of human sufTering can account for the

"In this discussion, as elsewhere, I refer to psychologically based distur-

bance, not to the major psychoses with a fundamental biochemical origin.
 The Four Ultimate Concerns 175

cornmon observation that patienthood is ubiquitous. Andre Malraux, to

cite one such observation, once asked a parish priest who had been tak-
ing confession for fifty years what he had learned about mankind. The
priest replied, "First of all, people are much more unhappy than one
thinks ... and then the fundamental fact is that there is no such thing as
a grown-up person.": Often it is only external circumstances that result
in one person, and not another, being labeled a patient: for example, fi-
nancial resources, availability of psychotherapists, personal and cultural
attitudes toward therapy, or choice of profession-the majority of psy-
chotherapists becorne themselves bona fide patients. The universality of
stress is one of the major reasons that scholars encounter such difficulty
when attempting to define and describe normality: the difference be-
tween normality and pathology is quantitative, not qualitative.
The contemporary model that seems most consistent with the evi-
dence is analogous to a model in physical medicine that suggests that in-
fectious disease is not simply a result of a bacterial or a viral agent
invading an undefended body. Rather, disease is a result of a disequilib-
rium between the noxious agent and host resistance. In other words,
noxious agents exist within the body at all times-just as stresses, insep-
arable from living, confront all individuals. Whether an individual de-
velops clinical disease depends on the body's resistance (that is, such
factors as immunological system, nutrition, and fatigue) to the agent:
when resistance is lowered, disease develops, even though the toxicity
and the virility of the noxious agent are unchanged. Thus, all human
beings are in a quandary, but some are unable to cope with it: psy-
chopathology depends not merely on the presence or the absence of
stress but on the interaction between ubiquitous stress and the individ-
ual's mechanisms of defense.
The claim that the ultimate existential concerns never arise in ther-
apy is entirely a function of a therapist's selective inattention: a listener
tuned in to the proper channel finds explicit and abundant material. A
therapist may choose, however, not to attend to the existential ultimate
concerns precisely because they are universal experiences, and therefore
nothing constructive can come from exploring them, Indeed, I have of-
ten noted in clinical work that when existential concerns are broached,
the therapist and the patient are intensely energized for a short while;
 176 TH E YA LO :-.·t R EA DER

but soon the discussion becomes desultory, and the patient and therapist
seem to say tacitly, "Well that's life, isn't it! Let's move on to something
neurotic, something we can do something about!"
Other therapists veer away from dealing with existential concerns
not only because these concerns are universal but because they are too
terrible to face. After all, neurotic patients (and therapists, too) have
enough to worry about without adding such cheery items as death and
meaninglessness. Such therapists believe that existential issues are best
ignored, since there are only two ways to deal with the brutal existential
facts of life-anxious truth or denial-and either is unpalatable. Cer-
vantes voiced this problem when his immortal Don said, "Which would
you have, wise madness or foolish sanity?"
An existential therapeutic position, as I shall attempt to demonstrate
in later chapters, rejects this dilemma, Wisdom does not lead to mad-
ness, nor denial to sanity: the confrontation with the givens of existence
is painful but ultimately healing. Good therapeutic work is always cou-
pled with reality testing and the search for personal enlightenment; the
therapist who decides that certain aspects of reality and truth are to be
eschewed is on treacherous ground. Thomas Hardy's comment, "if a
\vay to the Better there be, it exacts a full look at the Worst," is a good
frame for the therapeutic approach I shall describe.

The Field of Existential Psychotherapy

Existential psychotherapy is rather a homeless waif. It does not really
"belong" anywhere. It has no homestead, no formal school, no institu-
tion; it is not welcomed into the better academic neighborhoods. It has
no formal society, no robust journal (a few sickly offspring were carried
away in their infancy), no stable family, no paterfamilias. It does, how-
ever. have a genealogy, a few scattered cousins, and friends of the fam-
ily, some in the old country, some in America.

!:'xi.,·tential Philosophy: The Ancestral Home

"Existennalism is not easily definable." So begins the discussion of
existential philosophy in philosophy's major contemporary encyclope-
dia.1' ~:lost other reference works begin in similar fashion and under-
score the fact that two philosophers both labeled "existential" may

i
 The Four Ultimate Concerns 177

disagree on every cardinal point (aside from their shared aversion to be-
ing so labeled). Most philosophical texts resolve the problem of defini-
tion by listing a number of themes relating to existence (for example,
being, choice, freedom, death, isolation, absurdity), and by proclaiming
that an existential philosopher is one whose work is dedicated to explor-
ing them. (This is, of course, the strategy I use to identify the field of ex-
istential psychotherapy.)
There is an existential "tradition" in philosophy and a formal exis-
tential "school" of philosophy. Obviously the existential tradition is age-
less. What great thinker has not at some point in both work and life
turned his or her attention to life and death issues? The formal school of
existential philosophy, however, has a clearly demarcated beginning.
Some trace it to a Sunday afternoon in 1834, when a young Dane sat in a
cafe smoking a cigar and mused upon the fact that he was on his way to
becoming an old man without having made a contribution to the world.
He thought about his rnany successful friends:

... benefactors of the age who know how to benefit mankind by

making life easier and easier, some by railways, others by om-
nibuses and steamboats, others by telegraph, others by easily appre-
hended compendiums and short recitals of everything worth
knowing, and finally the true benefactors of the age who by virtue
of thought make spiritual existence systematically easier and easier."

His cigar burned out. The young Dane, Soren Kierkegaard, lit an-
other and continued musing. Suddenly there flashed in his mind this
thought:

You must do something but inasmuch as with your limited capaci-

ties it will be impossible to make anything easier than it has become,
you must, with the same humanitarian enthusiasm as the others,
undertake to make something harder.'

He reasoned that when all combine to make everything easier, then

there is a danger that easiness will be excessive. Perhaps someone is
needed to make things difficult again. It occurred to him that he had
 1 78 THE YA LO ~vi RE ADER

discovered his destiny: he was to go in search of difficulties-like a new

Socrates." And which difficulties? They were not hard to find. He had
only to consider his own situation in existence, his own dread, his
choices, his possibilities and limitations.
Kierkegaard devoted the remainder of his short life to exploring his
existential situation and during the 184os published several important
existential treatises. His work remained untranslated for many years
and exerted little influence until after the First World War, when it
found fertile soil and was taken up by Martin Heidegger and Karl
Jaspers.
The relation of existential therapy to the existential school of philos-
ophy is much like that of clinical pharmacotherapy to biochemical
bench research. I shall frequently draw upon philosophical works to ex-
plicate, corroborate, or illustrate some of the clinical issues; but it is not
my intention (nor within my range of scholarship) to discuss in a com-
prehensive fashion the works of any philosopher or the major tenets of
existential philosophy. This is a book for clinicians, and I mean it to be
clinically useful. My excursions into philosophy will be brief and prag-
matic; I shall limit myself to those domains that offer leverage in clinical
work. I cannot blame the professional philosopher who may liken me to
the Viking raider who grabbed gemstones while leaving behind their
intricate and precious settings.
As the education of the great majority of psychotherapists includes
little or no emphasis on philosophy, I shall not assume any philosophical
background in my readers. When I do draw upon philosophical texts, I
shall attempt to do so in a straightforward, jargon-free fashion-not an I
easy task, incidentally, since professional existential philosophers sur- .!
pass even psychoanalytic theoreticians in the use of turbid, convoluted
language. The single most important philosophical text in the field,
Heidegger's Being and Time, stands alone as the undisputed champion
of linguistic obfuscation.
I have never understood the reason for the impenetrable deep-
sounding language. The basic existential concepts themselves are not
complex; they do not need to be uncoded and meticulously analyzed as
much as they need to be uncovered. Every person, at some point in life,
enters a "brown study" and has some traffic with existential ultimate

,..
 The Four Ultimate Concerns 179

concerns. What is required is not fonnal explication: the task of the

philosopher, and of the therapist as well, is to de-repress, to reacquaint
the individual with something he or she has known all along. This is
precisely the reason that 1nany of the leading existential thinkers (for ex-
ample, Jean-Paul Sartre, Albert Camus, Miguel de Unamuno, Martin
Buber) prefer literary exposition rather than formal philosophical argu-
ment. Above all, the philosopher and the therapist must encourage the
individual to look within and to attend to his or her existential situation.

Existential Therapy and the Academic Community

Earlier I likened existential therapy to a homeless waif who was not per-
mitted into the better academic neighborhoods. The lack of academic
support from academic psychiatry and psychology has significant impli-
cations for the field of existential therapy, since academically dominated
institutions control all the vital supply routes that influence the develop-
ment of the clinical disciplines: the training of clinicians and academi-
cians, research funding, licensure, and journal publication.
It is worth taking a moment to consider why the existential approach
is so quarantined by the academic establishment, The answer centers
primarily on the issue of the basis of knowledge-that is, how do we
know what we know? Academic psychiatry and psychology, grounded
in a positivist tradition, value empirical research as the method of vali-
dating knowledge.
Consider the typical career of the academician (and I speak not only
from observation but from my own twenty-year academic career): the
young lecturer or assistant professor is hired because he or she displays
aptitude and motivation for empirical research, and later is rewarded
and promoted for carefully and methodically performed research. The
crucial tenure decision is made on the basis of the amount of empirical
research published in refereed scientific journals. Other factors, such as
teaching skills or nonempirical books, book chapters, and essays, are
given decidedly secondary consideration.
It is extraordinarily difficult for a scholar to carve out an academic
career based upon an empirical investigation of existential issues. The
basic tenets of existential therapy are such that empirical research mcth-
 j

180 THE Y ALO M R EADER

ods are often inapplicable or inappropriate. For example, the empirical

research method requires that the investigator study a complex organ-
ism by breaking it down into its component parts, each simple enough
to permit empirical investigation. Yet this fundamental principle
negates a basic existential principle. A story told by Viktor Frankl is il-
lustrative."
Two neighbors were involved in a bitter dispute. One claimed that
the other's cat had eaten his butter and, accordingly, demanded com-
pensation. Unable to resolve the problem, the two, carrying the accused
cat, sought out the village wise man for a judgment. The wise man
asked the accuser, "How much butter did the cat eat?" "Ten pounds',
was the response. The wise man placed the cat on the scale. Lo and be-
hold! It weighed exactly ten pounds. "Mirabile dictu ! " he proclaimed.
"Here we have the butter. But where is the cat?"
Where is the cat? All the parts taken together do not reconstruct the
creature. A fundamental humanistic credo is that "man is greater than
the sum of his parts." No matter how carefully one understands the
composite parts of the mind-for example, the conscious and the un-
conscious, the superego, the ego, and the id--one still does not grasp the
central vital agency, the person whose unconscious (or superego or id or
ego) it is. Furthermore, the empirical approach never helps one to learn
the meaning of chis psychic structure to the person who possesses it.
Meaning can never be obtained from a study of component parts, be-
cause meaning is never caused; it is created by a person who is supraor-
dinate to all his parts.
But there is in the existential approach a problem for empirical re-
search even more fundamental than the one of "Where is the cat?"
Rollo May alluded to it when he defined existentialism as "the endeavor
to understand man by cutting below the cleavage between subject and
object which has bedeviled Western thought and science since shortly
after the Renaissance."?' The "cleavage between subject and object"-
let us take a closer look at that. The existential position challenges the
traditional Cartesian view of a world full of objects and of subjects who
perceive those objects. Obviously, chis is the basic premise of the scien-
tific method: there are objects with a finite set of properties that can be
understood through objective investigation. The existential position

·~ ..
 The Four Ultimate Concerns 181

cuts below this subject-object cleavage and regards the person not as a
subject who can, under the proper circumstances, perceive external re-
ality but as a consciousness who participates in the construction of real-
ity. To emphasize this point, Heidegger always spoke of the human
being as dasein. Da C'there") refers to the fact that the person is there, is a
constituted object (an "em pirical ego"), but at the same time constitutes
the world (that is, is a "transcendental ego"). Dasein is at once the mean-
ing giver and the known. Each dasein therefore constitutes its own
world; to study all beings with some standard instrument as though
they inhabited the same objective world is to introduce monumental er-
ror into one's observations.
It is important to keep in mind, however, that the limitations of em-
pirical psychotherapy research are not confined to an existential orienta-
tion in therapy; it is only that they are more explicit in the existential
approach. Insofar as therapy is a deeply personal, human experience,
the empirical study of psychotherapy of any ideological school will con-
tain errors and be of limited value. It is common knowledge that psy-
chotherapy research has had, in its thirty-year history, little impact upon
the practice of therapy. In fact, as Carl Rogers, the founding father of
empirical psychotherapy research, sadly noted, not even psychotherapy
researchers take their research findings seriously enough to alter their
approach to psychotherapy. 'l
What is the alternative to an empirical approach? The proper
method of understanding the inner world of another individual is the
"phenomenological" one, to go directly to the phenomena themselves,
to encounter the other without "standardized" instruments and presup-
positions. So far as possible one must "bracket" one's own world per-
spective and enter the experiential world of the other. Such an approach
to knowing another person is eminently feasible in psychotherapy:
every good therapist tries to relate to the patient in this manner. That is
what is meant by empathy, presence, genuine listening, nonjudgmental
acceptance, or an attitude of "disciplined na'ivety"-to use May's felici-
tous phrase." Existential therapists have always urged that the therapist
attempt to understand the private world of the patient rather than to fo-
cus on the way the patient has deviated fron1 the "norms."
I have attempted to write this book in a style sufficiently lucid and
 182 THE Y ALOM READER

free of jargon that it will be intelligible to the lay reader. However, the
primary audience for whom I intend it is the student and the practicing
psychotherapist. It is important to note that, even though I assume for
my reader no formal philosophical education, I do assume some clinical
background. I do not mean this to be a "first" or a complete psychother-
apy text but expect the reader to be familiar with conventional clinical
explanatory systems. Hence, when I describe clinical phenomena from
an existential frame of reference, I do not always offer alternate modes
of explanation for them. My task, as I view it, is to describe a coherent
psychotherapy approach based on existential concerns which gives an
explicit place to the procedures that the majority of therapists em ploy
i m pl i c i ti y .
I do not pretend to describe the theory of psychopathology and psy-
chotherapy. Instead, I present a paradigm, a psychological construct,
that offers the clinician a system of explanation-a system that permits
him or her to make sense out of a large array of clinical data and to for-
mulate a systematic strategy of psychotherapy. It is a paradigm that has
considerable explanatory power; it is parsimonious (that is, it rests on
relatively few basic assumptions) and it is accessible (that is, the assump-
tions rest on experiences that may be intuitively perceived by every
introspective individual). Furthermore, it is a humanistically based par-
adigrn, consonant with the deeply human nature of the therapeutic
enterprrse.
But it is a paradigm, not the paradigm-useful for some patients, not
for all patients; employable by some therapists, not by all therapists. The
existential orientation is one clinical approach among other approaches.
It repattcrns clinical data but, like other paradigms, has no exclusive
hegemony and is not capable of explaining all behavior. The human be-
ing has too much complexity and possibility to permit that it do so.
Existence is inexorably free and, thus, uncertain. Cultural institu-
tions and psychological constructs often obscure this state of affairs,
but confrontation with one's existential situation reminds one that
paradigms are self-created, wafer-thin barriers against the pain of un-
certainty. The mature therapist must, in the existential theoretical ap-
proach as in any other, be able to tolerate this fundamental uncertainty.
 CHAPTER 5

Death, Anxiety, and

Psychotherapy

INTRODUCTION

Existential Psychotherapy is divided into four sections, each of which ex-

plores, from a clinical perspective, one of the core existential concerns-
death, freedom, isolation, and meaning in life. This chapter excerpts
what is perhaps the most fundamental and most important section of the
work-the discussion of death and its implications for psychopathology
and psychotherapy.

DEATH
[Let us explore] the role played by the concept of death in psychopathol-
ogy and psychotherapy. The basic postulates I describe arc simple:

1. The fear of death plays a major role in our internal experience; it

haunts as does nothing else; it rumbles continuously under the
 I 84 TH E YA LO M R E A DER

surface; it is a dark, unsettling presence at the rim of

consciousness.

2. The child, at an early age, is pervasively preoccupied with death,

and his or her major developmental task is to deal with terrifying
fears of obliteration.

3. To cope with these fears, we erect defenses against death

awareness, defenses that are based on denial, that shape character
structure, and that, if maladaptive, result in clinical syndromes.
In other words, psychopathology is the result of ineffective
modes of death transcendence.

+ Lastly, a robust and effective approach to psychotherapy rnay be

constructed on the foundation of death awareness.

LIFE, DEA TH, AND ANXIETY

"Don't scratch where it doesn't itch," the great Adolph Meyer counseled
a generation of student psychiatrists. Is that adage not an excellent ar-
1

gument against investigating patients' attitudes toward death? Do not

patients have quite enough fear and quite enough dread without the
therapist reminding them of the grimmest of life's horrors? Why focus
on bitter and immutable reality? If the goal of therapy is to instill hope,
why invoke hope-defeating death? The aim of therapy is to help the in-
dividual learn how to live. Why not leave death for the dying?
These arguments demand a response, and I shall address them in
this chapter by arguing that death itches all the time, that our attitudes
toward death influence the way we live and grow and the way we falter
and foll ill. I shall examine two basic propositions, each of which has
major implications for the practice of psychotherapy:

r. Life and death are interdependent; they exist simultaneously, not

consecutively; death whirs continuously beneath the membrane
of life and exerts a vast influence upon experience and conduct.

l
....J·
I
 Death, Anxiety, and Psychotherapy 185

2. Death is a primordial source of anxiety and, as such, is the

primary fount of psychopathology.

Life-Death Interdependence
A venerable line of thought, stretching back to the beginning of written
thought, emphasizes the interdigitation of life and death. It is one of
life's most self-evident truths that everything fades, that we fear the fad-
ing, and that we must live, nonetheless, in the face of the fading, in the
face of the fear. Death, the Stoics said, is the most important event in
life. Learning to live well is to learn to die well; and conversely, learning
to die well is to learn to live well. Cicero said, "To philosophize is to
prepare for death.?' and Seneca: "No man enjoys the true taste of life
but he who is willing and ready to quit it.": Saint Augustine expressed
the same idea: "It is only in the face of death that man's self is born."!
It is not possible to leave death to the dying. The biological life-death
boundary is relatively precise; but, psychologically, life and death merge
into each other. Death is a fact of life; a moment's reflection tells us that
death is not simply the last moment of life. "Even in birth we die; the
end is there from the start," Manilius said.5 Montaigne, in his penetrat-
ing essay on death, asked, "Why do you fear your last day? It con-
tributes no more to your death than each of the others. The last step
does not cause the fatigue, but reveals it."?
Virtually every great thinker (generally early in life or toward its
end) has thought deeply and written about death; and many have con-
cluded that death is inextricably a part of life, and that lifelong consider-
ation of death enriches rather than impoverishes life. Although the
physicality of death destroys man, the idea of death saves him.
This last thought is so important that it bears repeating: although the
physicality of death destroys man, the idea of death saves him. But what
precisely does this statement mean? How does the idea of death save
man? And save him from what?
A brief look at a core concept of existential philosophy rnay provide
clarification. Martin Heidegger, in 1926, explored how the idea of death
may save man, and arrived at the important insight that the awareness
 1 86 TH E YA LO M REA DER

of our personal death acts as a spur to shift us from one mode of exis-
tence to a higher one. Heidegger believed that there are two f undamen-
ral modes of existing in the world: (r) a state of forgetfulness of being or
(2) a state of mindfulness of being.'
When one lives in a state of [orgetfulncss of being, one lives in the
world of things and immerses oneself in the everyday diversions of life:
One is "leveled down," absorbed in "idle chatter," lost in the "they."
One surrenders oneself to the everyday world, to a concern about the
way things are.
In the other state, the state of mindfulnessof being, one marvels not
,
.I

about the way things are but that they are. To exist in this mode means
to be continually aware of being. In this mode, which is often referred to
as the "ontological mode" (from the Greek ontos, meaning "existence"),
one remains mindful of being, not only mindful of the fragility of being
but mindful, too, of one's responsibility for one's own being. Since it
is only in this ontological mode that one is in touch with one's self-
creation, it is only here that one can grasp the power to change oneself.
Ordinarily one lives in the first state. Forgetfulness of being is the
everyday mode of existence. Heidegger refers to it as "inauthentic"-a
mode in which one is unaware of one's authorship of one's life and
world, in which one "flees," "falls," and is tranquilized, in which one
avoids choices by being "carried along by the nobody."~ When, however,
one enters the second mode of being (mindfulness of being), one exists
authentically (hence, the frequent modern use of the term "authentic-
ity" in psychology). In this state, one becomes fully self-aware-aware
of oneself as a transcendental (constituting) ego as we11 as an empirical
(constituted) ego; one embraces one's possibilities and limits; one faces
,,

absolute freedorn and nothingness-and is anxious in the face of them. !

Now, what does death have to do with all this? Heidegger realized
that one doesn't move from a state of forgetfulness of being to a more
enlightened, anxious mindfulness of being by simple contemplation, by
bearing down, by gritting one's teeth. There are certain unalterable, ir-
remediable conditions, certain "urgent experiences" that jolt one, that
tug one from the first, everyday, state of existence to the state of mind-
fulness of being. Of these urgent experiences (Jaspers later referred to
them as "border" or "boundary" or "limit" situations)," death is the non-
 Death, Anxiety, and Psychotherapy 187

pareil: death is the condition that makes it possible for us to live life in an au-
thentic fashion.
This point of view-that death makes a positive contribution to
life-is not one easily accepted. Generally we view death as such an un-
mitigated evil that we dismiss any contrary view as an implausible joke.
We can manage quite well without the plague, thank you.
But suspend judgrnent for a moment and imagine life without any
thought of death. Life loses sornething of its intensity. Life shrinks
when death is denied. Freud, who for reasons I shall discuss shortly
spoke little of death, believed that the transience of life augments our
joy in it. "Limitation in the possibility of an enjoyment raises the value
of the enjoyment." Freud, writing during the First World War, said
that the lure of war was that it brought death into life once again: "Life
has, indeed, become interesting again; it has recovered its full content.'?"
When death is excluded, when one loses sight of the stakes involved, life
becomes impoverished. It is turned into something, Freud wrote, "as
shallow and empty as, let us say, an American flirtation, in which it is
understood from the first that nothing is to happen, as contrasted with a
continental love-affair in which both partners must constantly bear its
serious consequences in mind.'!"
Many have speculated that the absence of the fact of death, as well as
of the idea of death, would result in the same blunting of one's sensibili-
ties to life. For example, Montaigne imagines a conversation in which
Chiron, half-god, half-mortal, refuses immortality when his father, Sat-
urn (the god of time and duration), describes the implications of the
choice:

Imagine honestly how much less bearable and more painful to man
would be an everlasting life than the life I have given him. If you
did not have death, you would curse me incessantly for having de-
prived you of it. I have deliberately mixed with it a little bitterness
to keep you, seeing the convenience of it, from embracing it too
greedily and intemperately. To lodge you in the moderate state that
I ask of you, of neither fleeing life nor fleeing back from death, I
have tempered both of them between sweetness and bitterness."
 I 88 T HE YA LO M R EA D E R

I do not wish to advocate a life-denying morbidity. But it must not

be forgotten that our basic dilemma is that each of us is both angel and
beast of the field; we are the mortal creatures who, because we are self-
aware, know that we are mortal, A denial of death at any level is a de-
nial of one's basic nature and begets an increasingly pervasive restriction
of awareness and experience. The integration of the idea of death saves
us; rather than sentence us to existences of terror or bleak pessimism, it
acts as a catalyst to plunge us into more authentic life modes, and it en-
hances our pleasure in the living of life. As corroboration we have the
testimony of individuals who have had a personal confrontation with
death.

Confrontation with Death: Personal Change

Some of our greatest literary works have portrayed the positive ef-
fects on an individual of a close encounter with death.
Tolstoy's ~Var and Peace provides an excellent illustration of how
death may instigate a radical personal change." Pierre, the protagonist,
feels deadened by the meaningless, empty life of the Russian aristocracy.
A lost soul, he stumbles through the first nine hundred pages of the
novel searching for some purpose in life. The pivotal point of the book
occurs when Pierre is captured by Napoleon's troops and sentenced to
death by firing squad. Sixth in line, he watches the execution of the five
men in front of him and prepares to die--only, at the last moment, to be
unexpectedly reprieved. The experience transforms Pierre, who then
spends the remaining three hundred pages of the novel living his life
zestfully and purposefully. He is able to give himself fully in his rela-
tionships to others, to be keenly aware of his natural surroundings, to
discover a task in life that has meaning for him, and to dedicate himself
to It.
Tolstoy's story "The Death of Ivan Ilych" contains a similar mes-
sage." Ivan Ilych, a mean-spirited bureaucrat, develops a fatal illness,
probably abdominal cancer, and suffers extraordinary pain. His anguish
continues relentlessly until, shortly before his death, Ivan Ilych comes
upon a stunning truth: he is dying badly because he has lived badly. In the
few days remaining to him, I van Ilych undergoes a dramatic transfer-
mation that is difficult to describe in any other terms than personal
 Death, Anxiety, and Psychotherapy 189

growth. If Ivan Ilych were a patient, any psychotherapist would beam

with pride at the changes in him: he relates more empathica.,, to others;
his chronic bitterness, arrogance, and self-aggrandizement disappear.
In short, in the last few days of his life he achieves a far higher level of
integration than he has ever reached previously.
This phenomenon occurs with great frequency in the world of the
clinician. For example, interviews with six of the ten would-be suicides
who leaped off the Golden Gate Bridge and survived indicate that, as a
1'
result of their leap into death, these six had changed their views of life.
One reported, "My will to live has taken over. ... There is a benevolent
God in heaven who permeates all things in the universe." Another: "We
are all members of the Godhead-that great God humanity." Another:
"I have a strong life drive now ~1y whole life is reborn .... I have
broken out of old pathways I can now sense other people's exis-
tence." Another: "I feel I love God now and wish to do something for
others." Another:

I was refilled with a new hope and purpose in being alive. It's be-
yond most people's comprehension. I appreciate the miracle of
life-like watchinga bird fly--everything is more meaningful
when you come close to losing it. I experienced a feeling of unity
with all things and a oneness with all people. After rny psychic re-
birth I also feel for everyone's pain. Everything was clear and
bright.

Russell Naves studied two hundred individuals who had near-death

"
experiences (automobile accidents, drownings, mountain climbing falls,
and so forth), and reported that a substantial number (23 percent) de-
scribed, even years later, that as a result of their experience they pos-
sessed a

strong sense of the shortness of life and the preciousness of it ... a

greater sense of zest in life, a heightening of perception and erno-
tional responsivity to immediate surroundings ... an ability to live
in the moment and to savor each moment as it passes ... a greater
 I 90 TH E YA LO M R EA DER

awareness of life-awareness of life and living things and the urge

to enjoy it now before it is too late."

Many described a "reassessment of priorities," of becoming more com-

passionate and more human-oriented than they had been before.
Cancer: Confrontation with Death. The Chinese pictogram for
"crisis" is a combination of two symbols: "danger" and "opportunity."
Over my 1nany years of work with terminally ill cancer patients, I have
been struck by how many of them use their crisis and their danger as an
opportunity for change. They report startling shifts, inner changes that
can be characterized in no other way than "personal growth":

• A rearrangement of life's priorities: a trivializing of the trivial

• A sense of liberation: being able to choose not to do those things

that they do not wish to do

• An enhanced sense of livinj; 10 the immediate present, rather

than postponing life until retirement or some other point in the
future

• A vivid appreciation of the elemental facts of life: the changing

seasons. the wind, falling leaves, the last Christmas, and so forth

• Deeper communication with loved ones than before the crisis

• Fewer interpersonal fears, less concern about rejection, greater

willingness to take risks, than before the crisis.

An unusual confrontation with death afforded a turning point in the .l

life of Arthur, an alcoholic patient. The patient had had a progressive
downhill course. He had been drinking heavily for several years and
had had no periods of sobriety sufficiently long to permit effective psy-
I
1

chotherapeutic contact. He entered a therapy group and one day came

to the session so intoxicated that he passed out. The group, with Arthur
 Death, Anxiety, and Psychotherapy 191

unconscious on the couch, continued their meeting, discussed what to

do with Arthur, and finally carried him bodily from the session to the
hospital.
Fortunately the session was videotaped; and later, when Arthur
watched the videotape, he had a profound confrontation with death.
Everyone had been telling him for years he was drinking himself to
death; but until he saw the videotape, he never truly allowed that possi-
bility to register. The videotape of himself stretched out on the couch,
with the group surrounding his body and talking about him, bore an
uncanny resemblance to the funeral of his twin brother who had died of
alcoholism a year previously. He visualized himself at his own wake
stretched out on a slab and surrounded by friends talking about him.
Arthur was deeply shaken by the vision, embarked on the longest pe-
riod of sobriety he had had in adult life, and for the first time commit-
ted himself to therapeutic work, which was ultimately of considerable
benefit to him.
To summarize, the concept of death plays a crucial role in psy-
chotherapy because it plays a crucial role in the life experience of each of
us. Death and life are interdependent: though the physicality of death
destroys us, the idea of death saves us. Recognition of death contributes
a sense of poignancy to life, provides a radical shift of life perspective,
and can transport one from a mode of living characterized by diver-
sions, tranquilization, and petty anxieties to a more authentic mode.
There are, in the examples of individuals undergoing significant per-
sonal change after confrontation with death, obvious and important im-
plications for psychotherapy. What is needed are techniques to allow
psychotherapists to mine this therapeutic potential with all patients,
rather than be dependent upon fortuitous circumstances or the advent
of a terminal illness.

Death and Anxiety

Anxiety plays such a central and obvious role in psychotherapy that
there is little need to belabor the point. Therapists generally begin work
with a patient by focusing on manifest anxiety, anxiety equivalents, or
the defenses that the individual sets up in an attempt to protect himself
 192 THE Y ALOM READER

or herself from anxiety. Though therapeutic work extends in many di-

rections, therapists continue to use anxiety as a beacon or compass point:
they work toward anxiety, uncover its fundamental sources, and at-
tempt as their final goal to uproot and dismantle these sources.

Death Anxiety: An Influential Determinant of Human Experience and

Behavior
The terror of death is ubiquitous and of such magnitude that a con-
siderable portion of one's life energy is consumed in the denial of death.
Death transcendence is a major motif in human experience-from the
most deeply personal internal phenomena, our defenses, our motiva-
tions, our dreams and nightmares, to the most public macro-societal
structures, our monuments, theologies, ideologies, slumber cemeteries,
embalmings, our stretch into space, indeed our entire way of life-our
filling time, our addiction to diversions, our unfaltering belief in the
myth of progress, our drive to "get ahead," our yearning for lasting
fame.
These social ramifications of the fear of death and the quest for im-
mortality are widespread. Here I am primarily concerned with the ef-
fects of death anxiety on the internal dynamics of the individual. I shall
argue that the fear of death is a primal source of anxiety. Although this
position is simple and consonant with everyday intuition, its ramifica-
tions for theory and clinical practice are, as we shall see, extensive.

Death Anxiety: Definition

First, let me examine the meaning of "death anxiety." I shall use sev-
eral terms interchangeably: "death anxiety," "fear of death," "mortal
terror," "fear of finitude." Philosophers speak of the awareness of the
"fragility of being" (Jaspers), of dread of "non-being" (Kierkegaard), of
the "impossibility of further possibility" (Heidegger), or of ontological
anxiety (Tillich). Many of these phrases imply a difference in emphasis,
for individuals may experience the fear of death in very different ways.
Can we be more precise? What exactly is it that we fear about death?
Researchers investigating this issue have suggested that the fear is a
composite of a number of smaller, discrete fears. For example, James
Diggory and Doreen Rothman asked a large sample (N = 563) drawn
 Death, Anxiety, and Psychotherapy 193

from the general population to rank-order several consequences of

death. In order of descending frequency, these were the common fears
about death:

1. My death would cause grief to my relatives and friends.

2. All my plans and projects would come to an end.

3. The process of dying might be painful.

4. I could no longer have any experiences.

5. I would no longer be able to care for my dependents.

6. I am afraid of what might happen to me if there is a life after

death.

7. I am afraid of what might happen to my body after death.';

Of these fears, several seem tangential to personal death. Fears about

pain obviously lie on this side of death; fears about an afterlife beg the
question by changing death into a nonterminal event; fears about others
are obviously not fears about oneself. The fear of personal extinction
seems to be at the vortex of concern: "my plans and projects would come
to an end" and "I could no longer have any experiences." It is this fear of
ceasing to be (obliteration, extinction, annihilation), that seems more
centrally the fear of death; and it is this fear to which I refer in this
chapter.
Kierkegaard was the first to make a clear distinction between fear
and anxiety (dread); he contrasted fear that is fear of some thing with
dread that is a fear of no thing-"not," as he wryly noted, "a nothing
with which the individual has nothing to do.?" One dreads (or is anx-
ious about) losing oneself and becoming nothingness. This anxiety can-
not be located. As Rollo May says, "it attacks us from all sides at once.'?"
A fear that can neither be understood nor located cannot be confronted
and becomes more terrible still: it begets a feeling of helplessness which
invariably generates further anxiety.
How can we combat anxiety? By displacing it from nothing to Jome-
thing. This is what Kierkegaard meant hy "the nothing which is the ob-
 I 94 TH E YA LO M R EA DER

ject of dread becomes, as it were, more and more a something.'?" It is

what Rollo May means by "anxiety seeks to become fear.'?' If we can
transform a fear of nothing to a fear of something, we can mount some
self-protective campaign-that is, we can either avoid the thing we fear,
seek allies against it, develop magical rituals to placate it, or plan a sys-
tematic campaign to detoxify it.

Death Anxiety: Clinical Manifestations

The fact that anxiety seeks to become fear confounds the clinician's
attempt to identify the primal source of anxiety. Primal death anxiety is
rarely encountered in its original form in clinical work. Like nascent
oxygen, it is rapidly transformed to another state.To ward off death anx-
iety, the young child develops protective mechanisms which are denial-
based, pass through several stages, and eventually consist of a highly
complex set of mental operations that repress naked death anxiety and
bury it under layers of such defensive operations as displacement, subli-
mation, and conversion. Occasiona1ly some jolting experience in life
tears a rent in the curtain of defenses and permits raw death anxiety to
erupt into consciousness. Rapidly, however, the unconscious ego repairs
the tear and conceals once again the nature of the anxiety.
I can provide an illustration from my personal experience. While I
was engaged in writing Existential Psychotherapy, I was involved in a
head-on automobile collision. Driving along a peaceful suburban street,
I suddenly saw, looming before me, a car out of control and heading di-
rectly at rne. Though the crash was of sufficient force to demolish both
automobiles, and though the other driver suffered severe lacerations, I
was fortunate and suffered no significant physical injury. I caught a
plane two hours later and was able that evening to deliver a lecture in
another city. Yet, without question, I was severely shaken, I felt dazed,
was tremulous, and could not eat or sleep. The next evening I was un-
wise enough to see a frightening movie (Carrie) which thoroughly terri-
fied inc, and I left before its end. I returned home a couple of days later
with no obvious psychological sequelae aside from occasional insomnia
and anxiety dreams.
Yet a strange problem arose. At the time I was spending a year as a
fellow at the Center for Advanced Study in the Behavioral Sciences in
Palo Alto, California. I enjoyed 1ny colleagues and especially looked for-
 Death, Anxiety, and Psychotherapy 195

ward to the daily leisurely luncheon discussions of scholarly issues. Im-

mediately after the accident I developed intense anxiety around these
lunches. Would I have anything of significance to say? How would n1y
colleagues regard me? Would I make a fool of myself? After a few days
the anxiety was so extreme that I began to search for excuses to lunch
elsewhere by myself,
I also began, however, to analyze my predicament, and one fact was
abundantly clear: the luncheon anxiety appeared for the first time fol-
lowing the automobile accident. Furthermore, explicit anxiety about the
accident, about so nearly losing my life, had, within a day or two, en-
tirely vanished. It was clear that anxiety had succeeded in becoming
fear. Considerable death anxiety had erupted immediately following
the accident, and I had "handled" it primarily by displacement-by
splitting it from its true source and riveting it to a convenient specific
situation. My fundamental death anxiety thus had only a brief efflores-
cence before being secularized to such lesser concerns as self-esteem,
fear of interpersonal rejection, or humiliation.
Although I had handled, or "processed," my anxiety, I had not erad-
icated it; and traces were evident for months afterward. Even though I
had worked through my lunch phobia, a series of other fears
emerged-fears of driving a car, of bicycling. Months later when I went
skiing, I found myself so cautious, so frightened of some mishap that
my skiing pleasure and ability were severely compromised. Still these
fears could be located in space and time and could be managed in some
systematic way. Annoying as they were, they were not fundamental,
they did not threaten my being.
In addition to these specific fears, I noted one other change: the
world seemed precarious. It had lost, for me, its horniness: danger
seemed everywhere. The nature of reality had shifted, as I experienced
what Heidegger called "uncanniness" iunheimlich )-the experience of
"not being at home in the world," which he considered (and I can attest
to it) a typical consequence of death awareness."
One further property of death anxiety that has often created confu-
sion in mental health literature is that the fear of death can be experi-
enced at many different levels. One may, as I have discussed, worry
about the act of dying, fear the pain of dying, regret unfinished projects,
mourn the end of personal experience, or consider death as rationally
 I 96 TH E YA LO M R EA DER

and dispassionately as the Epicureans who concluded simply that death

holds no terror because "where I am, death is not; where death is, I am
not. Therefore death is nothing to me" (Lucretius). Yet keep in mind
that these responses are adult conscious reflections on the phenomenon
of death; by no means are they identical to the primitive dread of death
that resides in the unconscious-a dread that is part of the fabric of be-
ing, that is formed early in life at a time before the development of pre-
cise conceptual formulation, a dread that is chilling, uncanny, and
inchoate, a dread that exists prior to and outside of language and image.
The clinician rarely encounters death anxiety in its stark form: this
anxiety is handled by conventional defenses (for example, repression,
displacement, rationalization) and by some defenses specific only to it,
which will be discussed later. Of course this situation should not overly
trouble us: it prevails for every theory of anxiety. Primary anxiety is al-
ways transformed into something less toxic for the individual; that is the
function of the entire system of psychological defenses. It is rare, to use a
Freudian frame of reference, for a clinician to observe undisguised cas-
tration anxiety; instead, one sees some transformation of anxiety. For
example, a male patient may be phobic of women, or fearful of compet-
ing with males in certain social situations, or inclined to obtain sexual
gratification in some mode other than heterosexual intercourse.
A clinician who has developed the existential "set," however, will
recognize the "processed" death anxiety and be astonished at the
frequency and the diversity of its appearance. Let me give a clinical
example. I recently saw a patient who sought therapy not because of
existential anxiety but to solve commonplace, painful relationship
problems.
Joyce was a thirty-year-old university professor who was in the
midst of a painful divorce. She had first dated Jack when she was fifteen
and married him at twenty-one. The marriage had obviously not gone
well for several years, and they had separated three years previously. Al-
though Joyce had formed a satisfying relationship with another man,
she was unable to proceed with a divorce. In fact, her chief complaint
when entering therapy was her uncontrollable weeping whenever she
talked to Jack. An analysis of her weeping uncovered several important
factors.
 Death, Anxiety, and Psychotherapy 197

First, it was of the utmost importance that Jack continue to love her.
Even though she no longer loved him or wanted him, she wanted Yery
much that he think of her often and love her as he had never loved any
other woman. "Why?" I asked. "Everyone wishes to be remembered,"
she replied. "It's a way of putting myself into poster ity." She reminded
me that the Jewish Kaddish ritual is built around the assumption that,
as long as one is remembered by one's children, one continues to exist.
When Jack forgot her, she died a little.*
Another source of Joyce's tears was her feeling that she and Jack had
shared many lovely and important experiences. Without their union,
these events, she felt, would perish. The fading of the past is a vivid re-
minder of the relentless rush of time. As the past disappears, so does the
coil of the future shorten. Joyce's husband helped her to freeze tirne-
the future as well as the past. Though she was not conscious of it, it was
clear that Joyce was frightened of using up the future. She had a habit,
for example, of never quite completing a task: if she was doing house-
work, she always left one corner of the house uncleaned. She dreaded
being "finished." She never started a book without another one on her
night table awaiting its turn. One is reminded of Proust whose major
literary corpus was devoted to escaping "the devouring jaws of rime" by
recapturing the past.
Still another reason why Joyce wept was her fear of failure. Life had
until recently been an uninterrupted stairway of success. To fail in her
marriage meant that she would be, as she often put it, "just like every-
one else." Though she had considerable talent, her expectations were
grandiose. She anticipated achieving international prominence, perhaps
winning a Nobel prize for a research program upon which she was cm-
barking. If that success did not occur within five years, she planned to

• Allen Sharp in A Green Tree in Geddes describes a small Mexican cemetery

that is divided into two parts: the "dead" whose gran:s are still adorned with
flowers placed there by the living, and the "truly dead" whose grave sites are no
longer maintained-they are remembered by no living soul." In a sense, then,
when a very old person dies, many others die also; the dead person rakes them
along. All those recently dead who are remembered by no one else become, at
that moment, "truly" dead.
 198 THE YALOM READER

turn her energies to fiction and write the You Can't Go Home Again of
the 197os-although she had never written any fiction. Yet she had rea-
son for her sense of specialness: thus far she had not failed to accomplish
every one of her goals. The failure of her marriage was the first inter-
ruption of her ascent, the first challenge to her solipsistic assumptive
world. The failure of the marriage threatened her sense of specialness,
which is one of the most common and potent death-denying defenses.
Joyce's commonplace problem, then, had roots stretching back to
primal death anxiety. To me, an existentially oriented therapist, these
clinical phenomena-the wish to be loved and remembered eternally,
the wish to freeze time, the belief in personal invulnerability, the wish
to merge with another-all served the same function for Joyce: to as-
suage death anxiety.
As she analyzed each one and came to understand the common
source of these phenomena, Joyce's clinical picture improved remark-
ably. Most strikingly, as she gave up her neurotic needs for Jack, and
stopped using him for all the death-defying functions he served, she was
able to turn toward him for the first time in a truly loving fashion and
re-establish the rnarriage on an entirely different basis.

The Inattentionto Death in

PsychotherapyTheory and Practice
All of the foregoing perspectives on death bear strong implications
for psychotherapy. The incorporation of death into life enriches life;
it enables individuals to extricate themselves from smothering triviali-
ties, to live more purposefully and more authentically. The full aware-
ness of death 1nay promote radical personal change. Yet death is a
primary source of anxiety; it permeates inner experience, and we de-
fend against it by a number of personal dynamisms. Furthermore, as I
shall discuss later, death anxiety dealt with rnaladaptively results in the
vast variety of signs, symptoms, and character traits we refer to as "psy-
chopathology."
Yet despite these compelling reasons, the dialogue of psychotherapy
rarely includes the concept of death. Death is overlooked, and over-
looked glaringly, in almost all aspects of the mental health field: theory,
basic and clinical research, clinical reports, and all forms of clinical prac-

..
..,..
F
 Death, Anxiety, and Psychotherapy 199

rice. The only exception lies in the area in which death cannot be ig-
nored-the care of a dying patient. The sporadic articles dealing with
death that do appear in the psychotherapy literature are generally in
second- or third-line journals and are anecdotal in form, They are cu-
riosities that are peripheral to the mainstream of theory and practice.

Clinical Case Reports

The omission of the fear of death in clinical case reports, to take one
example, is so blatant that one is tempted to conclude that nothing less
than a conspiracy of silence is at work. There are three major strategies
for dealing with death in clinical case reports. First, the authors selec-
tively inattend to the issue and report no material whatsoever pertain-
ing to death. Second, authors 1nay present copious clinical data related
to death but ignore the mnter ial completely in their dynamic formula-
tion of the case. Third, authors n1ay present death-related clinical mate-
rial but, in a formulation of the case, translate "death" into a concept
compatible with a particular ideological school.
In a widely cited article, "The Attitudes of Psychoneurotics toward
Death," published in a leading journal, t\VO eminent clinicians, Walter
Bromberg and Paul Schilder, present several case histories in which
death plays a prominent role." For example, one female patient devel-
oped acute anxiety after the death of a woman friend for whom she had
had some erotic longings. Although the patient stated explicitly that her
personal fear of death was kindled by watching her friend die, the au-
thors conclude that "her anxiety reaction was against the unconscious
homosexual attachment with which she struggled ... her own death
meant the reunion with the homosexual beloved who had departed ...
to die means a reunion with the denied love object."
Another patient, whose father was an undertaker, described her se-
vere anxiety: "I have always feared death. I was afraid I would wake up
while they were embalming me. I have these queer feelings of imrni-
nent death. N1y father was an undertaker. I never thought of death
while I was with corpses ... but now I feel I want to run .... I think of it
steadily .... I feel as though I was fighting it off." The authors conclude
that "the anxiety about death is the expression of a repressed wish to be
passive and to be handled by the father-undertaker." In their view the
patient's anxiety is the product of her self-defense against these danger-
 •

200 TH E Y A LO M R EA DE R

ous wishes and of her desire for self-punishment because of her incest-
uous wish. The other case histories in the same article provide fur-
ther examples of translations of death into what the authors consider to
be more fundamental fears: "death means for this boy final sado-
masochistic gratification in a homosexual reunion with the father" or
"death means for him separation from the mother and an end to expres-
sion of his unconscious libidinal desires."
Obviously one cannot but wonder why there is such a press for trans-
lation. If a patient's life is curtailed by a fear, let us say, of open spaces,
dogs, radioactive fallout, or if one is consumed by obsessive ruminations
about cleanliness or whether doors are locked, then it seems to make
sense to translate these superficial concerns into more fundamental
meanings. But, res ipsa loquitur, a fear of death may be a fear of death
and not translatable into a "deeper" fear. Perhaps it is not translation
that the neurotic patient needs; he or she may not be out of contact with
reality but instead, through failing to erect "normal" denial defenses,
may be too close to the truth.

The Clinical Practitioner

Some therapists state that death concerns are simply not voiced by
their patients. I believe, however, that the real issue is that the therapist
is not prepared to hear them. A therapist who is receptive, who inquires
deeply into a patient's concerns, will encounter death continuously in
his or her everyday work.
Patients, given the slightest encouragement, will bring in an extraor-
dinary amount of material related to a concern about death. They dis-
cuss the deaths of parents or friends, they worry about growing old,
their dreams are haunted by death, they go to class reunions and are
shocked by how much everyone else has aged, they notice with an ache
the ascendancy of their children, they occasionally take note, with a
start, that they enjoy old people's sedentary pleasures. They are aware of
n1any small deaths: senile plaques, liver spots on their skin, gray hairs,
stiff joints, stooped posture, deepening wrinkles. Retirement ap-
proaches, children leave home, they become grandparents, their chil-
dren take care of them, the life cycle envelops them. Other patients may
speak of annihilation fears: the common horrifying fantasy of some
 Death, Anxiety, and Psychotherapy 201

murderous aggressors forcing entry into the home, or fearful reactions

to television or cinematic violence. The termination work that occurs in
the therapy of every patient is accompanied, if the therapist will only lis-
ten, by undercurrents of concern about death.
My personal clinical experience is highly corroborative of the ubiq-
uity of death concerns. Throughout the writing of Existential Psy-
chotherapy I have encountered considerable amounts of heretofore
invisible clinical material. Undoubtedly to some extent I have cued pa-
tients to provide me with certain evidence. But it is my belief that, in the
main, it was always there; I was simply not properly tuned in. Earlier,
for example, I presented a patient, Joyce, who had commonplace clinical
problems involving the establishment and the termination of interper-
sonal relationships. On deeper inquiry Joyce evinced much concern
about existential issues which I would never have been able to recognize
had I not had the appropriate psychological set.
Another exam pie of "tuning in" is offered by a psychotherapist who
attended a Saturday lecture I gave on the topic of death anxiety. A few
days later she wrote in a letter:

... I did not expect the subject to come up in my work now, since I
am a counselor at Reed College and our students are usually in good
physical health. But n1y first appointment Monday morning was
with a student who had been raped two months ago. She has been
suffering from many disagreeable and painful symptoms since then.
She made the comment, with an embarrassed laugh, "If I'm not dy-
ing of one thing, I'm dying of another." It was probably at least in
part because of your remarks that the interview turned towards her
fear of dying, and that being raped and dying used to he things she
thought would happen only to other people. She now feels vulnera-
ble and flooded with anxieties that used to be suppressed. She
seemed to be relieved that it was all right to talk about being afraid
to die, even if no terminal illness can be found in her body."

Psychotherapy sessions following even some passing encounter with

death often offer much clinical data. Dreams, of course, are especially
 ,
202 THE YA LOM READER

fertile sources of material. For example, one thirty-year-old woman, the

night following the funeral of an old friend, dreamed: "I'm sitting there
watching TV. The doctor comes over and examines my lungs with a
stethoscope. I get angry and ask him what right he has to do that. He
said I was srnoking like a smoke house. He said I have far advanced
'hourglass' disease of 1ny lungs." The dreamer does not smoke, but her
dead friend smoked three packs a day. Her association to "hourglass"
disease of the lungs was "rime is running out." <,
2

Denial plays a central role in a therapist's selective inattention to

death in therapy. Denial is a ubiquitous and powerful defense. Like an
aura, it surrounds the affect associated with death whenever it appears.
One joke from Freud's vast collection has it that a man says to his wife:
"If one of us two dies before the other, I think I'll move to Paris.":" De-
nial does not spare the therapist, and in the treatment process the denial
of the therapist and the denial of the patient enter into collusion. Many
therapists, though they have had long years of personal analysis, have
not explored and worked through their personal terror of death; they
phobically avoid the area in their personal lives and selectively inattend
to obvious death-linked material in their psychotherapy practice.

DEATH AND PSYCHOPATHOLOGY

The range of psychopathology, the types of clinical picture with which
patients present, is so broad that clinicians require some organizing
principle that will permit them to cluster symptoms, behaviors, and
characterological styles into meaningful categories. To the extent that
clinicians can apply some structuring paradigm of psychopathology,
they are relieved of the anxiety of facing an inchoate situation. They de-
velop a sense of recognition or of familiarity and a sense of mastery
which, in turn, engender in patients a sense of confidence and trust-
prerequisites for a truly therapeutic relationship.
The paradigm that I shall describe here rests, as do most paradigms
of psychopathology, on the assumption that psychopathology is a grace-
less, inefficient mode of coping with anxiety. An existential paradigm
assumes that anxiety emanates from the individual's confrontation with

,.
I

'1
I.
 Death, Anxiety, and Psychotherapy 203

the ultimate concerns in existence. I shall present a model of psy-

chopathology based upon the individual's struggle with death anxiety
and, in later chapters, models applicable to patients whose anxiety is
more closely related to other ultimate concerns-freedom, isolation,
and meaninglessness." Though for didactic purposes I must discuss
these concerns separately, all four represent strands in the cable of exis-
tence, and all must eventually be recombined into a unified existential
model of psychopathology.
All individuals are confronted with death anxiety; most develop
adaptive coping modes-modes that consist of denial-based strategies
such as suppression, repression, displacement, belief in personal om-
nipotence, acceptance of socially sanctioned religious beliefs that "detox-
ify" death, or personal efforts to overcome death through a wide variety
of strategies that aim at achieving symbolic immortality.
Either because of extraordinary stress or because of an inadequacy of
available defensive strategics, the individual who enters the realm called
"patienrhood" has found insufficient the universal modes of dealing
with death fear and has been driven to extreme modes of defense. These
defensive maneuvers, often clumsy modes of dealing with terror, consti-
tute the presenting clinical picture.
Psychopathology (in every system) is, by definition, an ineffective de-
fensive mode. Even defensive maneuvers that successfully ward off se-
vere anxiety prevent growth and result in a constricted and unsatisfying
life. Many existential theorists have commented upon the high price ex-
acted in the struggle to cope with death anxiety. Kierkegaard knew that
man limited and diminished himself in order to avoid perception of the
"terror, perdition and annihilation that dwell next door to any man.""
Otto Rank described the neurotic as one "who refused the loan (life) in
order to avoid the payment of the debt (death).":" Paul Tillich stated
that "neurosis is the way of avoiding non-being by avoiding bcing."1''
Ernest Becker made a similar point when he wrote: "The irony of
man's condition is that the deepest need is to be free of the anxiety of
death and annihilation; hut it is life itself which awakens it and so we

*The chapters referred to here constitute Parts II, lll, and IV of Existentia]
Psychotherapy.
 204 TH E y A LO M R EA I) ER
'
must shrink from being fully alive.'?' Robert Jay Lifton used the term
"psychic numbing" to describe how the neurotic individual shields him-
self from death anxiety .32
Naked death anxiety will not be easily apparent in the paradigm of
psychopathology I shall describe. But that should not surprise us: pri-
mary anxiety in pristine form is rarely visible in any theoretical system.
The defensive structures exist for the very purpose of internal camou-
flage: the nature of the core dynamic conflict is concealed by repression
and other dysphoria-reducing maneuvers. Eventually the core conflict
is deeply buried and can be inferred-though never wholly known-
only after laborious analysis of these maneuvers.
To take one example: an individual may guard himself from the
death anxiety inherent in individuation by maintaining a symbiotic tie
with Mother. This defensive strategy may succeed temporarily, but as
time passes, it will itself become a source of secondary anxiety; for ex-
ample, the reluctance to separate from Mother may interfere with atten-
dance at school or the development of social skills; and these deficiencies
are likely to beget social anxiety and self-contempt which, in turn, may
give birth to new defenses which temper dysphoria but retard growth
and accordingly generate additional layers of anxiety and defense. Soon
the core conflict is heavily encrusted with these epiphenomena, and the
excavation of the primary anxiety becomes exceedingly difficult. Death
anxiety is not immediately apparent to the clinician: it is discovered
through a study of dreams, fantasies, or psychotic utterances or through
painstaking analysis of the onset of neurotic symptoms.
The derivative, secondary forms of anxiety are nonetheless "real"
anxiety. An individual 1nay be brought down by social anxiety or by
pervasive self-contempt; and, as we shall see, treatment efforts generally
are directed toward derivative rather than toward primary anxiety. The
psychotherapist, regardless of his or her belief system concerning the
primary source of anxiety and the genesis of psychopathology, begins
therapy at the level of the patient's concerns: for example, the therapist
may assist the patient by offering support, by propping up adaptive de-
fenses, or by helping to correct destructive interpersonal modes of inter-
action. Thus in the treatment of many patients the existential paradigm
of psychopathology does not call for a radical departure from traditional
therapeutic strategies or techniques.

1
 Death, Anxiety. and Psychotherapy 205

Death Anxiety: A Paradigm of Psychopathology

A clinical paradigm that I believe to be of considerable practical and
heuristic value issues from the child's mode of coping with death aware-
ness. The two major bulwarks of the child's denial system are the ar-
chaic beliefs that one is either personally inviolable and/or protected
eternally by an ultimate rescuer. These two beliefs are particularly pow-
erful because they receive reinforcement from two sources: from the cir-
cumstances of early life, and from widespread culturally sanctioned
myths involving immortality systems and the existence of a personal,
observing deity.
The clinical expression of these two fundamental defenses became
particularly clear to me one day when I saw two patients, whom I shall
call Mike and Sam, in two successive hours. They provide a powerful
study in the two modes of death denial; the contrast between the two is
striking; and each, by illustrating the opposite possibility, sheds light on
the dynamics of the other.
Mike, who was twenty-five years old and had been referred to rne
by an oncologist, had a highly malignant lymphoma, and though a new
form of chemotherapy offered his only chance for survival, he refused
to cooperate in treatment. I saw Mike only once (and he was fifteen
minutes late for that meeting), but it was readily apparent that the
guiding motif of his life was individuation. Early in life he had strug-
gled against any form of control and developed remarkable skills at
self-sufficiency. Since the age of twelve he had supported himself, and
at fifteen he moved out of his parental home. After high school he went
into contracting and soon mastered all aspects of the trade-carpentry,
electrical work, plumbing, masonry. He built several houses, sold them
at substantial profits, bought a boat, married, and sailed with his wife
around the world. He was attracted to the self-sufficient individualistic
culture that he had found in an underdeveloped country, and was
preparing to emigrate when, four months before I saw him, his cancer
was discovered.
The most striking feature of the interview was Mike's irrational atti-
tude toward the chemotherapy treatment. True, the treatment was
markedly unpleasant, causing severe nausea and vomiting, but Mike's
fear exceeded all reasonable bounds: he could not sleep the night before
 206 THE Y ALOM READER

treatment; he developed a severe anxiety state and obsessed about meth-

ods of a voiding treatment. What was it precisely that Mike feared about
the treatment? He could not specify, but he did know that it had some-
thing to do with immobility and helplessness. He could not bear to wait
while the oncologist prepared his medication for injection. (It could not
be done in advance, since the dosage depended upon his blood count,
which had to be examined before each administration.) Most terrible of
all, however, was the intravenous: he hated the penetration of the nee-
dle, the taping, the sight of the drops entering his body. He hated to be
helpless and restrained, to lie quietly on the cot, to keep his arm immo-
bile. Though Mike did not consciously fear death, his fear of therapy
was an obvious displacement of death anxiety. What was truly dreadful
for Mike was to be dependent and static: these conditions ignited terror,
they were death equivalents; and most of his life he had overcome them
by a consummate self-reliance. He believed deeply in his specialness and
his invulnerability and had, until the cancer, created a life that rein-
forced this belief.
I could do little for Mike except to suggest to his oncologist that
Mike be taught to prepare his medications and to monitor and adjust
his own intravenous. These suggestions helped, and Mike finished his
course of treatment. He did not keep his next appointment with me but
called to ask for a self-help muscle-relaxation cassette. He chose not to
remain in the area for the oncological follow-up and decided to pursue
his plans to emigrate. His wife so disapproved of his plan that she re-
fused to go, and Mike set sail alone.
Sain was approximately the same age as Mike but resembled him in
no other way. He came to see me in extremis following his wife's deci-
sion to leave hirn. Though he was not, like Mike, confronted with death
in a literal sense, Sam 's situation was simila~ on a symbolic level. His be-
havior suggested that he faced an extraordinarily severe threat to his
survival: he was anxious to the point of panic, he wailed for hours on
end, he could not sleep or eat, he longed for surcease at any cost and se-
riously contemplated suicide. As the weeks passed, Sam's catastrophic
reaction subsided, but his discomfort lingered. He thought about his
wife continuously. He did not, as he stated, "live in life" but slunk about
outside life. "Passing time" became a conscious and serious proposition:
crossword puzzles, television, newspapers, magazines were seen in their
 Death, Anxiety, and Psychotherapy 207

true nature-as vehicles for filling the void, for getting time over with
as painlessly as possible.
Sam's character structure can be understood around the motif of
"fusion"-a motif dramatically opposed to Mike's of "individuation."
During the Second World War, Sam's family had, when he was very
young, moved many times to escape danger. He had suffered many
losses, including the death of his father when Sam was a preadolescent
and the death of his mother a few years later. He dealt with his situation
by forming close, intense ties: first with his mother and then with a se-
ries of relatives or adopted relatives. He was everyone's handyman and
perpetual baby-sitter. He was an inveterate gift giver, bestowing gener-
ous amounts of time and money on a large number of adults. Nothing
seemed more important to Sam than to be loved and cared for. In fact,
after his wife left him, he realized that he felt he existed only if he were
loved: in a state of isolation he froze, much like a terrified animal, into a
state of suspended animation--not living but not dying either. Once
when we talked about his pain following his wife's departure, he said,
"When I'm sitting home alone, the most difficult thing is to think that
no one really knows I'm alive." When alone, he scarcely ate or sought to
satisfy any but the most primitive needs. He did not clean his house, he
did not wash, he did not read; though he was a talented artist, he did not
paint. There was, as Sam put it, no point in "expending energy unless I
am certain it will be returned to me by another." He did not exist unless
someone was there to validate his existence. When alone, Sam trans-
formed himself into a spore, dormant until another person supplied life-
restonng energy.
In his time of need Sam sought help from the elders in his life: he
flew across the country for the solace of a few hours in the home of
adopted relatives; he received support by simply standing outside the
house he and his mother had once lived in for four years; he ran up as-
tronomical phone bills soliciting advice and comfort; he received much
support from his in-laws who, because of Sam's devotion to them,
threw their lot (and love) in with Sam rather than with their daughter.
Sam's efforts to help himself in his crisis were considerable but
monothematic: he sought in a number of ways to reinforce his beliefs
that some protective figure watched over and cared for him.
Despite his extreme loneliness, Sain was willing to take no steps to
 208 THE Y ALOM READER

alleviate it. I made a number of practical suggestions about how he

might meet friends: singles' events, church social activities, Sierra Club
events, adult education courses, and so forth. My advice, much to my
puzzlement, went completely unheeded. Gradually I understood: what
was important for Sam was not, despite his loneliness, to be with others
but to confirm his faith in an ultimate rescuer. He was explicit in his un-
willingness to spend time a\vay from his home on singles or dating ac-
tivities. The reason? He was afraid of missing a phone call! One phone
call from "out there" was infinitely more precious than joining dozens
of social activities. Above all, Sam wanted to be "found," to be pro-
tected, to be saved without having to ask for help and without having to
engineer his own rescue. In fact, at a deep level, Sam was made more
uncomfortable by successful efforts to assume responsibility for helping
himself out of his life predicament. I saw Sam over a four-month pe-
riod. As he became more comfortable (through my support and
through "fusion" with another woman), he obviously lost motivation
for continued psychotherapeutic work, and we both agreed that termi-
nation was in order.

Two Fundamental DefensesAgainst Death

What do we learn from Mike and Sam? We see clearly two radi-
cally different modes of coping with fundamental anxiety. Mike be-
lieved deeply in his specialness and personal inviolability; Sam put
faith in the existence of an ultimate rescuer. Mike's sense of self-suffi-
ciency was hypertrophied, while Sam did not exist alone but strove to
fuse with another. These two modes are diametrically opposed; and,
though by no means mutually exclusive, they constitute a useful dialec-
tic which permits the clinician to understand a wide variety of clinical
. .
situations.
In a crude, sweeping way, the two defenses constitute a dialectic-
the human being either fuses or separates, embeds or emerges. He af-
firms his autonomy by "standing out from nature" (as Rank put it)," or
seeks safety by merging with another force. Either he becomes his own
father or he remains the eternal son. Surely this is what Fromm meant
when he described man as either "longing for submission or lusting for
power." H
 Death, Anxiety, and Psychotherapy 209

This existential dialectic offers one paradigm that permits the clini-
cian to "grasp" the situation. There are many alternate paradigms, each
with explanatory power: Mike and Sam have character disorders-
schizoid and passive-dependency, respectively. Mike can be viewed
from the vantage points of a continued rebellious conflict with his par-
ents, of counter dependency, of neurotic perpetuation of the Oedipal
struggle, or of homosexual panic. Sam can be "grasped" from the van-
tage points of identification with Mother and unresolved grief, or of cas-
tration anxiety, or from a family dynamic perspective in which the
clinician focuses attention on Sam's interaction with his wife.
The existential approach is, therefore, one paradigm among many,
and its raison d'etre is its clinical usefulness. This dialectic permits the
therapist to comprehend data often overlooked in clinical work. The
therapist may, for example, understand why Mike and Sam responded
so powerfully and manneristically to their painful situations, or why
Sam balked at the prospect of "improving" his situation by the assump-
tion of responsibility for himself. This dialectic permits the therapist to
engage the patient on the deepest of levels. It is based on an understand-
ing of primary anxiety that exists in the immediate present: the therapist
views the patient's symptoms as a response to death anxiety that cur-
rently threatens, not as a response to the evocation of past trauma and
stress. Hence, the approach emphasizes awareness, immediacy, and
choice-an emphasis that enhances the therapist's leverage.
I shall describe here these two basic forms of death denial and the
types of psychopathology that spring from them. (Though many of the
familiar clinical syndromes can be viewed and understood in terms of
these basic denials of death, I make no pretense of an exhaustive classi-
fying system-that would suggest greater precision and comprehen-
siveness than is the case.) Both beliefs, in specialness and in an ultimate
rescuer, can be highly adaptive. Each, however, may be overloaded and
stretched thin, to a point where adaptation breaks down, anxiety leaks
through, the individual resorts to extreme measures to protect himself
or herself, and psychopathology appears in the fonn of either defense
breakdown or defense runaway.
For the sake of clarity I shall first discuss each defense separately. I
shall then need to integrate them again because they arc intricately in-
 210 THE Y ALOM READER

terdependent: the great majority of individuals have traces of both de-

fenses woven into their character structures.

Specialness
No one has ever described the deep irrational belief in our own special-
ness more powerfully or poignantly than Tolstoy who, through the lips
of I van Ilych, says:

In the depth of his heart he knew he was dying, but not only was he
not accustomed to the thought, he simply did not and could not
grasp it.
The syllogism he had learnt from Kiezewetter's Logic: "Caius is
a man, men are mortal, therefore Caius is mortal," had always
seemed to him correct as applied to Caius, but certainly not as ap-
plied to himself. That Caius-man in the abstract-was mortal,
was perfectly correct, but he was not Caius, not an abstract man, but
a creature quite, quite separate from all others. He had been little
Vanya, with a marnma and a papa, with Mitya and Volodya, with
the toys, a coachman and a nurse, afterwards with Katenka and
with all the joys, griefs, and delights of childhood, boyhood, and
youth. What did Caius know of the smell of that striped leather ball
Vanya had been so fond of? Had Caius kissed his mother's hand
like that, and did the silk of her dress rustle so for Caius? Had he ri-
oted like that at school when the pastry was bad? Had Caius been in
love like that? Could Caius preside at a session as he did? "Caius re-
ally was mortal, and it was right for him to die; but for me, little
Vanya, Ivan Ilyich, with all my thoughts and emotions, it's alto-
gether a different matter. It cannot be that I ought to die. That
would be too terrible. "15

We all know that in the basic boundaries of existence we are no dif-

ferent from others. No one denies that at a conscious level. Yet deep,
deep down each of us believes, as does I van Ilych, that the rule of mor-
tality applies to others but certainly not to ourselves. Occasionally one is
I
I

l
 Death, Anxiety, and Psychotherapy 211

caught off guard when this belief pops into consciousness, and is sur-
prised by one's own irrationality. Recently, for example, I visited my op-
tometrist to complain that my eyeglasses no longer functioned as of
yore. He examined me and asked my age. "Forty-eight," I said, and he
replied, "Yep, right on schedule." From somewhere deep inside the
thought welled up and hissed: "What schedule? iVho's on schedule? You
or others may be on a schedule, but certainly not I."
When an individual learns he or she has some serious illness-for
example, cancer-the first reaction is general1y some [orrn of denial.
The denial is an effort to cope with anxiety associated with the threat to
life, but also it is a function of a deep belief in one's inviolability. Much
psychological work must be done to restructure one's lifelong assump-
tive world. Once the defense is truly undermined, once the individual
really grasps, "My God, I'm really going to die," and realizes that life
will deal with him or her in the same harsh wav as it deals with others,
he or she feels lost and, in some odd \vay, betrayed.
In my work with terminally ill cancer patients I have observed that
individuals vary enormously in their willingness to know about their
deaths. Many patients for some time do not hear their physician tell
them their prognosis. Much internal restructuring must be done to al-
low the knowledge to take hold. Some patients become aware of their
deaths and face death anxiety in staccato fashion-a brief moment of
awareness, brief terror, denial, internal processing, and then prepared-
ness for more information. For others the awareness of death and the
associated anxiety flood in with a terrible rush.
One of my patients, Pam, a twenty-eight-year-old woman with cer-
vical cancer, had her myth of specialness destroyed in a striking fashion.
After an exploratory laparotomy, her surgeon visited her and informed
her that her condition was grave indeed, and that her life expectancy
was in the neighborhood of six months. An hour later Pam was visited
by a team of radiotherapists who had obviously not communicated with
the surgeon, and who informed her that they planned to radiate her and
that they were "going for a cure." She chose to believe her second visi-
tors, but unfortunately her surgeon, unbeknownst to her, spoke with
her parents in the waiting room and gave them the original n1essage-
namely, that she had six months to live.
 2 I2 T H E Y A LO r-.t R EA DER

Pam spent the next few months convalescing at her parents' home in
the most unreal of environments. Her parents treated her as though she
were going to be dead in six months. They insulated themse1ves and the
world from her; they monitored her phone calls to screen out unsettling
communications; in short, they made her "comfortable." Finally Pam
confronted her parents and demanded to know what in God's name
was going on. Her parents told her about their conversation with the
surgeon; Pam referred them to the radiotherapist, and the misunder-
standing was quickly cleared up.
Pain, however, was deeply shaken by the experience. The confronta-
tion with her parents made her realize, in a way that a death sentence
from the surgeon had not, that she was indeed veering toward death.
Her comments at this time are revealing:

I did seem to be getting better and it was a happier situation, but

they began to treat me like I was not going to live and I was stung
into this terrible feeling of realization that they had already accepted
my death. Because of an error and a miscommunication 1 was al-
ready dead to my family, and I started being dead and it was a very
hard way back to get myself to be alive. It was worse later on as I
was getting better than it was when I was very sick because when
the family suddenly realized that 1 was getting better then they left
and went back to their daily chores and I was still left with being
dead and I couldn't handle it very well. I'm still frightened and try-
ing to cross the boundary line that seems to be in front of me-s-the
boundary line of, am I dead or am I alive?

The point is that Pam truly understood what it meant to die not
from anything her doctors told her but from the crushing realization
that her parents would continue to live without her and that the world
would go on as hefore-that, as she put it, the good times would go on
without her.
Another patient with widespread metastatic cancer had arrived at
the same point when she wrote a letter to her children instructing them
how to divide some personal belongings of sentimental value. She had
 Death, Anxiety, and Psychotherapy 213

rather mechanically performed the other dreary administrative chores

of dying-the writing of a will, the purchase of a burial p1ot, the ap-
pointment of an executor-but it was the personal Jetter to her children
that made death real to her. It was the simple but dreadful realization
that when her children read her letter she would no longer exist: neither
to respond to them, to observe their reactions, to guide them; they
would be there but she would be nothing at all.
Another patient, Jan, had breast cancer that had spread to her brain.
Her doctors had forewarned her of paralysis. She heard their words but
at a deep level felt smugly irnmune to this possibility. When the inex-
orable weakness and paralysis ensued, Jan realized in a sudden rush
that her "specialness" was a myth. There was, she learned, no "escape
clause." She said all this during a group therapy meeting and then
added that she had discovered a powerful truth in the last week-a
truth that made the ground shake under her. She had been musing to
herself about her preferred life span-seventy would be about right,
eighty might be too old-and then suddenly she realized, "When it
comes to aging and when it comes to dying, what I wish has absolutely
nothing to do with it."
Perhaps these clinical illustrations begin to transmit something of
the difference between knowing and truly knowing, between the every-
day awareness of death we all possess and the full facing of "my death."
Accepting one's personal death means facing a number of other un-
palatable truths, each of which has its own force field of anxiety: that
one is finite; chat one's life really comes to an end; that the world will
persist nonetheless; that one is one of many-no more, no less; that the
universe does not acknowledge one's specialness; that all our lives we
have carried counterfeit vouchers; and, finally, that certain stark im-
mutable dimensions of existence are beyond one's influence. In fact,
what one wishes "has absolutely nothing to do with it."
When an individual arrives at the discovery that personal special-
ness is mythic, he or she feels angry and betrayed by life. Surely this
sense of betrayal is what Robert Frost had in mind when he wrote:
"Forgive, 0 Lord, my little jokes on Thee/ And I'll forgive Thy great
big one on me."11;
Many people feel that if they had only known, really known, earlier
 21.J THE YALOM READER

they would have lived their lives differently. They feel angry; yet the
rage is impotent, for it has no reasonable object. (The physician is, inci-
dentally, often a target for displaced anger, and especially for that of so
n1any dying patients.)
The belief in personal specialness is extraordinarily adaptive and
permits us to emerge from nature and to tolerate the accompanying
dysphoria: the isolation; the awareness of our smallness and the awe-
somcncss of the external world, of our parents' inadequacies, of our
creatureliness, of the bodily functions that tie us to nature; and, most of
all, the knowledge of the death which rumbles unceasingly at the edge
of consciousness. Our belief in exemption from natural law underlies
n1any aspects of our behavior. It enhances courage in that it permits us
to encounter danger without being overwhelmed by the threat of per-
sonal extinction. Witness the psalmist who wrote, "A thousand shall fa]l
at thy right hand, ten thousand at thy left, but death shall not come nigh
thee." The courage thus generated begets what many have called the
human being's "natural" striving for competence, effcctance, power,
and control. To the extent that one attains power, one's death fear is
further assuaged and belief in one's specialness further reinforced. Get-
ting ahead, achieving, accumulating material wealth, leaving works be-
hind as imperishable monuments become a way of life which effectively
conceals the mortal questions churning below.

Compulsiue Heroism
For n1any of us, heroic individuation represents the best that man
can <lo in light of his existential situation. The Greek writer Nikos
Kazantzakis was such a spirit, and his Zorba was the quintessential self-
sufficient man. (In his autobiography Kazantzakis cites the last words
of the man who was his model for Zorba the Greek: " ... if any priest
comes to confess me and give me communion, tell him to make himself
scarce, and may he give me his curse! ... Men like me should live a
thousand vcars.")" Elsewhere, through the lips of his Ulysses, Kazant-
zakis advises us to live life so completely that we leave death nothing
but a "burned-out castle.":" His own tombstone on the ramparts of Her-
aklcion hears the simple heroic epitaph: "I want nothing, I fear nothing,
I am free."
•
lj

j
-
 Death, Anxiety, and Psychotherapy 215

Push it a bit farther, though, and the defense becomes overextended:

the heroic pose caves in on itself, and the hero becomes a compulsive
hero who, like Mike, the young man with cancer, is driven to face dan-
ger in order to escape a greater danger within. Ernest Hemingway, the
prototype of the compulsive hero, was compelled throughout his life to
seek out and conquer danger as a grotesque way of proving there was
no danger. Hemingway's mother reports that one of his first sentences
was, "'Fraid of nothin '. ".w In an ironic ,vay he was afraid of nothing pre-
cisely because he, like all of us, was afraid of nothingness. The Heming-
way hero thus represents a runaway of the emergent, individualistic
solution to the human situation. This hero is not choosing; his actions
are driven and fixed; he does not learn from new experiences. Even the
approach of death does not turn his gaze within or increase his wisdom.
The Hemingway code contains no place for aging and diminishment,
for they have the odor of ordinariness. In The Old Man and the Sea, San-
tiago meets his approaching death in a stereotyped way-the same way
he faced every one of life's basic threats-by going out alone to search
for the great fish."
Hemingway himself could not survive the dissolution of the myth of
his personal invulnerability. As his health and physical prowess de-
clined, as his "ordinariness" (in the sense that he like eYeryone must face
the human situation) became painfully evident, he grew bereft and fi-
nally deeply depressed. His final illness, a paranoid psychosis with per-
secutory delusions and ideas of reference, temporarily bolstered his
myth of specialness. (All persecutory trends and ideas of reference flow
from a core of personal grandiosity; after all, only a \'ery special person
would warrant that much attention, albeit malevolent attention, from
his environment.) Eventually the paranoid solution failed; and, left with
no defense against the fear of death, Hemingway committed suicide.
Though it seems paradoxical that one would commit suicide beet use of
a fear of death, it is not uncommon. Many individuals ha Ye said in effect
that "I so fear death I am driven to suicide." The idea of suicide offers
some surcease from terror. It is an active act; it permits one to control
that which controls one. Furthermore, as Charles Wahl has noted,
many suicides have a magical view of <leach and regard it as rcrnporary
and reversible." The individual who commits suicide to t'Xpn.'.ss hostil-
 216 THE YALOM READER

ity or to generate guilt in others may believe in the continued existence

of consciousness, so that it will be possible to savor the harvest of his or
her death.

The Workaholic
The compulsive heroic individualist represents a clear, but not clini-
cally common, example of the defense of specialness which is stretched
too thin and fails to protect the individual from anxiety or degenerates
into a runaway pattern. A commonplace example is the "workaholic"-
I
··

the individual consumed by work. One of the most striking features of a

workaholic is the implicit belief that he or she is "getting ahead," "pro-
gressing," moving up. Time is an enemy not only because it is cousin to
finitude but because it threatens one of the supports of the delusion of
specialness: the belief that one is eternally advancing. The workaholic
must deafen himself or herself to time's message: that the past grows
fatter at the expense of a shrinking future.
The workaholic life mode is compulsive and dysfunctional: the
workaholic works or applies himself not because he wishes to but be- ~
cause he has to. The workaholic may push himself without mercy and
without regard for human limits. Leisure time is a time of anxiety and is
often frantically filled with some activity that conveys an illusion of ac-
complishment. Living, thus, becomes equated with "becoming" or "do-
ing"; time not spent in "becoming" is not "living" but waiting for life to •
commence.
Culture, of course, plays an important role in the shaping of the indi-
vidual's values. Regarding "activity," Florence Kluckholm suggests an
anthropological classification of value orientations that postulates three
categories: "being," "being-in-becoming," and "doing.":" The "being"
orientation emphasizes the activity rather than the goal. It focuses on
the spontaneous natural expression of the "is-ness" of the personality.
"Being-in-becoming" shares with the "being" orientation an emphasis
on what a person is rather than on what the person can accomplish, but
emphasizes the concept of "development." Thus, it encourages activity
of a certain type-activity directed toward the goal of the development
of all aspects of the self. The "doing" orientation emphasizes accom-
plishments measurable by standards outside of the acting individual.
 Death, Anxiety, and Psychotherapy 217

Obviously contemporary conservative American culture, with its em-

phasis on "what does the individual do?" and "getting things done," is
an extreme "doing" culture.
Still, in every culture there are wide ranges of individual variation.
Something within the workaholic individual interacts with the cultural
standard in a manner that breeds a hypertrophied and rigid internaliza-
tion of the value svstern.
., It becornes difficult for individuals to assume a
bird's-eye view of their culture and to view their value systen1 as one
among many possible stances. I had one workaholic patient who treated
himself to a rare noonday walk (as a reward for some particularly irn-
portant accorn plishrnent) and was staggered by the sight of hundreds of
people standing around sirnply sunning themselves. "What do they do
all day? How can people live that way?" he wondered. A frantic fight
with time may be indicative of a powerful death fear. Workaholic indi-
viduals relate to time precisely as if they were under the seal of irnrni-
nent death and were scurrying to get as much completed as possible.
Embedded in our culture, we accept unquestioningly the goodness
and rightness of getting ahead. Not too long ago I was taking a brief va-
cation alone at a Caribbean beach resort. One evening I was reading,
and from time to time I glanced up to watch the bar boy who was doing
nothing save languidly staring out to sea-much like a lizard sunning
itself on a warm rock, I thought. The comparison I made between him
and me made me feel \'ery smug, very cozy. He was simply doing noth-
ing-s-wasting time; I was, on the other hand, doing something useful,
reading, learning. I was, in short, getting ahead. All was well, until
some internal imp asked the terrible question: Getting ahead of what?
How? And (even worse) why? Those questions were, and are still,
deeply disquieting. What was brought home to me with unusual force
was how I lull myself into a death-defeating delusion by continually
projecting myself forward into the future. I do not exist as a lizard ex-
ists; I prepare, I become, I am in transit. John Maynard Keynes puts it
this way: "What the 'purposeful' man is always trying to secure is a spu-
rious and illusive immortality, immortality for his acts by pushing his
interest in them forward in time. He does not love his cat, but his cat's
kittens; nor, in truth the kittens, but only the kittens' kittens, and so on
forward forever to the end of cardom.''"
 218 THEY ALOM READER

Tolstoy, in Anna Karenina, describes the collapse of the "upward spi-

'
ral" belief system in the person of Alexey Alexandrovitch, Anna's hus-
band, a man for whom everything has always ascended, a splendid
career, a brilliant mar riage. Anna's leaving him signifies far more than
the loss of her: it is the collapse of a personal Weltanschauung.

He felt that he was standing face to face with something illogical

and irrational, and did not k now what was to he done. Alexey
Alexandrovitch was standing face to face with life, with the possi-
bility of his wife's loving someone other than himself, and this
seemed to him very irrational and incomprehensible because it was
life itself. All his life Alcxey Alexandrovitch had lived and worked
in official spheres, having to do with the reflection of life. And
every t.rne he had stumbled against life itself he had shrunk away
from it. Now he experienced a feeling akin to that of a man who,
while calmly crossing a precipice by a bridge, should suddenly dis-
cover that the bridge is broken, and that there is a chasm below.
That chasm was life itself, the bridge that artificial life in which
Alexey Alexandrovitch had lived."

"The chasm was life itself, the bridge that artificial life ... " No one
has said it more clearly. The defense, if successful, shields the individual
from the knowledge of the chasm. The broken bridge, the failed de-
fense, exposes one to a truth and a dread that an individual in midlife
following decades of self-deception is ill equipped to confront.
The specialness mode of coping with death fear generates maladap-
tive forms of the individualistic or a gen tic solution. But there is another
even more serious and intrinsic limitation to the defense of specialness.
Many keen observers have noted that though great exhilaration may for
some time accompany individualist expression and achievement, there
comes a point where anxiety sets in. The person who "emerges from
embeddedness" or "stands out from nature" must pay a price for his
success. There is sornethj ng frightening about individuation, about sep-
arating oneself from the whole, about going forward and living life as a
separate isolated being, about surpassing one's peers and one's parents.
 Death, Anxiety, and Psychotherapy 2 I9

Many clinicians have written on the "success neurosis"-a curious

condition where individuals on the point of the crowning success for
which they have long striven develop not euphoria but a crippling dys-
phoria which often ensures that they do not succeed. Freud refers to the
phenomenon as the "wrecked by success" syndrome." Rank describes it
as "life anxiety ''~ '-the fear of facing life as a separate being. Maslow
1

notes that we shrink away from our highest possibilities (as well as from
our lowest), and terms the phenomenon the "Jonah complex," since
Jonah like all of us could not bear his personal greatness and sought to
avoid his destiny."
How is one to explain this curious, self-negating human tendency?
Perhaps it is a result of an entanglement of achievement and aggression.
Some people use achievement as a method of vindictively surpassing
others; they fear that others will become aware of their motives and re-
taliate when success becomes too great. Freud thought it had much to
do with the fear of surpassing one's father and thereby exposing oneself
to the threat of castration. Becker advances our understanding when he
suggests that the terrible thing in surpassing one's father is not castra-
tion but the frightening prospect of becoming one's own father." To be-
come one's own father means to relinquish the comforting but magical
parental buttress against the pain inherent in one's awareness of per-
sonal finiteness.
Thus the individual who plunges into life is doomed to anxiety.
Standing out from nature, being one's own father or, as Spinoza put it,
"one's own god," means utter isolation; it means standing alone without
the myth of rescuer or deliverer and without the comfort of the human
huddle. Such unshielded exposure to the isolation of individuation is
too terrible for most of us to bear. When our belief in personal special-
ness and inviolability fails to provide the surcease frorn pain we require,
we seek relief from the other major alternative denial system: the belief
in a personal ultimate rescuer.

The Ultimate Rescuer

Ontogeny recapitulates phylogeny. In both the physical and the social
development of the individual, the development of the species is mir-
 220 TH E YA LO M R EA DER

rored. In no social attribute is this fact more clearly evident than in the
human belief in the existence of a personal omnipotent intercessor: a
force or being that eternally observes, loves, and protects us. Though it
may allow us to venture close to the edge of the abyss, it will ultimately
rescue us. Fromm characterizes this mythic figure as the "magic
helper,":" and Masserrnan as the "omnipotent servant.'?" Like the belief
in personal specialness, this belief system is rooted in events of early life
when parents seemed eternally concerned and satisfied one's every
need. Certainly humankind from the beginnings of written history has
clung to the belief in a personal god-a figure that might be eternally
loving, frightening, fickle, harsh, propitiated, or angered, but a figure
that was always there. No early culture has ever believed that humans
were alone in an indifferent world.
Some individuals discover their rescuer not in a supernatural being
but in their earthly surroundings, either in a leader or in some higher
cause. Human beings, for milleniums, have conquered their fear of
death in this manner and have chosen to lay down their freedom, in-
deed their lives, for the embrace of some higher figure or personified
cause.

The Rescuer Defense and Personality Restriction

Overall the ultimate rescuer defense is less effective than the belief in
personal specialness. Not only is it more likely to break down but it is
intrinsically restrictive to the person. Later I shall report on empirical
research that demonstrates this ineffectiveness, but it is an insight that
Kierkegaard arrived at intuitively over one hundred years ago. He has a
curious statement contrasting the perils of "venturing" (emergence, in-
dividuation, specialness) and not venturing (fusion, embeddedness, be-
lief in ultimate rescuer):

...it is dangerous to venture. And why? Because one may lose. Not
to venture is shrewd. And yet, by not venturing, it is so dreadfully
easy to lose that which it would be difficult to lose in even the most
venturesome venture, ... one's self. For if I have ventured amiss-
vcry well, then life helps me by its punishment. But if I have not
ventured at all-who then helps me? And, moreover, ifby not ven-

I
~'
 Death, Anxiety, and Psychotherapy 221

turing at all in the highest sense (and to venture in the highest sense is
precisely to become conscious of oneself) I have gained all earthly ad-
vantages ... and lose myself. What of that?"

To remain embedded in another, "not to venture," subjects one then to

the greatest peril of all-the loss of oneself, the failure to have explored
or developed the manifold potentials within oneself.

The Collapse of the Rescuer

Through much of life the belief in an ultimate rescuer provides con-
siderable solace and functions smoothly and invisibly. Most individuals
remain unaware of the structure of their belief system until it fails to
serve its purpose; or until, as Heidegger put it, there is a "breakdown in
the machinery.?" There are many possibilities for breakdown and many
forms of pathology associated with the collapse of the defense.
Fatal Illnesses. Perhaps the severest test for the effectiveness of the
ultimate rescuer delusion is presented by fatal illness. Many individuals,
so stricken, channel a great deal of energy into bolstering their belief in
the presence and power of a protector. As the obvious candidate for the
role of rescuer is the physician, the patient-doctor relationship becomes
charged and complex. In part, the robe of rescuer is thrust upon the
physician by the patient's wish to believe; in part, however, the physi-
cian dons the robe gladly because playing God is the physician's method
of augmenting his belief in his personal specialness. Either way, the re-
sult is the same: the doctor becomes larger than life, and the patient's at-
titude to him or her is often irrationally obeisant. Commonly, patients
with a fatal illness dread angering or disappointing their physicians;
these patients apologize for taking a physician's time and arc so flus-
tered in a physician's presence that they forget to ask the pressing ques-
tions they have prepared.
To patients it is so important that doctors retain their power that a
patient will neither challenge nor doubt one. Many patients, in fact, in a
highly magical way, permit physicians to maintain the role of the suc-
cessful healer by concealing important information from them about
their (the patients') psychological and even physical distress. ( )ftcn,
thus, the physician is the last to know about the depth of a patient's de-
 222 T HE Y A LO M R EA D ER

spair. A patient who is perfectly able to talk openly to nurses or social

workers about his anguish maintains a cheery, plucky face toward the
physician, who concludes that the patient is handling the situation as
well as could be expected.
Individuals differ in the tenacity with which they ding to denial, but
eventually all denial crumbles in the face of overwhelming reality.
Kubler-Ross, for example, reports that in her long experience she has
seen only a handful of individuals maintain denial to the moment of
death. A patient's reaction to learning that no medical or surgical cure
exists is catastrophic. He or she feels angry, deceived, and betrayed. At
whom, however, can one be angry? At the cosmos? At fate? Many pa-
tients are angry at the doctor for failing them-not for failing medically
but for failing to incarnate the patients' personal myth of an ultimate
deliverer.
Depression. In his study of psychotically depressed individuals, Sil-
vano Ar ieti describes a central motif, a life ideology that precedes and
"prepares the ground" for depression." His patients lived a type of me-
diated existence; they lived not for themselves but for either the "domi-
nant other" or the "dominant goal." Though the terminology differs,
Arieti's description of these two ideologies coincides closely with the
two defenses against the fear of death I have described. The individual
who lives for the "dominant goal" is the individual who fashions his or
her life around a belief in personal specialness and inviolability. As I dis-
cussed earlier, depression often ensues when the belief in an ever-as-
cendi ng spiral C'dominant goal") collapses.
To live for the "dominant other" is to attempt to merge with another
whom one perceives as the dispenser of protection and meaning in life.
The dominant other may be one's spouse, mother, father, lover, thera-
pist, or an anthropomorphization of a business or a social institution.
The ideology 1nay collapse for 1nany reasons: the dominant other may
die, leave, withdraw love and attention, or prove too fallible for the task.
When patients recognize the failure of their ideology, they are often
overwhelmed; they may feel that they have sacrificed their lives for a
currency that has proven counterfeit. Yet they have available no alterna-
tive strategy for coping.
The patient 1nay attempt to re-establish the relationship or to search

.
 Death, Anxiety, and Psychotherapy 223

for another. If these attempts fail, the patient is without resources and
feels both depleted and self-condemnatory. Restructuring a life ideology
is beyond comprehension; and many patients, rather than question their
basic belief svstern, conclude that they a re too worthless or too bad to
warrant the love and protection of the ultimate rescuer. Their depres-
sion is abetted, furthermore, by the fact that, unconsciously, suffering
and self-immolation function as a last desperate plea for love. Thus,
they are bereft because they have lost love, and they remain bereft in or-
der to regain it.
Masochism. I have described a cluster of behaviors associated with
the hypertrophied belief in the ultimate rescuer: self-effacement, fear
of withdrawal of love, passivity, dependency, self-immolation, refusal
to accept adulthood, and depression at collapse of the belief system.
When accented, each of these may produce a characteristic clinical syn-
drome. When self-immolation dominates, the patient is referred to as
"masochistic."
Karen, a forty-year-old patient I treated for two years, taught me a
great deal about the dynamics behind the urge to inflict pain on oneself.
Karen entered therapy for a number of reasons: masochistic sexual
propensities, an inabil icy to achieve sexual pleasure wi th her "straight"
boyfriend, depression, a pervasive inertia, and terrifying nightmares
and hypnagogic experiences. In therapy she rapidly developed a power-
ful positive transference. She devoted herself to the project of eliciting
care and concern from me. Her masturbatory fantasies consisted of her
becoming very ill (either with a physical disease like tuberculosis, or a
psychotic breakdown) and m y feeding and cradling her. She delayed
leaving my office so as to spend a few extra minutes with me; so as to
have my signature, she saved her canceled checks with which she had
paid my bills; she attempted to visit my lectures so as to catch sight of
me. Nothing seemed to please her more than for me co be stern with
her; in fact, if I expressed any irritation, she experienced sexual excita-
tion in my office. In every way she made me bigger than lifo and selec-
tively ignored all of 1ny obvious flaws.
She responded similarly to signs of weakness or limitation in other
important and powerful figures in her life. If her boyfriend became ill
or evinced any sign of weakness, confusion, or indecision, she cxpcri-
 224 THE YALOM READER
1•
enced much anxiety. She could not bear to see him falter. Once when he
l
was severely injured in an auto accident, she became phobic about visit-
ing his hospital room. She responded similarly to her parents and was
sorely threatened by their increasing age and frailty. As a child, she had
related to them through illness. "Being sick was the lie of my life," said
Karen. She sought pain to get succor. On more than one occasion dur-
ing her childhood, she spent weeks in bed with a fictitious disease. Dur-
ing adolescence she became anorexic, only too glad to exchange physical
starvation for the attention and solicitude it incited.
Her sexuality joined in the pursuit for safety and deliverance: force,
restraint, strength, and pain aroused her, while weakness, passivity,
even tenderness repulsed her. To be punished was to be protected; to be
bound, confined, or restricted was wonderful: it meant that limits were
being set, and that some powerful figure was setting them. Her
masochism was overdetermined: she sought survival not only through
subjugation but also through the symbolic and magical value of suffer-
ing. A small death, after all, is better than the real thing.
Treatment was successful in alleviating the acute depression, the
nightmares, the suicidal preoccupation; but there came a time when
treatment with me seemed to impede further growth, since, to avoid
losing me, Karen continued to immolate herself. I, therefore, set a ter-
mination date six months in the future and told her that after that time I
would not see her again in treatment. Over the next few weeks we
weathered the storm of a severe recrudescence of all symptomatology.
Not only did her severe anxiety and nightmares return, but she had ter-
rifying hallucinatory experiences consisting of gigantic swooping bats
attacking her whenever she was alone.
This was a period of great fear and despair for Karen. Her delusion
of the ultimate rescuer had always protected her against the terror of
death and its removal left her overly exposed to dread. Wonderful po-
ems she wrote in her journal (mailed to me after termination of therapy)
describe her terror graphically.

With death in my mouth I speak to you

And maggots eating at my heart.
In the cacophony of bells
Aly protestsgo unheard.

-·i:I
 Death, Anxiety, and Psychotherapy 225

Death is disappointment,
A bitter bread.
You cram it down my throat
To stifle my screams.

As the termination date approached, Karen pulled out all stops. She
threatened suicide if I would not continue treating her. Another poem
expressed her mood and her threat:

Death is no pretense.
It is as stark a reality,
as complete a presence as life itself,
the other ultimate choice.

I feel myself running into shadows,

clothing myself in cobtoebs,
hiding from the reality you thrust at me.
I want to hold up my dark cloak, death,
and threaten you tuith it.

Do you understand?
I will wrap myself in this if you persist.

Though I felt frightened by Karen's threats and provided her as

much support as possible, I decided not to budge from my stand and
maintained that at the end of the six months I would not continue to see
her regardless of how ill she was. Our termination was to be final and
irrevocable; no degree of distress on her part could influence it. Grad u-
ally her efforts to merge with me subsided, and she turned toward the
task at hand: how to use our final sessions as constructively as possible.
It was only then, when she had relinquished all hope of my continued,
eternal presence, that she could work truly effectively in therapy. She
allowed herself to know and to make known her strengths and her
growth. She rapidly obtained a full-time position commensurate with
her talents and skills (she had procrastinated finding this work for four
years!). She changed her demeanor and grooming radically frorn woe-
begone waif to mature, attractive woman,
 226 THE Y ALOM READER

Two years after termination she asked to see me again because of the
'
,·
death of a friend. I agreed to meet with her for a single session and
learned that she not only had maintained her changes but had under-
gone considerably more growth. It seems that one important thing for
patients to learn is that, though therapists can be helpful, there is a point
beyond which they can offer nothing more. In therapy, as in life, there is
an inescapable substrate of lonely work and lonely existence.
The Rescuer Defense and Interpersonal Difficulties. The fact that
some individuals avoid the fear of death through a belief in the exis-
tence of an ultirnate rescuer offers the clinician a useful frame of refer-
ence for some baffling, interpersonal minuets. Consider the following
examples of a common clinical problem: the patient who is enmeshed in
a patently ungratifying, even destructive relationship and yet is unable
to wrench free.
Bonnie was forty-eight years old, had a severe circulatory disorder
(Buerger' s disease), and after a twenty-year childless marriage, had been
separated for ten years. Her husband, a fervent outdoorsman, appeared
to be a highly insensitive, self-centered autocrat who finally left Bonnie
when her poor health made it impossible for her to accompany him on
hunting and fishing expeditions. He provided her no financial support
during the ten years of separation, had affairs with numerous women
(descriptions of which he did not fail to share with her), and visited
Bonnie's home once every week or two to use the washing machine, to
pick up recorded phone messages for the business phone he maintained
there, and, once or twice a year, to have sexual relations with her. Bon-
nie, because of strong moral standards, refused to date other men while
she was still married. She continued to be obsessed with her husband-
at times enraged at the sight of him, at times enamored of him. Her life
diminished. as she became ill, lonely, and tormented by his weekly
washing machine visits. Yet she could neither divorce him, disconnect
his phone, or terminate his laundry privileges.
Martha was thirty-one years old and desperate to marry and raise a
family. For several years she had been involved with a man who be-
longed to a mystical religious sect that taught him that the fewer com-
mitments an individual makes, the greater is his freedom. Consequently,
though he enjoyed Martha, he refused to live with her or make any long-
term commitrnent to her. He was alarmed by her need for him; and, the

·]
1
 Death, Anxiety, and Psychotherapy 227

tighter she clutched, the less was he willing to promise. Martha was ob-
sessed with binding him and was pained beyond description at his lack of
commitment. Yet she felt addicted and was unable to wrench herself
free; each time she broke with him, she suffered a painful state of with-
drawal and finally in depression or panic reached for the telephone to
call him. He, during times of separation, was maddeningly tranquil;
he cared for her but could manage well without her. Martha was too
consumed with him to search effectively for other relationships: her
major project in life was to extract a commitment from him-a com-
mitment that reason and experience strongly suggested was not to be
forthcoming.
Each of these patients was involved in a relationship that was re-
sponsible for considerable anguish; each realized that continuing in the
relationship was self-destructive. Each tried. in vain, to wrench herself
free; in fact these futile attempts constituted the major theme of the
therapy of each woman. \Vhat made disengagement so difficult? What
welded each of them so tightly to another person? An obvious and a
common thread runs through the concerns of the t'\VO patients, and it
quickly became apparent when I asked each one to tell me what came to
mind when she thought of separating from her mate.
Bonnie had a twenty-year marriage to a husband who had made
every decision for her. He was a man who could do everything and
"took care" of her. Of course, as she was to learn when she separated,
"being taken care of' restricted her growth and self-sufficiency. But it
was so comforting to know that someone was always there to protect
and rescue her. Bonnie had a serious illness and doggedly continued to
believe, even after ten years' separation, that her husband was "out
there" taking care of her. Every time I urged her to reflect on life with-
out his presence (and I speak here of symbolic presence; aside from the
shared washing machine and a few mechanical coital acts, there had
been no meaningful physical presence for years), she became very anx-
ious. What would she do in an emergency? Whom would she call? Life
would be unbearably lonely without him. Obviously he was a symbol
that shielded her from confronting the harsh reality that there is no one
"out there," that the "emergency" is inevitable and no person, symbolic
or real, can obviate it.
Martha permitted her life to he governed by the future. Whenever I
 228 T HE Y ALO M R EA D ER

asked her to meditate on what it would be like to give up her relation-

ship with her uncommitted boyfriend, she always responded that all she
could think of was "eating alone at sixty-three." When I asked her for
her definition of commitment, she replied, "It's the assurance I'll never
have to live alone or die alone." The thought of dining alone or going to
the movies alone filled her with shame and dread. What was it that she
really wanted from a relationship? "Being able to get help without hav-
ing to ask for it," she replied.
Martha was tyrannized by the always present, desperate fear that she
would be alone in the future. Like many neurotic patients, she did not
really live in the present, but instead attempted to find the past (that is,
the comforting bond with mother) in the future. Martha's fear and her
need were so great that they ensured that she would not establish a grat-
ifying relationship with a man, She was too frightened of loneliness to
give up her current unsatisfying relationship, and her need was so obvi-
ously frenzied that she frightened away prospective partners.
For each of these women, then, the bonding force was not the rela-
tionship per se but the terror of being alone; and what was especially
fearful about being alone was the absence of that magical, powerful
other who hovers about each of us, observing, anticipating our needs,
providing each of us with a shield against the destiny of death.

Toward an Integrated View of Psychopathology

I have, for didactic purposes, focused separately on two major modes of
coping with death anxiety and presented vignettes of patients who show
extreme forms of one of these two basic defenses, but now it is time to
integrate them. Most patients do not, of course, present with clear and
monothematic clinical pictures. Generally one does not construct a sin-
gle ponderous defense but instead uses multiple, interlaced defenses in
an attempt to wall off anxiety. Most individuals defend against death
anxiety through both a delusional belief in their own inviolability and a
helief in the existence of an ultimate rescuer. Although I have thus far
presented these two defenses as a dialectic, they are closely interdepen-
dent. Because we have an observing, omnipotent being or force continu-
ously concerned with our welfare, we are unique and immortal and
 Death, Anxiety, and Psychotherapy 229

have the courage to emerge from ernbeddedness. Because we are unique

and special beings, special forces in the universe are concerned with us.
Though our ultimate rescuer is omnipotent, he is at the same time our
eternal servant.
Otto Rank in a thoughtful essay entitled "Life Fear and Death Fear"
posited a basic dynamic that illuminates the relationship between the
two defenses." Rank felt that there is in the individual a primal fear that
manifests itself sometimes as a fear of life, sometimes as a fear of death.
By "fear of life" Rank meant anxiety in the face of a "loss of connection
with a greater whole." The fear of life is the fear of having to face life as
an isolated being, it is the fear of individuation, of ·'going forward," of
"standing out from nature." Rank believed that the prototypical life fear
was "birth," the original trauma and the original separation. By "fear of
death" Rank meant the fear of extinction, of loss of individuality, ,. of be-
ing dissolved again into the whole.
Rank stated that "between these two fear possibilities, these poles of
fear, the individual is thrown back and forth all his life." The individual
attempts to separate himself, to individuate, to affirm his autonomy, to
go forward, to fulfill his potential. Yet there comes a time when he de-
velops fear in the face of life. Individuation, emergence--or, as I put it
here, affirmation of specialness-are not duty-free: they entail a fearful,
lonely sense of unprotectedness-a sense that the individual assuages by
reversing direction: one goes "backward," relinquishes individuation,
finds comfort in fusing, in dissolving oneself: in giving oneself up to an-
other. Yet the comfort is unstable because this alternative evokes fear
also-the fear of death: relinquishment, stagnation, and finally, inor-
ganicity. Between these two poles of fear, lzfe fear and death fear, the in-
dividual shuttles throughout life.
Though the paradigm I offer here of the dual defenses of specialness
and the ultimate rescuer is not identical with Rank's life-fear, death-
fear dialectic, they obviously overlap. Rank's poles of fear correspond
closely to the inherent limits of the defenses I have described. "Life anx-
iery" emerges from the defense of specialness: it is the price one pays for
standing out, unshielded, from nature. "Death anxiety" is the toll of fu-
sion: when one gives up autonomy, one loses oneself and suffers a type
of death. Thus one oscillates, one goes in one direction until the anxiety
 'I
230 THE YALOM READER

outweighs the relief of the defense, and then one moves 10 the other
direction.

DEATH AND PSYCHOTHERAPY

The leap from theory to practice is not easy. In this section I shall trans-
port us from metaphysical concerns about death to the office of the
practicing psychotherapist and attempt to extract from those concerns
what is relevant to everyday therapy.
The reality of death is important to psychotherapy in two distinct
ways: death awareness 1nay act as a "boundary situation" and instigate a
radical shift in life perspective, and death is a primary source of anxiety.
I shall discuss the application of each way, in turn, to the technique of
therapy.

Death as a Boundary Situation

A "boundary situation" is an event, an urgent experience, that propels
one into a confrontation with one's existential "situation" in the world.
A confrontation with one's personal death ("n1y death") is the nonpareil
boundary situation and has the power to provide a massive shift in the
way one lives in the world. Death acts as a catalyst that can move one
from one state of being to a higher one: from a state of wondering about
how things are to a state of wonderment that they are. An awareness of
death shifts one away from trivial preoccupations and provides life with
depth and poignancy and an entirely different perspective.
Earlier I considered illustrative examples from literature and clinical
records of individuals who, after a confrontation with death, have un-
dergone a radical personal transformation. Tolstoy's Pierre in War and
Peace and I van Ilych in "The Death of I van Ilych" are obvious instances
of "personality change" or "personal growth." Another striking illustra-
tion is everyone's favorite miraculously transformed hero: Ebenezer
Scrooge. Many of us forget that Scrooge's transformation was not sim-
ply the natural result of yule warmth melting his icy countenance. What
changed Scrooge was a confrontation with his own death. Dickens's
 Death, Anxiety, and Psychotherapy 2 31

Ghost of the Future (Ghost of the Christmas Yet to Corne) used a pow-
erful form of existential shock therapy: Scrooge was permitted to ob-
serve his own death, to overhear members of the community discuss his
death and then dismiss it lightly, and to watch strangers quarreling over
his material possessions, including even his bedsheets and nightshirt.
Scrooge then witnessed his own funeral and, finally, in the last scene be-
fore his transformation, Scrooge knelt in the churchyard and examined
the letters of his name inscribed on his tombstone.

Death Confrontation and Personal Change: Mechanism of Action

How does death awareness instigate personal change? What is the
inner experience of the individual thus transformed? We have already
discussed the type and the degree of positive change that some terminal
cancer patients have undergone. Interviews with these patients provide
insights into some of the mechanisms of change.
Cancer Cures Psychoneurosis. One patient had disabling interper-
sonal phobias that almost miraculously dissolved after she developed
cancer. When asked about this cure, she responded, "Cancer cures psy-
choneurosis." Although she tossed this statement off almost flippantly,
there is an arresting truth in it: not the dismal truth that death elimi-
nates life with all its attendant sor rows, but the optimistic truth that the
anticipation of death provides a rich perspective for life concerns. When
asked to describe her transformation, she stated that it was a simple
process: having faced and, she felt, conquered her fear of death-a fear
that had dwarfed all her other fears-she experienced a strong sense of
personal mastery.
Existence Cannot Be Postponed. Eva, forty-five years old and
deeply depressed, had advanced ovarian cancer and was highly con-
flicted about whether she should take one last trip. In the midst of our
therapeutic work she reported this dream:

There was a large crowd of people. It looked something like a

Cecil B. DeMille scene. I can recognize my mother in there. They
were all chanting, "You can't go, you have cancer, you are ill." The
chanting went on and on. Then I heard my dead father, a quiet
reassuring voice, saying, "I know you have lung cancer like me. hut
 232 THE YALOM READER

don't stay home and eat chicken soup, waiting to die like me. Go to
Africa-live."

Eva's father had died many years ago of a lingering cancer. She last
saw him several months before his death and had sorrowed not only at
her loss but at the way he died. No one in the family had dared tell him
about his cancer, and the symbol of staying home and eating chicken
soup was apt: his remaining life and his death were unenlightened and
unheroic. The dream bore powerful counsel; Eva heeded it well and al-
tered her life dramatically. She confronted her physician and demanded
all available information about her cancer and insisted that she share in
the decisions made about her treatment. She re-established old friend-
ships; she shared her fears with others and helped them share their grief
with her. She did take that last journey to Africa which, though it was
cut short by illness, did leave her with the satisfaction of having drunk
deeply from life until the last draught.
The matter can be summed up simply: "Existence cannot be post-
poned." Many patients with cancer report that they live more fully in
the present. They no longer postpone living until some time in the fu-
ture. They realize that one can really live only in the present; in fact, one
cannot outlive the present-it always keeps up with you. Even in the
moment of looking back over one's life--even in the last moment--one
is still there, experiencing, living. The present, not the future, is the
eternal tense.
Another individual, a university professor, as a result of a serious
bout with cancer, decided to enjoy the future in the immediate present.
He discovered, with astonishment, that he could choose not to do those
things he did not wish to do. When he recovered from his surgery and
returned to work, his behavior changed strikingly: he divested himself
of onerous administrative duties, immersed himself in the most excit- I,

ing aspects of his research (eventually attaining national prominence),

and-let this be a lesson to us all-never attended another faculty
meeting.
Fran was chronically depressed and fearful and had for fifteen rears
been locked into a highly unsatisfying marriage which she could not ·i,
bring herself to end. The final obstacle to separation was her husband's l'
 Death, Anxiety, and Psychotherapy 2 33

extensive home aquarium ! She wished to remain in the house so that

her children could keep their friends and remain in the same school; yet
she could not undertake the two hours of time needed for the daily
feeding of the fish. Nor could the huge aquarium be moved except at
enormous expense. The problem seemed insoluble. (On such trifling is-
sues is a life sacrificed.)
Fran then developed a malignant form of bone cancer which
brought home to her the simple fact that this was her one and only life.
She said that she suddenly realized that time's clock runs continuously,
and that there are no "time-outs" when it stops. Though her illness was
so severe that her need for her husband's physical and economic support
were very great indeed, she nonetheless made the courageous decision
to separate, a decision she had postponed for over a decade.
Death rerninds us that existence cannot be postponed. And that there
is still time for life. If one is fortunate enough to encounter his or her
death and to experience life as the "possibility of possibility" (Kierke-
gaard)55 and to know death as the "impossibility of further possibility"
(Heidegger)? then one realizes that, as long as one lives, one has possi-
bility-one can alter one's life until-but only until- the last moment.
If, however, one dies tonight, then all of tomorrow's intentions and
promises die stillborn. That is what Ebenezer Scrooge learned; in fact,
the pattern of his transformation consisted of a systematic reversal of his
misdeeds of the previous day: he tipped the caroler he had cursed, he
donated money to the charity workers he had spurned, he embraced the
nephew he had scorned, he gave coal, food, and n1oney to Cratchit
whom he had tyrannized.
Count Your Blessings. Another mechanism of change energized
by a confrontation with death was well illustrated by a patient who had
cancer that had invaded her esophagus. Swallowing became difficult;
gradually she shifted to soft foods, then to pureed foods, then to liquids.
One day in a cafeteria, after having been unable even to swallow some
clear broth, she looked around at the other diners and wondered, "Do
they realize how lucky they are to be able to swallow? Do they ever
think of that?" She applied this simple principle to herself and became
aware of what she could do and could experience: the elemental facts of
life, the changing seasons, the beauty of her natural surroundings, sec-
 I
J

2 34 T HE Y A LO ~t RE A D ER

ing, listening, touching, and loving. Nietzsche expresses this principle in

a beautiful passage:

Out of such abysses, from such severe sickness one returns new-
born, having shed one's skin, more ticklish and malicious, with a
more delicate taste for joy, with a more tender tongue for all good
things, with merrier senses, with a second dangerous innocence in
joy, more childlike and yet a hundred times subtler than one has
ever seen before."

Count your blessings! How rarely do we benefit from that simple

homily? Ordinarily what we do have and what we can do slips out of
awareness, diverted by thoughts of what we lack or what we cannot do,
or dwarfed by petty concerns and threats to our prestige or our pride
systems, By keeping death in mind, one passes into a state of gratitude,
of appreciation for the countless givens of existence. This is what the
Stoics meant when they said, "Contemplate death if you would learn
how to live.?" The imperative is not, then, a call to a morbid death pre-
occupation but instead an urging to keep both figure and ground in fo-
cus so that being becomes conscious- and life becomes richer. As
Santayana put it: "The dark background which death supplies brings
out the tender colors of life in all their purity.?"
Disidentification. In everyday clinical work the psychotherapist
encounters individuals who are severely anxious in the face of events
that do not seem to warrant anxiety. Anxiety is a signal that one per-
ceives some threat to one's continued existence. The problem is that the
neurotic person's security is so tentative that he or she extends his or her
defensive perimeter a long way into space. In other words, the neurotic
not only protects his or her core but defends many other attributes
(wor k , prestige, role, vanity, sexual prowess, or athletic ability) with the
same intensity. Many individuals become inordinately stressed, there-
fore, at threats to their career or to any of a number of other attributes.
They believe in effect,"[ am rny career," or "I am my sexual attractive-
ness." The therapist wishes to say, "No, you are not your career, you are
not your splendid body, you are not mother or father or wise man or
eternal nurse. You are your self, your core essence. Draw a line around

J.
 Death, Anxiety, and Psychotherapy 2 35

it: the other things, the things that fall outside. they arc not you; they
can vanish, and you will still exist."
Unfortunatelv , such self-evident exhortations, like all self-evident ex-
hortations, are rarely effective in catalyzing change. Psychotherapists
look for methods to increase the power of the exhortation. One such
method l have used, with groups of cancer patients as well as in the
classroom, is a structured "disidcntification '' exercise." The procedure is
simple and takes approximately thirty to [ortv-fivc minutes. I choose a
quiet peaceful setting and ask the participants to list, on separate cards,
eight important answers to the question "Who am I?" I then ask them
to review their eight answers and to arrange their cards in order of im-
portance and ccntr icity: the answers closest to their core at the bottom,
the more peri phcr al responses at the top. Then l ask them to study their
top card and meditate on what it would be like to give up that attribute.
After approximately two to three minutes I ask them (some quiet signal
like a bell is less distracting) to go on to the next card and so on until
they have divested themselves of all eight attributes. Following that, it is
advisable to help the participants integrate by going through the proce-
dure in reverse. This simple exercise generates powerful emotions. I
once led three hundred individuals in an adult education workshop
through it; and, even years afterward, participants gratuitously in-
formed me how momentously important the procedure had been to
them.
The individual with a chronic illness who copes well with his or her
situation often spontaneously goes through this process of disidentifica-
tion. One patient whom I remember well had always closely identified
herself with her physical energy and activities. Her cancer gradually
weakened her to the point where she could no longer backpack, ski, or
hike, and she mourned these losses for a long time. Her range of physi-
cal activities inexorably diminished, but eventually she was able to tran-
scend her losses. After months of work in therapy she was able to accept
the limitations, to say "I cannot do it" without a sense of personal
worthlessness and futility. Then she transmuted her energy into other
forms of expression that were within her limits. She set feasible final

*Suggested co me by James Bugenral.

 236 THE YALOM READER
'
projects for herself: completing personal and professional unfinished
business, expressing unvoiced sentiments to other patients, friends, doc-
tors, and children. Much later she was able to take another, major
'
I

I,
I

i
step-to disidentifyeven with her energy and impact and to realize that
she existed apart from these, indeed apart from all other qualities.
Disidentification is an obvious and ancient mechanism of change-
the transcendence of material and social accoutrements has long been
embodied in ascetic traditions-but it is not easily available for clinical
use. It is the awareness of death that promotes a shift in perspective and
makes it possible for an individual to distinguish between core and ac-
cessory: to reinvest one and to divest the other.

Death Awareness in Everyday Psychotherapy

If we psychotherapists accept that awareness of personal death can
catalyze a process of personal change, then it is our task to facilitate a
patient's awareness of death. But how? Many of the examples I have
cited arc of individuals in an extraordinary situation. What about the
psychotherapist treating the everyday patient-who does not have ter-
minal cancer, or who is not facing a firing squad, or who has not had a
near fatal accident?
Several of my cancer patients posed the same question. When speak-
ing of their growth and what they had learned from their confrontation
with death, they lamented, "What a tragedy that we had to wait till
now, till our bodies were riddled with cancer, to learn these truths!"
There arc many structured exercises that the therapist may employ
to simulate an encounter with death. Some of these are interesting, and
I shall describe them shortly. But the most important point I wish to
make in this regard is that the therapist does not need to provide the ex-
perience; instead, the therapist needs merely to help the patient recog-
nize that which is everywhere about him or her. Ordinarily we deny, or
selectively inattend to, reminders of our existential situation; the task of
the therapist is to reverse this process, to pursue these reminders, for
they arc not, as I have attempted to demonstrate, enemies but powerful
allies in the pursuit of integration and maturity.
Consider this illustrative vignette. A forty-six-year-old mother takes
the youngest of her four children to the airport where he departs for
college. She has spent the last twenty-six years rearing her children and
 Death, Anxiety, and Psychotherapy 237

longing for this day. No more impositions, no more incessantly living

for others, no more cooking dinners and picking up clothes, only to be
reminded of her futile efforts by dirty dishes and a room in new disar-
ray. Finally she is free.
Yet, as she says good-bye, she unexpectedly begins sobbing loudly,
and on the way home from the airport a deep shudder passes through
her body. "It is only natural," she thinks. It is only the sadness of saying
good-bye to someone she loves very much. But it is more than that. The
shudder persists and shortly turns into raw anxiety. What could it be?
She consults a therapist. He soothes her. It is but a cornmon problem:
the "empty nest" syndrome. For so many years she has based her self-
esteem on her performance as mother and housekeeper. Suddenly she
finds no way to validate herself. Of course she is anxious: the routine,
the structure of her life have been altered, and her life role and primary
source of self-esteem have been removed. Gradually, with the help of
Valium, supportive psychotherapy, an assertiveness training women's
group, several adult education courses, a lover or two, and a part-time
volunteer job, the shudder shrinks to a tremble and then vanishes alto-
gether. She returns to her "premorbid" level of comfort and adaptation.
This patient, treated by a psychiatric resident some years ago, was
part of a psychotherapy outcome research project. Her treatment results
could only be described as excellent: on each of the measures used-
symptom checklists, target problem evaluation, self-esteem-she had
made considerable improvement. Even now, in retrospect, it seems
clear that the psychotherapist fulfilled his function. Yet I also look upon
this course of treatment as a "misencounter," as an instance of missed
therapeutic opportunities.
I compare it with another patient I saw recently in almost precisely
the same life situation. In the treatment of this patient I attempted to
nurse the shudder rather than to anesthetize it. The patient experienced
what Kierkegaard called "creative anxiety," and her anxiety led us into
important areas. It was true that she had problems of self-esteem, she did
suffer from "empty nest" syndrome, and she also was deeply troubled
by her great ambivalence toward her child: she loved him but also re-
sented and envied him for the chances in life she had never had (and, of
course, she felt guilty because of these "ignoble" sentiments).
We followed her shudder, and it led us into important realms and
 238 THE YALOM READER

raised fundamental questions. It was true enough that she could find
ways to fill her time, but what was the meaning of the fear of the empty
nest? She had always desired freedom but now, having achieved it, was
terrified of it. Why?
A dream helped to illuminate the meaning of the shudder. Her son
who had just left home for college had been an acrobat and a juggler in
high school. Her dream consisted simply of herself holding in her hand
a 35-millimetcr photographic slide of her son juggling. The slide was
peculiar, however, in that it was a slide in movement: it showed her son
juggling and tumbling in a multitude of movements all at the same
time. Her associations to the dream revolved around time. The slide
captured and framed time and movement. It kept everything alive but
made everything stand still. It froze life. "Time moves on," she said,
"and there's no way I can stop it. I didn't want John to grow up. I really
treasured those years when he was with us. Yct whether I like it or not,
time moves on. It moves on for John and it moves on for me as well. It is
a terrible thing to understand, to really understand."
This dream brought her own finiteness into clear focus, and rather
than rush to fill time with distractions, she learned to wonder at and to
appreciate time and life in richer ways than she previously had. She
moved into the realm that Heidegger describes as authentic being: she
wondered not at the ivay that things arc but that things are. In my judg-
ment, therapy helped the second patient more than the first. It would
not be possible to demonstrate this conclusion on standard outcome
measures; in fact, the second patient probably continued to experience
more anxiety than the first did. But anxiety is a part of existence, and no
individual who continues to grow and to create will ever be free of it.
N cvcrtheless, such a value judgment evokes many questions about the
therapist's role. Is the therapist not assuming too much? Does the pa-
tient engage his or her services as a guide to existential awareness? Or :.!.
do not most patients say in effect,"[ fed bad, help me feel better"; and if
this is the case, why not use the speediest, most efficient means at one's
disposal-for example, pharmacological tr anquilization or behavioral
mo<lification? Such questions, which pertain to all forms of treatment
based on self-awareness, cannot be ignored, and they will emerge here
again and again. ~
 Death, Anxiety, and Psychotherapy 239

In the treatment of every patient, situations arise that, if sensitively

emphasized by the therapist, would increase the patient's awareness of
the existential dimensions of his or her problems. The most obvious sit-
uations are the stark reminders of finiteness and the irreversibility of
time. The death of someone close will, if the therapist persists, always
lead to an increased death awareness. There are many components to
grief--the sheer loss, the ambivalence and guilt, the disruption of a life
plan-and all need to be thoroughly dealt with in treatment. But, as I
stressed earlier, the death of another also brings one closer to facing
one's own death; and this part of the grief work is commonly omitted.
Some psychotherapists may feel that the bereaved is already too over-
whelmed to accept the added task of dealing with his or her own finite-
ness. I think, however, that assumption is often an error: some
individuals can grow enormously as a result of personal tragedy.
The Death of Another and Existential Awareness. For many, the
death of a close fellow creature offers the most intimate recognition one
can have of one's own death. Paul Landsburg, discussing the death of a
loved one, says:

We have constituted an "us" with the <lying person. And it is in this

"us," it is through the specific power of this new and utterly per-
sonal being that we are led toward the living awareness of our own
having to die .... My community with that person seems to be bro-
ken off; but this community in some degree was I myself, I feel
death in the heart of my own existence."

John Donne made the same point in his famous sermon: "And therefore
never send to know for whom the bell tolls. It tolls for thee.'?"
The loss of a parent brings us in touch with our vulnerability; if our
parents could not save themselves, who will save us? With parents gone
nothing stands between ourselves and the grave. On the contrary, we
become the barrier between our children and death. The experience of a
colleague after the death of his father is illustrative. He had long been
expecting his father's death and bore the news with equanirnity. How-
ever, as he boarded an airplane to fly home for the funeral, he panicked.
Though he was a highly experienced traveler, he suddenly lost faith in
 240 T HE Y A LO .M R EADER

the plane's capacity to take off and land safely-as though his shield
against precariousness had vanished.
The loss of a spouse often evokes the issue of basic isolation; the loss
of the significant other (sometimes the dominant other) increases one's
awareness that, try as hard as we may to go through the world two by
two, there is nonetheless a basic aloneness that we must bear. No one
can die one's own death with one or for one.
A therapist who attends closely to a bereaved patient's associations
and dreams will discover considerable evidence of the latter's concern
with his or her own death. For example, a patient reported this night-
mare on the night after learning that his wife had inoperable cancer:

I was living in n1y old house in . [A house that had been in

the fotnily for three generations.] A Frankenstein monster was
chasing me through the house. I was terrified. The house was
deteriorating, decaying. The tiles were crumbling and the roof
leaking. Water leaked all over my mother. [His mother had died
six months ago.] I fought with him. I had a choice of weapons. One
had a curved blade with a handle, like a scythe. T slashed him and
tossed him off the roof. He lay stretched out on the paven1ent
below. But he got up and once again started chasing me through
the house.

The patient's first association to the dream was: "I know I've got a hun-
dred thousand miles on me." The symbolism of the dream seemed
clear. His wife's impending death reminded him that his life, like his
house, was deteriorating; he was inexorably pursued by death, personi-
fied, as in his childhood, by a monster who could not be halted.
The loss of a son or daughter is often the bitterest loss of all to us, and
we simultaneously mourn our child and ourselves. Life seems to hit us,
at such a time, on all fronts at once. Parents first rail at the injustice in
the universe but soon begin to understand that what seemed injustice is,
in reality, cosmic indifference. They also are reminded of the limit of
their power: there is no time in life when they have greater motivation
to act and yet arc helpless; they cannot protect a defenseless child. As
 Death, Anxiety, and Psychotherapy 241

night follows day, the bitter lesson follows that we, in our turn, will not
be protected.
The psychiatric grief literature does not emphasize this dynamic but
instead often focuses on the guilt (thought to be associated with uncon-
scious hostility) that parents experience at the death of a child. Richard
Gardner?' studied parental bereavement empirically by systematically
interviewing and testing a large sample of parents whose children suf-
fered from some type of fatal illness. Though he confirmed that many
parents suffered considerable guilt, his data indicated that the guilt,
rather than emanating from "unconscious hostility," was four times
more commonly an attempt by the parent to assuage his or her O\Vn ex-
istential anxiety, to attempt to "control the uncontrollable.'' After all, if
one is guilty about not having done something one should have done,
then it follows that there fr something that could have been done-a far
more comforting state of affairs than the hard existential facts of life.
The loss of a child has another portentous implication for the par-
ents. It signals the failure of their major immortality project: they will
not be remembered, their seed will not take root in the future.
Milestones. Anything that challenges the patient's permanent view
of the world can serve as a fulcrum with which the therapist can wedge
open the patient's defenses and permit him a view of life's existential in-
nards. Heidegger emphasizes that only when machinery suddenly
breaks down do we become aware of its functioning."3 Only when de-
fenses against death anxiety are removed do we become fully aware of
what they shielded us from. Therefore, the therapist who looks may
find existential anxiety lurking when any major event, especially an ir-
reversible one, occurs in a patient's life. Marital separation and divorce
are prime exam pies of such events. These experiences are so painful that
therapists often make the error of focusing attention entirely on pain al-
leviation and miss the rich opportunity that reveals itself for deeper
therapeutic work.
For some patients, the commitment to a relationship, rather than the
termination of one, acts as a boundary situation. Commitment carries
with it the connotation of finality, and many individuals cannot settle
into a permanent relationship because that would mean "this is it," no
more possibilities, no more glorious dreams of continued ascendancy.
 242 TH E YA LO M R EA DER

The passage into adulthood is often particularly difficult. Individu-

als in their late teens and early twenties are often acutely anxious about
death. In fact, a clinical syndrome in adolescents called the "terror of
life" has been described: it consists of marked hypochondriasis and pre-
occupation with the aging of the body, with the rapid passage of time,
and with the inevitability of death."
Jaques, in his wonderful essay "Death and the Mid-Life Crisis,"
stresses that the individual in midlife is especially bedeviled by the
thought of death." This is the time of life when a person may become
preoccupied with the thought, often unconscious, that he or she "has
stopped growing up and has begun to grow old." Having spent the first
half of life in the "achievement of independent adulthood," one may
reach the prime of life (Jung called age forty the "noon of life")" only to
become acutely aware that death lies beyond. As one thirty-six-year-old
patient, who had become increasingly aware of death in his analysis, put
it: "Up till now, life has seemed an endless upward slope with nothing
but the distant horizon in view. Now suddenly I seemed to have
reached the crest of the hill, and there stretching ahead is the downward
slope with the end of the road in sight-far enough away, it's true-but
there is death observably present at the end." I
I

A threat to one's career or the fact of retirement (especially in indi- •

viduals who had believed that life was an ever-ascending spiral) can be a ~
particularly potent catalyst for increasing one's awareness of death. A
recent study of individuals making a midlife radical career shift sug-
gests that most of them had made the decision to "drop out" or to sim-
'1
plify their lives in the context of a confrontation with their existential
situation."
Simple milestones, such as birthdays and anniversaries, can be use-
ful levers for the therapist. The pain elicited by these signs of the pas-
I
sage of time runs deep (and for that reason is generally dealt with by
reaction formation, in the form of a joyous celebration). Sometimes
mundane reminders of aging offer an opportunity for increased exis-
tential awareness. Even a penetrating look in the mirror can open the
issue. One patient told me that she said to herself, "I'm just a little
gnome. I'm the same little Isabelle inside, but outside I'm an old lady.
I'm sixteen going on sixty. I know it's perfectly all right for others to
 Death, Anxiety, and Psychotherapy 243

age, but somehow I never thought it would happen to me." Even the
recognition that one enjoys "old people's" pleasures-watching, walk-
ing, serene quiet times-may act as a spur to death awareness. The
same may be said about looking at old photographs of oneself and not-
ing how one resembles one's parents when they were considered old, or
seeing friends after long intervals and noting how they have aged. The
therapist who listens carefully will be able to use any of these everyday
occurrences. Or the therapist may tactfully contrive such situations.
Freud, for instance, had no qualms about requesting Fraulein Elisa-
beth to meditate at the site of her sister's grave.
A careful monitoring of dreams and fantasies will invariably provide
material to increase death awareness. Every anxiety dream is a dream of
death; frightening fantasies involving such themes as unknown aggres-
sors breaking into one's home always, when explored, lead to the fear of
death. Discussions of unsettling television shows, movies, or books may
similarly lead to essential material.
Severe illness is such an obvious catalyst that no therapist should let
this opportunity pass by unmined. Noyes studied t\.VO hundred patients
who had had near-death experiences through sudden illness or accident
and found that a substantial number (25 percent) had a new and power-
ful sense of death's omnipresence and nearness. One of his subjects
commented, "I used to think death would never happen or, if it did, I
would be eighty years old. But now I realize it can happen any time, any
place, no matter how you live your life. A person has a very limited per-
ception of death until he is confronted with it." Another described his
death awareness in these terms: "I have seen death in life's pattern and
affirmed it consciously. I am not afraid to live because I feel that death
has a part in the process of my being." Though a few of Noyes's subjects
reported an increased terror of death and a greater sense of vulnerabil-
ity, the great majority reported that their increased death awareness had
been a positive experience resulting in a greater sense of life's precious-
ness and a constructive reassessment of their life's priorities."
Artificial Aids to Increase Death Awareness. Though the naturally
occurring reminders of death's presence are numerous, they are not,
therapists often find, sufficiently potent to combat a patient's ever-
vigilant denial. Consequently many therapists have sought vivid tech-
 244 TH E Y ALO M R EA D ER

niques to bring patients to face the fact of death. In the past, intentional
and unintentional reminders of death were far more common than they
are today. It was precisely for the purpose of reminding one of life's
transiency that a human skull was a common furnishing in a medieval
monk's cell. John Donne, the seventeenth-century British poet and cler-
gyman, wore a funeral shroud when he preached "Look to eternity" to
his congregation; and earlier, Montaigne, in his splendid essay "That to
Philosophize Is to Learn How to Die," had much to say on the subject
of intentional reminders of our finiteness:

... we plant our cemeteries next to churches, and in the most fre-
quented parts of town, in order (says Lycurgus) to accustom the
common people, women and children, not to grow panicky at the
sight of a dead man, and so that the constant sight of bones, tombs,
and funeral processions should remind us of our condition .... To
feasts, it once was thought, slaughter lent added charms/Mingling
with foods the sight of combatants in arms/ And gladiators fell
amid the cups, to pour/Onto the very tables their abundant gore .
. . . And the Egyptians, after their feasts, had a large image of death
shown to the guests by a man who called out to them: "Drink and
be merry, for when you are dead you will be like this."
So I have formed the ha bit of having death continually present,
not merely in my imagination, but in my mouth. And there is noth-
ing that I investigate so eagerly as the death of men: what words,
what look, what bearing they maintained at that time; nor is there a
place in the histories that I note so attentively. This shows in the
abundance of my illustrative examples: I have indeed a particular
fondness for this subject. If I were a maker of books, I would make
a register, with comments, of various deaths. He who would teach
men to die would teach them to live."

Some encounter-group leaders have used a form of "existential

shock" therapy by asking each member to write his or her own epitaph
or obituary. "Destination" labs held for harried business executives
commonly began with this structured exercise:
 Death, Anxiety, and Psychotherapy 245

On a blank sheet of paper draw a straight line. One end of that line
represents your birth; the other end, your death. Draw a cross to
represent where you are now. Meditate upon this for five minutes.

This short, simple exercise almost invariably evokes powerful and pro-
found reactions.
Interaction with the Dying. There are many such exercises. As in-
triguing as many of them are, they nonetheless are make-believe.
Though one can be drawn into such an exercise for a period of time, de-
nial quickly sets in, and one reminds oneself that one still exists, that one
is merely observing these experiences. It was precisely because of the
persistence and ubiquity of denial to assuage dread that several years
ago I started to treat individuals with a fatal illness, individuals who
were continually in the midst of urgent experience and could not deny
what was happening to them. My hope was not only to be useful to
these patients but to be able to apply what I learned to the treatment of
the physically healthy patient.
Group therapy sessions with terminal patients are often powerful
with the evocation of much affect and the sharing of much wisdom.
Many patients feel that they have learned a great deal about life but are
frustrated in their efforts to be helpful to others. One patient put it, "I
feel I have so much to teach, but my students will not listen." I have
searched for ways to expose everyday psychotherapy patients to the wis-
dom and power of the dying and shall describe here my limited experi-
ence with one approach.
Observation of a Terminal Cancer Group by Everyday Psychother-
apy Patients. One patient who observed a meeting of the group of
cancer patients was Karen, whom I discussed earlier. Karen's major
dynamic conflict was her pervasive search for a dominant other-an
ultimate rescuer-which took the form of psychic and sexual maso-
chism. Karen would limit herself or inflict pain on herself, if necessary,
to gain the attention and protection from some "superior" figure. The
meeting she observed was particularly powerful. One patient, Eva, an-
nounced to the group that she had just learned she had a recurrence of
cancer. She said that she had done something chat morning that she
had long postponed: she had written a letter to her children giving in-
 246 THE Y ALOM READER
1
I
1
structions about the division of minor sentimental items. In placing the ~
letter in her safe-deposit box, she realized with a clarity she had never
before attained that indeed she would cease to be. As I have described,
she realized that when her children read that letter, she would not be
there to observe or to respond to them. She wished, she said, that she
had done her work on death in her twenties rather than waiting until
now. Once one of her teachers had died (Eva was a school principal);
and, rather than concealing the death from the students, she realized
how right she had been to hold a memorial service and openly discuss
death-the death of plants, animals, pets, and humans-s-with the chil-
dren. Other group members, too, shared their moments of full realiza-
tions about their deaths, and some discussed the ways they had grown
as a result of that realization.
An interesting debate developed as one member told about a neigh-
bor who had been perfectly healthy and had died suddenly during the
night. "That's the perfect death," she said. Another member disagreed
and in a few moments had presented compelling reasons that that type
of death was unfortunate: the dead woman had had no time to put her
affairs in order, to complete unfinished business, to prepare her hus-
band and her children for her death, to treasure the end of life as some
of the members in the group had learned to do. "[ust the same," the first
quipped, "that's still the way I'd like to die. I've always loved surprises!"
Karen reacted strongly to the meeting she had observed. It was im-
mediately thereafter that she arrived at 1nany deep insights about her-
self. For example, she realized that because of her fear of death, she had
sacrificed much of her life. She had so feared death that she had orga-
nized her life around the search for an ultimate rescuer; therefore, she
had feigned illness during her childhood and stayed sick in adulthood
to remain near her therapist. While observing the group, she realized
with horror that she would have been willing to have cancer in order to
be in that group and sit next to me, perhaps even hold my hand (the
group ended with a hand-holding period of meditation). When I
pointed out the obvious-that is, that no relationship is eternal, that I, as
well as she, would die-she said that she felt that she would never be
alone if she could <lie in my arms. The evocation and the subsequent
work ing through of this mater ial helped move Karen into a new phase
 Death, Anxiety, and Psychotherapy 247

of therapy, especially into a consideration of termination-an issue that

previously she had never been willing to broach.
Another everyday therapy patient who observed the group was Su-
san, the wife of an eminent scientist who, when she was fifty, had sued
her for divorce. In her marriage she had lived a mediated existence,
serving him and basking in his accomplishments. Such a life pattern,
not uncommon among wives of successful husbands in these days, had
certain inevitable tragic consequences. First, she did not live her life; in
her effort to build up credit with the dominant other she submerged
herself, she lost sight of her wishes, her rights, and her pleasure. Second,
because of the sacrifice of her own strivings, interests, desires, and spon-
taneity, she became a less stimulating partner and was considerably
more at risk for divorce.
In our work Susan passed through a deep depression and gradually
began to explore her pro-active feelings, not the reactive ones to which
she had always limited herself. She felt her anger-deep, rich, and vi-
brant; she felt her sorrow-not at the loss of her husband but at the loss
of herself all those years; she felt outraged at all the restrictions to which
she had consented. (For example. to ensure that her husband had opti-
mal working conditions at home, she was not permitted to watch televi-
sion, to speak on the phone, to garden while he was home-his study
looked out on the garden and her presence distracted hirn.) She ran the
risk of being overcome with regret for so much wasted life, and the task
of therapy was to enable her to revitalize the remainder of her life. After
two months of therapy she watched a poignant meeting of the cancer
group, was moved by the experience, and immediately plunged into
productive work which finally permitted her to understand that the di-
vorce might be salvation rather than requiem. After therapy she moved
to another city and several months later wrote a debriefing letter which
included:

First of all, I've thought that those women with cancer need not be
reminded of the inevitability of death; that the awareness of death
helps them to see things and events in their proper proportions and
corrects our ordinarily poor sense of time. The life ahead of me may
be very short. Life is precious, don't waste it! Make the most of
 THE YALOM READER

every day in the ways you value! Reappraise your values! Check
your priorities! Don't procrastinate! Do!
I, for one, have wasted time. Every once in a while in the past,
I'd feel vividly that I was only a spectator or an understudy watch-
ing the drama of life from the wings, but always hoping and believ-
ing that one day I'd be on the stage myself. Sure enough there had
been times of intense living, but more often than not life seemed
just a rehearsal for the "real" life ahead. But what if death comes be-
fore the "real" life has started? It would be tragic to realize when it's
too late, that one has hardly lived at all.

Death as a Primary Source of Anxiety

The concept of death provides the psychotherapist with two major
forms of leverage. I have discussed the first: that death is of such mo-
mentous importance that it can, if properly confronted, alter one's life
perspective and promote a truly authentic immersion in life. The sec-
ond, to which I shall now turn my attention, is based on the premise
that the fear of death constitutes a primary source of anxiety, that it is
present early in life, is instrumental in shaping character structure, and
continues throughout life to generate anxiety that results in manifest
distress and in the erection of psychological defenses.
First, some general therapeutic principles. It is important to keep in
mind that death anxiety, though it is ubiquitous and has pervasive ram-
ifications, exists at the deepest levels of being, is heavily repressed, and is
rarely experienced in its full sense. Death anxiety per se is not easily evi-
dent in the clinical picture of most patients; nor does it often become an
explicit theme in the therapy, especially not in brief therapy, of most pa-
tients. Some patients are, however, suffused with overt death anxiety
from the very onset of therapy. There are also life situations in which
the patient has such a rush of death anxiety that the therapist, try as he
or she might, cannot evade the issue. Furthermore, in long-term inten-
sive therapy which explores deep levels of concern, explicit death anxi-
ety is always to be found and must be considered in the therapeutic
process.
 Death, Anxiety, and Psychotherapy 249

Since death anxiety is so intimately tied to existence, it has a different

connotation from "anxiety" in other frames of reference. Though the
existential therapist hopes to alleviate crippling levels of anxiety, he or
she does not hope to eliminate anxiety. Life cannot be lived nor can
death be faced without anxiety. Anxiety is guide as well as enemy and
can point the way to authentic existence. The task of the therapist is to
reduce anxiety to comfortable levels and then to use this existing anxiety
to increase a patient's awareness and vitality,
Another major point to keep in mind is that, even though death anx-
iety may not explicitly enter the therapeutic dialogue, a theory of anxi-
ety based on death awareness provides the therapist with a frame of
reference, an explanatory system, that may greatly enhance his or her
effectiveness.

Repression of Death Anxiety

Earlier I described a head-on automobile collision where, had cir-
cumstances been less fortunate, I would have lost my life. 1-f y response
to that accident serves as a transparent model for the workings of death
anxiety in neurotic reactions. Recall that within a day or two I no longer
experienced any explicit death anxiety but instead noted a specific pho-
bia surrounding luncheon discussions. What happened was that I "han-
dled" death anxiety by repression and displacement. I bound anxiety to
a specific situation. Rather than being fearful of death or of nothingness,
I became anxious about something. Anxiety is al ways ameliorated by
becoming attached to a specific object or situation. Anxiety attempts to
become fear. Fear is fear of some thing; it has a location in time and
space; and, because it can be located, it can be tolerated and even "man-
aged'' (one may avoid the object or develop some systematic plan of con-
quering one's fear); fear is a current sweeping over one's surface-it
does not threaten one's foundation.
I believe that this course of events is not uncommon. Death anxietv• is
deeply repressed and not part of our everyday experience. Gregory Zil-
boorg, in speaking of the fear of death, said: "If this fear were constantly
conscious, we should be unable to function normally. It must be prop-
erly repressed to keep us living with any modicum of comfort. ,,_
No doubt the repression, and subsequent invisibility, of death a nxi-
 250 T HE y ALO M R EADER

ety is the reason that many therapists neglect its role in their work. But
surely the same state of affairs applies to other theoretical systems. The
therapist always works with tracings of and defenses against primal
anxiety. How often, for example, does an analytically oriented therapist
encounter explicit castration anxiety? Another source of confusion is
II
that the fear of death can be experienced at many different levels. One i

may, for example, consider death dispassionately and intellectually. Yet

this adult perception is by no means the same as the dread of death that
l
I
resides in the unconscious, a dread that is formed early in life at a time
prior to the development of precise conceptual formulation, a dread that
is terrible and inchoate and exists outside of language and image. The
original unconscious nucleus of death anxiety is made more terrifying
yet by the accretion of a young child's horrible misconceptions of death.
As a result of repression and transformation, existential therapy
deals witn anxiety that seems to have no existential referent. Later I
shall discuss patients who have much overt death anxiety and also how
layers of explicit death anxiety must always be reached through long
and intensive therapy. But even in those courses of therapy where death
anxiety never becomes explicit, the paradigm based on death anxiety
may enhance the therapist's effectiveness.
The Therapist Is Provided with a Frame of Reference That Greatly
Enhances His or Her Effectiveness. As nature abhors a vacuum, we
humans abhor uncertainty. One of the tasks of the therapist is to in-
t,
crease the patient's sense of certainty and mastery. It is a matter of no i
small importance that one be able to explain and order the events in our I'
l
lives into some coherent and predictable pattern. To name something,
to locate its place in a causal sequence, is to begin to experience it as un-
der our control. No longer, then, is our internal experience or behavior ! :

frightening, alien, or out of control; instead, we behave (or have a par-

ticular inner experience) because of something we can name or iden-
tify. The "because" offers one mastery (or a sense of mastery that
phenomenologically is tantamount to mastery). I believe that the sense
of potency that flows from understanding occurs even in the matter of
our basic existential situation: each of us feels less futile, less helpless,
and less alone, even when, ironically, what we come to understand is
the fact that each of us is basically helpless and alone in the face of cos-
mic indifference.
 Death, Anxiety, and Psychotherapy 251

I've already discussed an explanatory system of psychopathology

based on death anxiety. The importance of such an explanatory system
is as important for the therapist as it is for the patient. Every therapist
uses an explanatory systeru-s-some ideological frame of reference-to
organize the clinical material with which he or she is faced.
The therapist's sense of certainty issuing from an explanatory system
of psychopathology has a benefit for therapy which is curvilinear in na-
ture. There is an optimal amount of therapist certainty: too little and too
much are counterproductive. Too little certainty, for reasons already
discussed, retards the formation of the necessary level of trust. Too
much certainty, on the other hand, becomes rigidity. The therapist re-
jects or distorts data that will not fit into his system; furthermore, the
therapist avoids facing, and helping the patient to face, one of the core
concepts in existential therapy-that uncertainty exists, and that all of
us must learn to coexist with it.

Interpretative Options: An Illustrative Case Study

Earlier I described some general existential dynamics underlying
common clinical syndromes involving death anxiety. I shall present
here specific interpretative options in a case of compulsive sexuality.
Bruce was a middle-aged male and had since adolescence been con-
tinually, as he put it, "on the prowl." He had had sexual intercourse
with hundreds of women but had never cared deeply for any one of
them. Bruce did not relate to a woman as to a whole person but as a
"piece of ass." The women were more or less interchangeable. Theim-
portant thing was bedding a woman-but, once orgasm was reached,
he had no particular desire to remain with her. It was not unusual,
therefore, once a woman had left, for him to go out searching for an-
other, sometimes only minutes later. The compulsive quality of his be-
havior was so clear that it was evident even to him. He was aware often
of "needing" or "having" to pursue a woman when he did not wish to.
Now Bruce could be understood from many perspectives, none of
which had exclusive hegemony. The Oedipal overtones were clearly ev-
ident: he desired but feared women who resembled his mother. He was
usually impotent with his wife. The closer he came in his travels to the
city his mother inhabited, the stronger was his sexual desire. Further-
more, his dreams groaned with incestuous and castration themes. There
 252 THE YA LOM READER

was also evidence that his compulsive heterosexuality was powered by

the need to handle the eruption of unconscious homosexual impulses.
Bruce's self-esteem was severely impaired, and the successful seduction
of women could be understood as an attempt to bolster his self-worth.
Still another perspective: Bruce had both a need and a fear of closeness.
The sexual encounter, at once closeness and caricature of closeness, hon-
ored both the need and the fear.
During more than eight years of analysis and several courses of ther-
apy with competent therapists, all of these explanations, and many oth-
ers besides, were explored fully, but without effect on his compulsive
sexual drive.
During my work with Bruce I was struck by the rich, unmined exis-
tential themes. Bruce's compulsivity could be understood as a shield
against confrontation with his existential situation. For example, it was
apparent that Bruce was fearful of being alone. Whenever he was away
from his family, Bruce took great pains to avoid spending an evening
alone.
Anxiety can be a useful guide, and there are times when the therapist
and patient must openly court anxiety. Accordingly, when Bruce had
increased his ability to tolerate anxiety, I suggested that he spend an
evening entirely alone and record his thoughts and feelings. What tran-
spired that night was exceedingly important in his therapy. Raw terror
is the best term for the experience. He encountered, for the first time
since childhood, his fear of the supernatural. By sheer chance there was
11
a brief power failure and Bruce gre\v terrified of the dark. He imagined
that he saw a dead woman lying on the bed (resembling the old woman
in the film The Exorcist); he imagined he saw a death's-head in the win-
dow; he feared that he might be touched by "something, perhaps a hand
of a skeleton all dressed in rags." He gained enormous relief from the
presence of a dog and for the first time realized the strong bond be-
tween some individuals and their pets: "What is needed," he said, "is
not necessarily a human companion but something alive near you."
The terror of that evening was gradually, through the work of ther-
apy, transformed into insight. Spending an evening alone made the
function of sex abundantly clear. Without the protection of sex Bruce
encountered massive death anxiety: the images were vivid-a dead
woman, a skeleton's hand, a death's-head. How did sex protect Bruce
 Death, Anxiety, and Psychotherapy 253

from death? In a number of ways, each of which we analyzed in ther-

apy. Sexual compulsivity, like every symptom, is overdetermined. For
one thing sex was a form of death defiance. There was something
frightening about sex for Bruce; no doubt sex was deeply entangled
with buried incestuous yearnings and with fears of retaliatory castra-
tion-and by "castration" I mean not literal castration but annihilation.
Thus the sexual act was counterphobic. Bruce stayed alive by jamming
his penis into the vortex of life. Viewed in this way, Bruce's sexual com-
pulsivity dovetailed with his other passions-parachuting, rock climb-
ing, and motorcycling.
Sex also defeated death by reinforcing Bruce's belief in his personal
specialness. Bruce stayed alive, in one sense, by being the center of his
universe. Women revolved about him. All over the world women
adored him. They existed for him alone. Bruce never thought of them
as having independent lives. He imagined they remained in suspended
animation for him; that, like Joseph K.'s flagellators in Kafka's The
Trial, they were there for him every time he opened their doors, and
that they froze into immobility when he did not call upon them. And of
course sex served the function of preventing the conditions necessary for
a true confrontation with death. Bruce never had to face the isolation
that accompanies the awareness of one's personal death. Women were
"something alive and near," much like the dog on the night of his ter-
ror. Bruce was never alone, he was always in the midst of coitus (a fre-
netic effort to fuse with a woman), searching for a woman, or just
having left a woman. Thus, his search for a woman was not truly a
search for sex, nor even a search powered by infantile forces, by "the
stuff from which," as Freud liked to say, "sex will come,'?' but instead it
was a search to enable Bruce to deny and to assuage his fear of death.
Later in therapy an opportunity arose for him to go to bed with a
beautiful woman who was the wife of his immediate boss. He deliber-
ated about this chance and discussed it with a friend who counseled him
against taking it because it might have destructive ramifications. Bruce
also knew that the toll he would have to pay in anxiety and guilt would
be prohibitive. Finally with a mighty wrench he, for the first time in his
life, decided to forgo the sexual conquest. In our next therapy hour I
agreed with him that he was acting indeed in his best interests.
His reaction to his decision was enlightening. He accused me of tak-
 254 TH E YA LO M R EA DER

ing his life's pleasures away from him. He felt "done for," "finished."
The following day, at a time when he could have had a sexual assig-
nation, he read a book and sunbathed. "This is what Yalom wanted,"
he thought, "for rne to grow old, sit in the sun and bleach like an old
dog turd." He felt lifeless and depressed. That night he had a dream
that illuminates better than any dream I have known the use of dream
symbolism:

I had a beautiful how and arrow, I was proclaiming it as a great

work of art that possessed magical qualities. You and X (a friend]
differed and pointed out that it was just a Yery ordinary bow and
arrow. I said, "No, it's magic, look at those features, and these!"
[pointing at two protuberances]. You said, "No, it's very ordinary."
And you proceeded to demonstrate to me how simply the bow was
constructed, how simple twigs and bindings accounted for its shape.

What Bruce's dream illustrates so beautifully is another way that sex

is death defeating. Death is connected with banality and ordinariness.
The role of rnagic is to allow one to transcend the laws of nature, to
transcend the ordinary, to deny one's creaturely identity-an identity
that condemns one to biological death. His phallus was an enchanted
bow and arrow, a rnagic wand lifting him above natural law. Each af-
fair magically constituted a mini-life; although each of his affairs was a
maze ending in a cul-de-sac, his affairs, all of them taken together, pro-
vided him with the illusion of a constantly lengthening lifeline.
As we worked through the material generated by his taking these t
two stands-spending time alone and not accepting a sexual invita- ~
•
tion-a great deal of insight ensued to illuminate not only his sexual
pathology but n1any other aspects of his life. For example, he had al-
ways related to others in a highly limited, sexual way. When his sexual
corn pulsiveriess waned, he began for the first time to confront the ques-
tion, What are people for?-a question that launched a valuable explo-
ration of Bruce's confrontation with existential isolation. Indeed,
Bruce's course of therapy illustrates the interdependence of all the ulti-
mate concerns. Bruce's decision, and his subsequent reluctance to accept
that decision, to pass up a sexual invitation was the tip of the iceberg of
 Death, Anxiety, and Psychotherapy 255

another extraordinarily important existential concern, freedom, and es-

pecially of the issue of assuming responsibility. Lastly, Bruce's eventual
relinquishment of his sexual compulsion confronted him with another
ultimate concern-meaninglessness. With the removal of his major rai-
son d'etre, Bruce began to confront the problem of purpose in life.

Death Anxiety in Long-Term Therapy

Though brief courses of therapy often entirely circumvent any ex-
plicit consideration of death anxiety, any long-term intensive therapy
will he incomplete without working through awareness and fear of
death. As long as a patient continues to atternpt to ward off death
through an infantile belief that the therapist will deliver him or her
from it, then the patient will not leave the therapist. "As long as I am
with you, I will not die" is the unspoken refrain that so often emerges in
late stages of therapy.
Death cannot be ignored in an extensive venture of self-exploration,
because a major task of the mature adult is to come to terms with the re-
ality of decline and diminishment. The Divine Comedy, which Dante
wrote in his late thirties, may be understood on many allegorical levels,
but certainly it reflects its author's concern about his personal death.
The opening verses describe the fearful confrontation with one's own
mortality that frequently occurs in midlife.

In the middle of the course of our life, I came to myself within a

dark wood, having lost the direct way. Ah, how difficult it is to de-
scribe what that wood was like, thick and savage and harsh, just the
thought of which renews my fear."

Individuals who have had significant emotional distress in their

lives, and whose neurotic defenses have resulted in self-restriction, ,nay
encounter exceptionally severe difficulty in midlife, the time when ag-
ing and impending death must be recognized. The therapist who treats
a patient in midlife must remind himself or herself that much psy-
chopathology emanates from death anxiety. Jaques, in his essay on the
midlife crisis, states this clearly:
 256 THE YALOM READER

A person who reaches midlife, either without having successfully

established himself in marital and occupational life, or having
established himself by means of manic activity and denial with
consequent emotional impoverishment, is badly prepared for
meeting the demands of middle age, and getting enjoyment out of
his maturity. In such cases, the midlife crisis, and the adult en-
counter with the conception of life to be lived in the setting of an
approaching personal death, will likely be experienced as a period
of psychological disturbance and depressive breakdown. Or break-
down may be avoided by means of a strengthening of manic de-
fenses, with a warding off of depression and persecution about
aging and death, but with an accumulation of persecutory anxiety
to be faced when the inevitability of aging and death eventually
demands recognition.
The compulsive attempts, in many men and women reaching
middle age, to remain young, the hypochondriacal concern over
health and appearance, the emergence of sexual promiscuity in or-
der to prove youth and potency, the hollowness and lack of genuine
enjoyment of life, and the frequency of religious concern are famil-
iar patterns. They are attempts at a race against time."

Problems of Psychotherapy

Denial by Patient and Therapist

Despite the omnipresence of death and the vast number of rich op-
portunities available for exploring it, most therapists will find extraordi-
narily difficult the tasks of increasing the patient's death awareness and
working through death anxiety. Denial confounds the process every
step of the way. Fear of death exists at every level of awareness-from
the most conscious, superficial, intellectualized levels to the realm of
deepest unconsciousness. Often a patient's receptivity, at superficial lev-
els, to the therapist's interpretation acts in the service of denial at deeper
layers. A patient may be responsive to the therapist's suggestion that the
patient examine his or her feelings about his or her finiteness, but grad-
 Death, Anxiety, and Psychotherapy 257

ually the session becomes unproductive, the mater ial runs dry, and the
discourse moves into an intellectualized discussion. It is important at
these times that the therapist not leap to the erroneous conclusion that
he or she is drilling a dry well. The blocking, the lack of associations,
the splitting off of affect are all manifestations of resistance and should
be treated accordingly. One of Freud's first discoveries in the practice of
dynamic therapy was that the therapist repeatedly comes up against a
psychological force in the patient that opposes the therapeutic work.
The Therapist Must Persevere. The therapist must continue to col-
lect evidence, to work with dreams, to persist in his or her observations,
to make the same points, albeit with different emphases, over and over
again. Observations about the existence of death 1nay seem so banal, so
overly obvious that the therapist feels fatuous in persisting to make
them, Yet simplicity and persistence are necessary to overcome denial.
One patient, a depressed, masochistic, suicidal individual, in a debrief-
ing session some months after termination of therapy, described the
most important comment I had made to her during therapy. She had
frequently described her yearning for death and, at other times, the var-
ious things she would like to do in life. I had made, more than once, the
embarrassingly simple observation that there is only one possible se-
quence for these events: experience first and death last.
The patient is not the only source of denial, of course. Frequently the
denial of the therapist silently colludes with that of the patient. The
therapist no less than the patient must confront death and be anxious in
the face of it. Much preparation is required of the therapist who must in
everyday work be aware of death. ~1y co-therapist and I became acutely
aware of this necessity while leading a group of patients with metastatic
cancer. During the first months of the group the discussion remained
superficial: much talk about doctors, medicines, treatment regimes,
pain, fatigue, physical limitations, and so forth. We considered this su-
perficiality to be defensive in nature-a signal of the depth of the pa-
tients' fear and despair. Accordingly, we respected the defense and led
the group in a highly cautious manner.
Only much later did we learn that we therapists had played an ac-
tive role in keeping the group superficial. When we could tolerate our
anxiety and follow the patients' leads, then there was no subject too
 258 THE YALOM READER

frightening for the group to deal with explicitly and constructively.

The discussion was often extraordinarily painful for the therapists.
The group was observed through a one-way mirror by a number of
student mental health professionals, and on several occasions some had
to leave the observation room to compose themselves. The experience I

of working with dying patients has propelled many therapists back for I
another course of personal therapy-often highly profitable for them,
since many had not dealt with concerns about death in their first, tradi-
tional therapy experiences.
If a therapist is to help patients confront and incorporate death into
life, he or she must have personally worked through these issues. An in-
teresting parallel is to be found in the initiation rites of healers in primi-
tive cultures, n1any of which have a tradition requiring that a shaman
pass through some ecstatic experience that entails suffering, death, and I

resurrection. Sometimes the initiation is a true sickness, and the individ-

ual who hovers long between life and death is selected for shamanism.
Generally the experience is a mystical vision. To take one, not atypical
example, a Tungus (a Siberian tribe) shaman described his initiation as
consisting of a confrontation with shaman ancestors who surrounded
him, pierced him with arrows, cut off his flesh, tore out his bones, drank
his blood, and then reassembled him." Several cultures require that the
novice shaman sleep on a grave or remain bound for several nights in a
cemetery /5

Why Stir Up a Hornet's Nest?

Many therapists avoid discussions of death with a patient not because
of denial but because of a deliberate decision based on the belief that the
thought of death would aggravate that patient's condition. Why stir up
a hornet's nest? Why plunge the patient deeply into a theme that can
only increase anxiety and about which one can do nothing? Everyone
must face death. Does not the neurotic patient have quite enough trou-
bles without being burdened with reminders of the bitter quaff await-
ing all humans?
It is one thing, these therapists feel, to excavate and examine neu-
rotic problems; there at least they can be of some help. But to explore
the real reality, the bitter, immutable facts of life, seems not only folly
 Death, Anxiety, and Psychotherapy 259

but antitherapeutic, The patient dealing with unreconciled Oedipal

conflicts, for example, is hamstrung by phantasmal torments: some
constellation of internal and external events that occurred long ago
persists in the timeless unconscious and haunts the patient. The patient
responds to current situations in distorted fashion: to the present as
though it were the past. The therapist's mandate is clear: to illuminate
the present, to expose and scatter the demons of the past, to help the pa-
tient detoxify events that are intrinsically benign but irrationally expe-
rienced as noxious.
But death? Death is not a ghost from the past. And it is not intrinsi-
cally benign. What can be done with it?
Increased Anxiety in Therapy. First, it is true that the thought of
our finitude has a force field of anxiety about it. To enter the field is to
heighten anxiety. The therapeutic approach I describe here is dynamic
and uncovering; it is not supportive or repressive. Existential therapy
does increase the patient's discomfort. It is not possible to plunge into
the roots of one's anxiety without, for a period of time, experiencing
heightened anxiousness and depression.
Bugental, in his excellent discussion of the subject, refers to this
phase of treatment as the "existential crisis"-an inevitable crisis which
occurs when the defenses used to forestall existential anxiety are
breached, allowing one to become truly aware of one's basic situation
in life.'6

Life Satisfaction and Death Anxiety:

A Therapeutic Foothold
From a conceptual standpoint the therapist does well to keep in mind
that the anxiety surrounding death is both neurotic and normal. All hu-
man beings experience death anxiety, but some experience such exces-
sive amounts of it that it spills into many realms of their experience and
results in heightened dysphoria and/or a series of defenses against anxi-
ety which constrict growth and often themselves generate secondary
anxiety. Why some individuals are brought down by the conditions that
all must face is a question I have already addressed: the individual, be-
cause of a series of unusual life experiences, is unduly traumatized by
 260 T HE Y ALO M R EA DER

death anxiety and fails to erect the "normal" defenses against existential
anxiety. What the therapist encounters is a failure of the homeostatic
regulation of death anxiety.
One approach available to the therapist is to focus on the patient's
current dynamics that alter that regulation. I believe that one particu-
larly useful equation for the clinician is: death anxiety is inversely propor-
tional to lifesatisfaction.
John Hinton reports some interesting and relevant research find-
ings." He studied sixty patients with terminal cancer and correlated
their attitudes (including "sense of satisfaction or fulfillment in life")
with their feelings and reactions during terminal illness. The sense of
satisfaction in life was rated from interviews with the patient and the
patient's spouse. The feelings and reactions during the terminal illness
were measured by interviews with the patients and by rating scales
completed by nurses and spouses. The data revealed that, to a highly J
significant degree, "when life had appeared satisfying, dying was less 1'
troublesome .... Lesser satisfaction with past life went with a more
troubled view of the illness and its outcome." The lesser the life satisfac-
tion, the greater was the depression, anxiety, anger, and overall concern
about the illness and levels of satisfaction with the medical care.
These results seem counterintuitive because, on a superficial level,
one might conclude that the unsatisfied and disillusioned might wel-
come the respite of death. But the opposite is true: a sense of fulfillment,
a feeling that life has been well lived, mitigates against the terror of
death. Nietzsche, in his characteristic hyperbole, stated: "What has be-
come perfect, all that is ripe-wants to die. All that is unripe wants to I
1
live. All that suffers wants to live, that it may become ripe and joyous
and longing-longing for what is further, higher, brighter. "78
I
Surely this insight gives the therapist a foothold! If he can help the I
patient experience an increased satisfaction in life, he can allay excessive
anxiety. Of course, there is a circularity about this equation since it is be-
cause of an excessive death anxiety that the individual lives a constricted
life-a life dedicated more to safety, survival, and relief from pain than
to growth and fulfillment.
Yet still there is a foothold. The therapist must not be overawed by
the past. It is not necessary that one experience forty years of whole, in-
 Death, Anxiety, and Psychotherapy 261

tegrated living to compensate for the previous forty years of shadow life.
Tolstoy's Ivan Ilych, through his confrontation with death, arrived at an
existential crisis and, with only a few days of life remaining, trans-
formed himself and was able to flood, retrospectively, his entire life
with meaning.
The less the life satisfaction, the greater the death anxiety. This prin-
ciple is clearly illustrated by one of my patients, Philip, a fifty-three-
year-old, highly successful business executive. Philip had always been a
severe workaholic; he worked sixty to seventy hours a week, always
lugged a briefcase brimming with work home in the evening, and dur-
ing one recent two-year period worked on the East Coast and com-
muted weekends to his home on the West Coast. He had little life
satisfaction: his work afforded safety, not pleasure; he worked not be-
cause he wanted to, but because he had to, to assuage anxiety. He hardly
knew his wife and children. Years ago his wife had had a brief extra-
marital affair, and he had never forgiven her-not so much for the ac-
tual act, but because the affair and its attendant pain had been a major
source of distraction from his work. His wife and children had suffered
from the estrangement, and he had never dipped into this potential
reservoir of love, life satisfaction, and meaning.
Then a disaster occurred that stripped Philip of all his defenses. Be-
cause of severe setbacks in the aerospace industry, his company failed
and was absorbed by another corporation. Philip suddenly found him-
self unemployed and possibly, because of his age and high executive po-
sition, unemployable. He developed severe anxiety and at this point
sought psychotherapy. At first his anxiety was entirely centered on his
work. He ruminated endlessly about his job. Waking regularly at 4
A.M., he lay awake for hours thinking of work: how to break the news to
his employees, how best to phase out his department, how to express his
anger at the way he had been handled.
Philip could not find a new position, and as his last day of work ap-
proached, he became frantic. Gradually in therapy we pried loose his
anxiety from the work concerns to which it adhered like barnacles to a
pier. It became apparent that Philip had considerable death anxiety.
Nightly he was tormented by a dream in which he circled the very edge
of a "black pit." Another frightening recurrent dream consisted of his
 262 TH E Y A LO M R EA D ER

walking on the narrow crest of a steep dune on the beach and losing his
balance. He repeatedly awoke from the dream mumbling, "I'm not go-
ing to make it." (His father was a sailor who drowned before Philip was r
born.)
Philip had no pressing financial concerns: he had a generous sever-
ance settlement, and a recent large inheritance provided considerable
security. But the time! How was he going to use the time? Nothing
meant very much to Philip, and he sank into despair. Then one night an
important incident occurred. He had been unable to go to sleep and at
approximately 3:00 A.M. went downstairs to read and drink a cup of tea.
He heard a noise at the window, went over to it, and found himself face
to face with a huge stocking-masked man. After his startle and the
alarm had subsided, after the police had left and the search was called
off, Philip's real panic began. A thought occurred to him, a jarring
thought, that sent a powerful shudder through his frame: "Something
might have happened to Mary and the children." When, during our
therapy hour, he described this incident, his reaction, and his thought, I,
rather than comfort him, reminded him that something toil! happen to
Mary, to the children, and to himself as well.
Philip passed through a period of feeling wobbly and dazed. All of
his customary denial structures no longer functioned: his job, his spe-
cialness, his climb to glory, his sense of invulnerability. Just as he had
faced the masked burglar, he now faced, at first flinchingly and then
more steadily, some fundamental facts of life: groundlessness, the inex-
orable passage of time, and the inevitability of death. This confrontation
provided Philip with a sense of urgency, and he worked hard in therapy
to reclaim some satisfaction and meaning in his life. We focused espe-
cially on intimacy-an important source of life satisfaction that he had
'I
never enjoyed.
Philip had invested so much in his belief in specialness that he
dreaded facing (and sharing with others) his feelings of helplessness. I
urged him to tell all inquirers the truth-that he was out of a job and
having trouble finding another-and to monitor his feelings. He
shrank away from the task at first but gradually learned that the shar-
ing of vulnerability opened the door to intimacy. At one session I of-
fered to send his resume to a friend of mine, the president of a company
in a related field, who might have a position for him. Philip thanked me
 Death, Anxiety, and Psychotherapy 26 3

in a polite, forn1al manner; but when he went to his car, he "cried like a
baby" for the first time in thirty-five years. We talked about that cry a
great deal, what it meant, how it felt, and why he could not cry in front
of me. As he learned to accept his vulnerability, his sense of cornmu-
nion, at first with me and then with his family, deepened; he achieved
an intimacy with others he had never previously attained. His orienta-
tion to time changed dramatically: no longer did he see time as an en-
emy-to be concealed or killed. Now, with day after day of free time,
he began to savor time and to luxuriate in it. He also became acquainted
with other, long dormant parts of himself and for the first time in
decades allowed some of his creative urges expression in both painting
and writing. After eight months of unemployment, Philip obtained a
new and challenging position in another city. In our last session he said,
"I've gone through hell in the last few months. But, you know, as horri-
ble as this has been, I'm glad I couldn't get a job immediately. I'm
thankful I was forced to go through this." What Philip learned \Vas that
a life dedicated to the concealment of reality, to the denial of death, re-
stricts experience and will ultimately cave in upon itself.

Death Desensitization
Another concept that offers a therapeutic foothold against death anxiety
is "desensitization." "Desensitization to dcath"-a vulgar phrase, which
is demeaning because it juxtaposes the deepest human concerns with
mechanistic techniques. Yet it is difficult to avoid the phrase in a discus-
sion of the therapist's techniques for dealing with death anxiety. It
seems that, with repeated contact, one can get used to anything-even
to dying. The therapist may help the patient deal with death terror in
ways similar to the techniques that he uses to conquer any other fonn of
dread. He exposes the patient over and over to the fear in attenuated
doses. He helps the patient handle the dreaded object and to inspect it
from all sides.
Montaigne was aware of this principle and wrote:

It seems to me, however, that there is a certain way of familiarizing

ourselves with death and trying it out to some extent. 'vVc can have
an experience of it that is, if not entire and perfect, at least not use-
 264 THE Y ALOM READER

less, and that makes us more fortified and assured. If we cannot

reach it, we can approach it, we can reconnoiter it; and if we do not
penetrate as far as its fort, at least we shall see and become ac-
I
quainted with the approaches to it."
I'

In several years of working with groups of cancer patients, I have l

seen desensitization many times. Over and over a patient approaches his
or her dread until gradually it diminishes through sheer familiarity.
The model set by other patients and by the therapist-whether it be res-
oluteness, uneasy stoic acceptance, or equanimity-helps to detoxify
death for many patients.
A basic principle of a behavioral approach to anxiety reduction is I
l
that the individual be exposed to the feared stimulus (in carefully cali- I
brated amounts) in a psychological state and setting designed to retard i
the development of anxiety. The group approach employed this strat-
egy. The group often began (and ended) with some anxiety-reducing
meditational or muscle-relaxing exercise; each patient was surrounded
l
by others with the same illness; they trusted one another and felt com-
pletely understood. The exposure was graduated in that one of the oper-
ating norms of the group was that each member be allowed to proceed
at his or her own speed and that no pressure be placed on anyone to con-
front more than he or she wished to.
Another useful principle in anxiety management is dissection and
analysis. One's feeling of organismic catastrophic dread generally in-
cludes many fearful components that can yield to rational analysis. It
may be helpful to encourage the patient (both the everyday psychother-
apy patient and the dying one) to examine his or her death and sort out
all the various component fears. Many individuals are overwhelmed by
a sense of helplessness in the face of death; and, indeed, the groups of
dying patients I have worked with devoted much time to counteracting
I
;:

this source of dread. The major strategy is to separate ancillary feelings

of helplessness from the true helplessness that issues from facing one's
unalterable existential situation. I have seen dying patients regain a
sense of potency and control by electing to control those aspects of their
lives that were amenable to control. For example, a patient may change
his mode of interacting with his physician: he may insist on being in-
 Death, Anxiety, and Psychotherapy 265

formed fully about his illness or on being included in important treat-

ment decisions. Or he may change to another physician if he is dissatis-
fied with the current one. Other patients involve themselves in social
action. Others develop a sense of choicefulness; they discover with exhil-
aration that they can elect not to do the things they do not wish to do.
There are other component fears: the pain of dying, afterlife, the fear
of the unknown, concern for one's family, fear for one's body, loneli-
ness, regression. In achievement-oriented Western countries death is
curiously equated with failure. Each of these component fears, exam-
ined separately and rationally, is less frightening than the entire gestalt.
Each is an obviously disagreeable aspect of dying; yet neither separately
nor in concert do these fears need to elicit a cataclysmic reaction. It is
significant, however, that many patients, when asked to analyze their
death terrors, find that they correspond to none of these but to some-
thing primitive and ineffable. In the adult unconscious dwells the
young child's irrational terror: death is experienced as an evil, cruel,
mutilating force. These fantasies, no less than Oedipal or castration
fears, are atavistic unconscious tags that disrupt the adult's ability to rec-
ognize reality and to respond appropriately. The therapist works with
such fears as with any other distortions of reality: he attempts to iden-
tify, to illuminate, and to scatter these ghosts of the past.

Death is only one component of the human being's existential situation,

and a consideration of death awareness illuminates only one facet of ex-
istential therapy. To arrive at a fully balanced therapeutic approach, we
must examine the therapeutic implications of each of the other ultimate
concerns. Death helps us understand anxiety, offers a dynamic structure
upon which to base interpretation, and serves as a boundary experience
that is capable of instigating a massive shift in perspective. Each of the
other ultimate concerns contributes another segment of a comprehen-
sive psychotherapy system: freedom helps us understand responsibility
assumption, commitment to change, decision and action; isolation illu-
minates the role of relationship; whereas meaninglessness turns our at-
tention to the principle of engagement.
i
l
 PART III

ON WRITING
.,
~·
 CHAPTER 6

Literature Informing
Psychology
Literary Vignettes

INTRODUCTION

Histories of psychology often begin with the advent of scientific method

and the pioneering experimental psychologists like Wundt and Pavlov. I
have always considered this a shortsighted historical view: the discipline
of psychology began long before, in the works of the great psychological
thinkers who wrote about innermost human motivations: Sophocles,
Aeschylus, Euripides, Epicurus, Lucretius, Shakespeare, and especially
(for me) the great psychological novelists Dostoevsky, Tolstoy, and, later,
Mann, Sartre, and Camus. Freud identified himself as a scientist, yet not
a single one of his great insights was born of science: invariably they
arose from his own intuition, his artistic imagination, and his deep
knowledge of literature and philosophy.
I often turn to a great writer for a phrase or literary device that brings
home an insight with power and clarity. Some examples follow.
 2 70 THE y r\ L () M R EA D ER

Isolation. There are many forms of isolation. Interpersonal isolation

refers to the gulf between oneself and others. It is experienced as loneli- I

ness and may be ameliorated by a greater capacity to develop and sus-

tain intimacy with others. lntrapersonal isolation refers to the lack of
personal integration, to the existence of split-off parts of oneself. Existen-
tial isolation cuts deeper: it refers to an unbridgeable gulf not only be-
tween oneself and any other being but between oneself and the world.
For the most part, existential isolation is concealed from us, but as this
passage from Existential Psychotherapy illustrates, it is generally revealed
by the imminence of death.

No one can take the other's death away from him.' Though we may be
'
I
surrounded with friends, though others 1nay die for the same cause, }
even though others 1nay die at the same time (as in the ancient Egyptian
practice of killing and burying servants with the pharaoh, or in suicide
pacts), still at the most fundamental level dying is the most lonely hu-
I
man expenence.
Eueryman, the best-known medieval morality play, portrays in a
powerful and simple mariner the loneliness of the human encounter
with death.' Everyman is visited by Death, who informs him that he
must take his final pilgrimage to God. Everyman pleads for mercy, but
to no avail. Death informs him that he must make himself ready for the
day that "no man living may escape away." In despair Everyman hur-
riedly casts about for help. Frightened and, above all, isolated, he pleads
to others to accon1pany him on his journey. The character Kindred re-
fuses to go with him:

Ye be a merry man:
Take good heart to you and make no moan
But one thing I warn you, by Saint Anne,
As for me, ye shall go alone.

As does Everyrnan's cousin, who pleads that she is indisposed:

 Literature Informing Psychology 271

No, by our Lady! I have the cramp in my toe

Trust not to me. For so God me speed,
I will deceive you in your most need.

He is forsaken in the same way by each of the other allegorical char-

acters in the play: Fellowship, Worldly Goods, and Knowledge. Even
his attributes desert him:

Beauty, strength and discretion.

When death bloweth his blast
They all run from me full fast.

Everyman is finally saved from the full terror of existential isolation

because one figure, Good Deeds, is willing to go with him even unto
death. And, indeed, that is the Christian moral of the play: good works
within the context of religion provide a buttress against ultimate isola-
tion. Today's secular Everyman who cannot or does not embrace reli-
gious faith must indeed take the journey alone.

Isolation. If we do not come to terms with existential isolation, we

tend to search for solace in our interpersonal relationships. Rather
than relate authentically, with caring, we use the other for a function.
In this passage from Existential Psychotherapy, I draw on Lewis Car-
roll's work in my discussion of one such function: using the other to
verify our existence.

"The worst thing about being alone, the thought that drives me ba-
nanas, is that, at that moment, no one in the world may be thinking
about me." So declared a patient in a group session who had been hospi-
talized because of panic attacks when alone. There was, an1ong the
other patients in this inpatient therapy group, instantaneous agrcen1cnt
with this experience. One nineteen-year-old, who had been hospitalized
for slashing her wrists following the brcaku p of a romantic rclarionshi p,
said simply, "I'd rather be dead than alone!" Another said, "When I'm
alone, that's when I hear voices. Maybe n1y voices are a way not to be
 272 THE Y ALO~t READER

alone!" (an arresting phenomenological explanation of hallucination).

Another patient who, on several occasions, had mutilated herself stated
that she had done so because of her despair about a highly unsatisfying
relationship with a man. Yet she could not leave him because of her ter-
ror of being alone. When I asked her what terrified her about loneli-
ness, she said with stark, direct, psychotic insight, "I don't exist when
I , ma l one. ,,
'. 'I
The same dynamic speaks in the child's incessant plea, "Watch me,"
"Look at 1ne"-the presence of the other is required to make reality . I

real. (Here, as elsewhere, I cite the child's experience as anterior mani-

festation, not as cause, of an underlying conflict.) Lewis Carroll's
Through the Looking-Glass wonderfully expressed the stark belief, held
by many patients, that "I exist only so long as I am thought about." Al-
ice, Tweedledee, and Tweedledum come upon the Red King sleeping:

"He's dreaming now," said Tweedledee, "and what do you think

he's dreaming about?"
Alice said, "Nobody can guess that."
"Why, about you!" Tweedledee exclaimed, clapping his hands
rr iumphant ly. "And if he left off dreaming about you, where do you
suppose you'd be?"
"Where I am now, of course," said Alice.
"Not you!" Tweedledee retorted contemptuously. "You'd be
nowhere. Why, you're only a sort of thing in this dream!"
"If that there King was to wake," added Tweedledum, "you'd
go out-bang!-just like a candle!" ~
I r
' ~
"I shouldn't!" Alice exclaimed indignantly. "Besides, if I'm only I 1
a sort of thing in his dream, what are you, I should like to know?"
"Ditto," said Tweedledum.
"Ditto, ditto!" cried Tweedledee.
He shouted this so loud that Alice couldn't help saying, "Hush!
You'll be waking him, I'm afraid, if you make so much noise."
"Well, it's no use your talking about waking him," said Twee-
I
dledum, "when you're only one of the things in his dream. You r
know ,-cry well you're not real."
"I am real!" said Alice, and began to cry.
 Literature Informing Psychology 273

.. You won't make yourself a bit realer by crying," Tweedledee

remarked. "There's nothing to cry about."
"If I wasn't real," Alice said-halflaughing through her tears, it
all seemed so ridiculous-"I shouldn't be able to cry."
"I hope you don't suppose those are real tears?" Tweedledum
interrupted in a tone of great contempt. i

Love and freedom. Subgrouping, especially romantic pairing, in psy-

chotherapy groups is generally destructive to the group. But occasion-
ally, if two romantically involved patients are highly committed to their
therapy work and willing to analyze their relationship, considerable ben-
efit may ensue. In a long vignette in The Theory and Practice of Group
Psychotherapy J describe the tale of Jan and Bil I, members of a long-term
outpatient therapy group, who, for a brief time, became sexually in-
volved and remained in the group to analyze what the relationship
taught them about themselves. The following excerpt discussing Bill
draws upon several ideas about love and freedom from Camus's novel
The Fall.

For many sessions, the group plunged into the issues oflove, freedom,
and responsibility. Jan, with increasing directness, confronted Bill. She
jolted him by asking exactly how much he cared for her. He squirmed
and alluded both to his love for her and to his unwillingness to establish
an enduring relationship with any woman. In fact, he found himself
"turned off, by any woman who wanted a long-term relationship.
I was reminded of a comparable attitude toward love in the novel
The Fall, where Camus expresses Bill's paradox with shattering clarity:

It is not true, after all, that I never loved. I conceived at least one
great love in my life, of which I was al ways the object ... sensuality
alone dominated 1ny love life .... In any case, my sensuality (to limit
myself to it) was so real that even for a ten-minute adventure I'd
have disowned father and mother, even were I to regret it bitterly.
Indeed-especially for a ten-minute adventure and even more so if
I were sure it was to have no sequel.'
 274 THE Y ALOM READER

The group therapist, if he was to help Bill, had to make certain that
there was to be a sequel.
Bill did not want to be burdened with Jan's depression. There were
women all around the country who loved him (and whose love made
him feel alive), yet for him these women did not have an independent
existence. He preferred to think that his women came to life only when
he appeared to them. Once again, Camus spoke for him:

I could live happily only on condition that all the individuals on

earth, or the greatest possible number, were turned toward me,
eternally in suspense, devoid of independent life and ready to an-
swer my call at any moment, doomed in short to sterility until the
day I should deign to favor them. In short, for me to live happily it
was essential for the creatures I chose not to live at all. They must
receive their life, sporadically, only at my bidding.5

Jan pressed Bill relentlessly. She told him that there was another
man who was seriously interested in her, and she pleaded with Bill to
level with her, to be honest about his feelings to her, to set her free. By
now Bill was quite certain that he no longer desired Jan. (In fact, as we
were to learn later, he had been gradually increasing his commitment to
the woman with whom he lived.) Yet he could not allow the words to
pass his lips-a strange type of freedom, then, as Bill himself gradually
grew to understand: the freedom to take but not to relinquish. (Camus
again: "Believe me, for certain men at least, not taking what one doesn't
desire is the hardest thing in the world !")6 He insisted he be granted the
freedom to choose his pleasures, yet, as he came to see, he did not have
the freedom to choose for himself. His choice almost invariably resulted
I
in his thinking less well of himself. And the greater his self-hatred, the I

more compulsive, the less free, was his mindless pursuit of sexual con- I
quests that afforded him only an evanescent balm.

Transference-that is, our proclivity to experience another in an irra-

tional fashion-is particularly complex in therapy groups where patients
 Literature Informing Psychology 275

not only must relate to the therapist, who holds a position of great au-
thority in the group, but to the other members. In this selection from The
Theory and Practice of Group Psychotherapy I draw from Tolstoy's War
and Peace to illuminate the nature of transference.

Freud was very sensitive to the powerful and irrational manner in

which group members view their leader, and made a major contribu-
tion by systematically analyzing this phenomenon and applying it to
psychotherapy. Obviously, however, the psychology of member and
leader has existed since the earliest human grouping, and Freud was not
the first to note it. To cite only one example, Tolstoy in the nineteenth
century was keenly aware of the subtle intricacies of the member-leader
relationship in the two most important groups of his day: the church
and the military. His insight into the overevaluation of the leader gives
War and Peace much of its pathos and richness. Consider Rostov's re-
gard for the tsar:

He was entirely absorbed in the feeling of happiness at the Tsar's

being near. His nearness alone made up to him by itself, he felt, for
the loss of the whole day. He was happy, as a lover is happy when
the moment of the longed-for meeting has come. Not daring to
look around from the front line, by an ecstatic instance without
looking around, he felt his approach. And he felt it not only from
the sound of the tramping hoofs of the approaching cavalcade, he
felt it because as the Tsar came nearer everything grew brighter,
more joyful and significant, and more festive. Nearer and nearer
moved this sun, as he seemed to Rostov, shedding around him rays
of mild and majestic light, and now he felt himself enfolded in that
radiance, he heard his voice-that voice caressing, calm, majestic,
and yet so simple .... And Rostov got up and went out to wander
about among the campfires, dreaming of what happiness it would
be to die-not saving the Emperor's life (of that he did not dare to
dream), but simply to die before the Emperor's eyes. He really was
in love with the Tsar and the glory of the Russian arms and the
hope of coming victory. And he was not the only man who felt thus
 276 THE Y ALOM READER

m those memorable days that preceded the battle of Austerlitz:

nine-tenths of the men in the Russian army were at that moment in
love, though less ecstatically, with their Tsar and the glory of the
Russian arms.'

Indeed, it would seem that submersion in the love of a leader is a pre-

requisite for war. How ironic that more killing has probably been done
under the aegis of love than of hatred!
Napoleon, that consummate leader of men, was, according to Tol- 11
stoy, not ignorant of transference, nor did he hesitate to utilize it in the
service of victory. In War and Peace, Tolstoy had him deliver this dis-
patch to his troops on the eve of battle:

Soldiers! I will myself lead your battalions. I will keep out of fire, if
you, with your habitual bravery, carry defeat and disorder into the
ranks of the enemy. But if victory is for one moment doubtful, you
will see your Emperor exposed to the enemy's hottest attack, for
there can be no uncertainty of victory, especially on this day, when
it is a question of the honor of the French infantry, on which rests
the honor of our nation.'

One of the fundamental sources of anxiety from an existential frame of

reference is meaninglessness. We appear to be meaning-seeking crea-
tures who are thrown into a universe and a world which lack intrinsic
meaning. In the following selection from Existential Psychotherapy I l.
draw upon passagesfrom Sartre's play The Flies to illustrate several pos- I
sible modes of creating a sense of life meaning.
j
Sartre, more than any other philosopher in this century, has been un-
compromising in his view of a meaningless world. His position on the
meaning of life is terse and merciless: "Al] existing things are born for
no reason, continue through weakness and die by accident .... It is
meaningless that we are born; it is meaningless that we die.?" Sartre's
view of freedom leaves one without a sense of personal meaning and
 Literature Informing Psychology 277

with no guidelines for conduct; indeed, many philosophers have been

highly critical of the Sartrean philosophical system precisely because it
lacks an ethical component. Sartre's death in 1980 ended a prodigiously
productive career, and his long-promised treatise on ethics will never be
written.
However, in his fiction Sartre often portrayed individuals who dis-
cover something to livefor and something to live by. Sartre's depiction
of Orestes, the hero of his play The Flies (Les Mouches), is particularly il-
lustrative." Orestes, reared away from Argos, journeys home to find his
sister Electra, and together they avenge the murder of their father
(Agamernnon) by killing the murderers-e-their mother, Clytemnestra,
and her husband, Aegisthus. Despite Sartre's explicit statements about
life's meaninglessness, his play may be read as a pilgrimage to meaning.
Let me follow Orestes as he searches for values on which to base his life.
Orestes first looks for rneaning and purpose in a return to home, roots,
and comradeship:

Try to understand I want to be a man who belongs to someplace, a

man among comrades. Only consider. Even the slave bent beneath
his load dropping with fatigue and staring dully at the ground and
foot in front of him-why even that poor slave can say that he's in
his town as a tree is in a forest or a leaf upon a tree. Argos is all
around him, warm, compact, and comforting. Yes, Electra, I'd
gladly be that slave and enjoy that feeling of drawing the city round
me like a blanket and curling myself up in it."

Later he questions his O\Vn life conduct and realizes that he has always
done as they (the gods) wished in order to find peace within the status
quo.

So that is the right thing. To live at peace-always at perfect peace.

I see. Always to say "excuse me," and "thank you." That's what's
wanted, eh? The right thing. Their Right Thing."

At this moment in the play Orestes wrenches himself away from his
previous meaning system and enters his crisis of meaninglessness:
 278 THE Y ALOM READER

What a change has come on everything ... until now I felt some-
thing warm and living round me, like a friendly presence. That
something has just died. What emptiness. What endless emptiness."

Orestes, at that moment, makes the leap that Sartre made in his per-
sonal life-not a leap into faith (although it rests on no sounder argu-
ment than a leap of faith) but a leap into "engagement," into action, into
a project. He says good-bye to the ideals of comfort and security and
pursues, with crusader ferocity, his newfound purpose:

I say there is another parh-s-my path. Can't you see it. It starts here
and leads down to the city. I must go down into the depths among
you. For you are living all of you at the bottom of a pit .... Wait.
Give me time to say farewell to all the lightness, the aery lightness
that was mine .... Come, Electra look at our city .... It fends me off
with its high walls, red roofs, locked doors. And yet it's mine for the
taking. I'll turn into an ax and hew those walls asunder ... .'4

Orestes' new purpose evolves quickly, and he assumes a Christlike bur-

den:

Listen, all those people quaking with fear in their dark rooms-
supposing I take over all their cr imes. Supposing Iset out to win the
name of "guilr-stcalcr" and heap on myself all their remorse."

Later Orestes, in defiance of Zeus, decides to kill Aegistheus. His decla-

ration at that time indicates a clear sense of purpose: he chooses justice,
freedom, and dignity and indicates that he knows what is "right" in life.

What do I care for Zeus. Justice is a matter between men and I have
no God to teach me it. It's right to stamp you out like the foul brute
you are, and to free the people from your evil influence. It is right to
restore to them their sense of human dignity.11'

And glad he is to have found his freedom, his mission, and his path.
Though Orestes must carry the burden of being his mother's murderer,
 Literature Informing Psychoiogv 279

it is better thus than to have 110 mission. no meaning, to wander point-

lessly through life.

The heavier it is to carry, the better pleased I shall be: for that bur-
den is tny freedom. Only yesterday I walked the earth haphazard;
thousands of roads I tramped that brought me nowhere, for they
were other men's roads .... Today I have one path only. and heaven
knows where it leads. But it is my path."

Then Orestes finds another and, for Sartre, an important meaning-e-

that there is no absolute meaning, that he is alone and must create his
own meaning. To Zeus he says:

Suddenly, out of the blue, freedom crashed down on me and swept

me off my feet. My youth went with the wind, and I know myself
alone ... and there was nothing left in heaven. no right or wrong.
nor anyone to give me orders .... I am doomed to have no law but
mine .... Even·. man must find his own wav."
'

When he proposes to open the eyes of the townspeople, Zeus protests

that, if Orestes tears the veils from their eyes, "they will see their lives as
they are: foul and futile." But Orestes maintains that they are free, that
it is right they face their despair, and utters the famous existential rnani-
festo: "Human life begins on the far side of despair.'' 1'"

One final purpose, self-realization, emerges when Orestes takes his

sister's hand to begin their journey. Electra asks, "Whither? ·· and
Orestes responds:

Toward ourselves. Beyond the river and mountains are an Orestes

and an Electra waiting for us, and we must make our patient way
towards them."

And so Sartre-the same Sartre who says that "man is a futile passion,"
and that "it is meaningless that we arc born; it is meuninglcss that \\'C
die"-arrived at a position in his fiction that clearly values the search for
meaning and even suggests paths to take in that search. These include
 280 TH E YA LO M R EA D ER

finding a "home" and comradeship in the world, action, freedom, rebel-

lion against oppression, service to others, enlightenment, self-realization,
and engagement-always and above all, engagement. I
And why are there meanings to be fulfilled? On that question Sartre
is mute. Certainly the meanings are not divinely ordained; they do not I,
exist "out there," for there is no God, and nothing exists "out there" out-
side of man. Orestes simply says, "I want to belong," or "ft is right" to
serve others, to restore dignity to man, or to embrace freedom; or every
man "must" find his own way, must journey to the fully realized Orestes
who awaits him. The terms "want to" or "it is right" or "must" are
purely arbitrary and do not constitute a firm basis for human conduct;
yet they seem to be the best arguments Sartre could muster. He seems to
agree with Thomas Mann's pragmatic position. "Whether that be so or
not, it would be well for man to behave as if it were so."
What is important for both Sartre and Camus is that human beings
recognize that one must invent one's own meaning (rather than dis-
cover God's or nature's meaning) and then commit oneself fully to ful-
filling that meaning. This requires that one be, as Gordon Allport put
it, "half-sure and whole-heartcd" '-not an easy feat. Sartre's ethic re-
2

quires a leap into engagement. On this one point most Western theolog-
ical and atheistic existential systems agree: it is good and right to immerse
oneself in the stream of life.
The secular activities that provide human beings with a sense of life
purpose are supported by the same arguments that Sartre advanced for
Orestes: they seem right; they seem good; they are intrinsically satisfy-
ing and need not be justified on the basis of any other motivation.

Decisions. Every psychotherapist deals frequently with patients who

are tormented by decisions. In my discussion of the ultimate concern of
freedom in Existential Psychotherapy I deal extensively with the impedi-
ments to wishing, willing, and deciding. John Gardner was a wonderful
philosophical novelist and in this brief selection I use a passage from his
novel Grendel to clarify one aspect of decision making.

There is something highly painful about unmade decisions. As I re-

view n1y patients and attempt to analyze the meaning (and the threat)
 Literature Informing Psychology 281

that decision has for them, I am struck first of all by the diversity of re-
sponse. Decisions are difficult for many reasons: some obvious, some
unconscious, and some, as we shall see, that reach down to the deepest
roots of being.
Alternatives Exclude. The protagonist of John Gardner's novel
Grendel made a pilgrimage to an old priest to learn about life's myster-
ies. The wise man said, "The ultimate evil is that Time is perpetual per-
ishing and being actual involves elimination." He summed up his
meditations on life in two simple but terrible propositions, four devas-
tating words: "Things fade: alternatives exclude.':" I regard that priest's
message as deeply inspired. "Things fade" refers to the fundamental
pervasiveness of death anxiety, and "alternatives exclude" is one of the
fundamental reasons that decisions are difficult.
 CHAPTER 7

Psychology Informing
Literature

"Ernest Hemingway:
A Psychiatric View"

INTRODUCTION

"Ernest Hemingway: A Psychiatric View," which I wrote with my wife,

Marilyn, was published in the Archives of General Psychiatry (lune
1971 ). This article illustrates another facet of the interdependent relation-
ship between literature and psychology. Here, we reverse the process:
rather than drawing on insights of literature to illuminate psychology, we
use psychodynamic expertise to illuminate an author's life and work.
Such an approach is useful only for certain authors and for certain works
of art. Psychodynamic insights have much to offer in understanding
Ernest Hemingway who, though a stylistic genius, was (as a result of his
personal torments) a narrow guide to life. This selection posits that Hem-
ingway's inner conflicts informed, dominated, and perhaps hobbled his
artistic vision as he struggled again and again in his fiction with the same
set of personally unresolved issues.
 Psychology Informing Literature 28 3

ERNEST HEMINGWAY:
A PSYCHIATRIC VIEW
(Arch. Gen. Psychiatry, 24:485-494., 1971)

Ernest Hemingway died by suicide on July 2, 1961. Since then his bones
have been stirred by hordes of journalists, critics, biographers, and eulo-
gizers, all of them, and we too, attempting to appraise the Hemingway
heritage. As scholars we gather around his historical and literary re-
mains-Hemingway would have said like hyenas around carrion.
We join this congregation knowing that it is already overcrowded
and realizing that we court the dead man's curse rather than his bless-
ing. What do a psychiatrist and still another professor of literature have
to add to the innumerable words which have already been published? It
was perhaps the appearance of the long-awaited Baker biography'
which convinced us that, despite the thoroughness of this useful ency-
clopedic work, some extremely important areas of Hemingway's inner
world are still to be explored. Much as the psychiatrist tries to under-
stand his patient, we shall undertake an examination of the major psy-
chodynamic conflicts with which Hemingway struggled. We do not, of
course, propose to explain or dissect his genius, but only to clarify the in-
ternal forces which so shaped the structure and substance of his work.
Our data consist of the recorded events of Hemingway's life and his
own writings. We have also been fortunate enough to have the counsel
of Major General Charles T. (Buck) Lanham, one of Hemingway's
closest friends, whose insightful memories and suggestions have been
invaluable in the preparation of this manuscript.
To a psychiatrist, Hemingway is considerably more than another
important writer, even more than the best-known American novelist of
the century. When alive he was a public figure of the first magnitude,
recognizable on sight to the literate of this country and most of Europe.
His name was a synonym for an approach to life characterized by ac-
tion, courage, physical prowess, stamina, violence, independence, and
above all "grace under pressure't-c-atrributes so well known that any of
our readers could have compiled a comparable list. He was, in short, the
heroic model of an age.
 284 THE Y ALOM READER

A popular hero is, to a large extent, a reflection, symbol, or symptom

of the culture which creates him. The Hemingway image was of such
vitality, however, that he not only mirrored his culture but helped to
shape and perpetuate it. Wide exposure to Hemingway in multimedia
imprinted his values into contemporary psychic life; he has been incor-
porated into the fabric of the character structure of a generation of
Americans. Even those who did not read him were familiar with his
famous cinema surrogates: Gary Cooper in A Farewell to Arms and
For Whom the Bell Tolls, Humphrey Bogart in To Have and Have Not,
Tyrone Power in The Sun Also Rises, Gregory Peck in The Snows of
Kilimanjaro, Burt Lancaster in The Killers, and Spencer Tracy in The
Old Afan and the Sea.
Today Hemingway still has a large following, especially among ado-
lescents and college students, though they have newer idols. While the
young cannot deny him his literary position as the leader of a revolution
in prose style, there are many indications that he is no longer an heroic
model for a rising generation of culture makers. Those militantly com-
mitted to a national policy of peace find it hard to emulate a man who
wrote that he did not believe in anything except that one should fight
for one's country whenever necessary.' Young activists are disenchanted
with the author who eschewed political and social involvement, for he
was basically an apolitical man, drawn to battle less from ideological
commitment than from the lure of danger and excitement. Unlike the
socially minded writers of the 1930s who unsuccessfully attempted to
activate him, he early lost any idealistic desire to change the world, as he
humorously expressed in this 1924 verse:

I know monks masturbate at night

That pet cats screw
That some girls bite
And yet
Hlhat can I do
To set things right?'

In the retrospect of scarcely ten years, it appears to us that Heming-

way's legacy is one more of form than of substance, that he will be re-
membered as a stylistic genius but as a very narrow guide to life. While
 Psychology Informing Literature 285

we appreciate the existential considerations generated by the Heming-

way encounters with danger and death, we do not find the same mea-
sure of universality and timelessness we associate with a Tolstoy or a
Conrad or a Camus. Why, we ask ourselves, is this so? \Vhy is the
Hemingway world view so restricted? \\1e suspect that the limitations of
Hemingway's vision are related to his personal psychological restric-
tions. There are many questions he never raised about the universe.
There are even more he never dared to ask about himself, Just as there
is no doubt that he was an extremely gifted writer, there is also no doubt
that he was an extremely troubled man, relentlessly driven all his life.
who in a paranoid depressive psychosis killed himself at the age of 62.
During his training the psychiatrist is usually required to write for
each patient a report which attern pts to "explain" the inner world of the
patient through an analysis of the past and current interpersonal and in-
trapersonal forces operating on him. This "dynamic forrnulation," as it
is labeled, is invariably the student's most difficult chore: generally he is
lost in a sea of information, multiple theoretical schools stream by like
so many sturdy transport ships, yet none seems capable of carrying the
entire cargo of clinical information available for each patient. The "reli-
ability" of the dynamic formulation is low, that is, rnany psychiatrists
with similar information will con1pose radically different fonnulations.
"Validity" fares no better, for the dynamic formulation has little corre-
lation with the diagnosis and clinical course of the patient.
The psychiatrist who gratuitously offers a dynamic formulation for
the patient he has never seen must be particularly humble. Ernest Hern-
ingway resisted professional psychological introspection during his life
and now, posthumously, he remains uncooperative to clinical inquiry.
We nonetheless hope to suggest a frame of reference through which dis-
parate pieces of information 1nay be organized into a coherent logical
schema, which 1nay generate new hypotheses for future investigation.
Unlike the student psychiatrist struggling to make sense of an
avalanche of anarnnestic interview data, fantasy, dream, and dream-
associated material as well as auxiliary information from concerned and
generally cooperative relatives and friends, we-the Hemingway for-
tnulators-are obliged to rely on scanty and often unreliable data.
Hemingway's own statements offer little assistance: he was not cele-
brated for telling the truth about himself \Vorld traveler and explorer,
 286 T H E Y A LO ,\1 R EA DER

he never purposefully and publicly embarked upon an inward journey

and he opposed those psychologically oriented critics who attempted the
journey on his behalf. The difference between his attitude to psycholog- I
. I

ical inquiry and that of another major American writer was vividly
demonstrated to one of us (I. Y.) by the following incident.
Several months ago, at a psychiatric meeting, I attempted to inter-
~ :

view Howard Rome, the psychiatrist who treated Hemingway in his fi-
nal depression. A friend pointed him out to me in a room crowded with
colleagues, but as chance would have it, I approached the wrong man.
After apologizing and explaining my interest in Hemingway, he re-
marked that, though he knew little about Hemingway, he had been Eu-
gene O'Neill's psychiatrist! He continued by informing me that O'Neill
had left him 1nany personal effects, including letters and recorded con-
versations, and had encouraged him to write an in-depth account of his
final years. It was not so with Hemingway. When I finally located Dr.
Rome, he informed me, with a finger across his mouth, that before
treating Hemingway, he had been obliged to promise that his lips
would be forever sealed.
The reconstruction of the early formative ye~us is a particularly vex-
ing task. Baker's comprehensive and scholarly biography, exceeding 600
pages, devotes to Hemingway's first 17 years only 20 pages and much of
that is prosaic factual material, which does not provide the kind of in-
formation useful for an investigation of the inner world. Other biogra-
phies, including the ones by Hemingway's brother Leicester" and his
sister Marcelline, are considerably less helpful. Perhaps, though, we
should not mourn the irretrievable loss of the early years. The recon-
struction of the past and the subsequent use of this construct to compre-
hend the present (and the future) is an inferential, risky process. It has
been well established by psychological research that recall of one's early
life, especially of affect-laden events, is subject to considerable retro-
spective falsification." The process of recall, in effect, tells us more about
present psychological realities than about past events; present attitudes
dictate which of the entire panoply of early life experiences we choose to .I
remember and imbue with power. Common sense has it that the pres-
ent is determined by the past and, yet, is not the converse equally true?
The past becomes alive for us only as it is reexperienced through the fil-
 Psychology Informing Literature 287

ter of our present psychic apparatus. In different emotional states, in

different stages of life, the past may assume a variety of hues. Mark
Twain tells us that when he was 17 he thought his father was a damn
fool, but when he was 21 he was surprised to see how much the old fool
had learned!
V./e propose, then, a horizontal exploration rather than a vertical
one. To understand an individual fully, one must understand all the
conflicting internal forces operating on him at a point in time; the verti-
cal or genetic exploration is, contrary to the lay conception of psychiatry,
merely ancillary to the horizontal goal. \Ve turn to the past only to ex-
plicate the present, much as a translator turns to history to elucidate an
obscure text." To aid us in our reconstruction of a psychological cross
section, there is a not inconsiderable body of data from the middle and
late years-anecdotal accounts by friends, a few recorded interviews, a
large body of letters, and, most of all, the fiction itself. Hemingway's let-
ters and notes corroborate the highly autobiographical nature of his
writing. Baker cites a conversation with Irving Stone where Heming-
way clearly said that his stories "could be called biographical novels
rather than pure fictional novels because they emerged out of 'lived ex-
perience.?" Like that of all latter-day romantics, his material is psycho-
logically, if not factually, personal: Hemingway's loves, needs, desires,
conflicts, values, and fantasies swarm nakedly across the written page.
Observe Hemingway at any point during his mature years and one
meets a powerful, imposing figure-the Hemingway imago which he
presented to others and to himself. "He was," said the poet John Pudney
of Hemingway in 1944, "a fellow obsessed with playing the part of
Ernest Hemingway!"9 Whatever else we can see, always there is virility,
strength, courage: he is the soldier searching out the eye of the battle
storm; the intrepid hunter and fisherman compelled to pursue the
greatest fish and stalk the most dangerous animal from the Gulf Stream
to Central Africa; the athlete, swimmer, brawler, boxer; the hard
drinker and hard lover who boasted that he had bedded every girl he
wanted and some that he had not wanted;" the lover of danger, of the
bullfight, of flying, of the wartime front lines; the friend of bra vc men,
heroes, fighters, hunters, and matadors.
The list is so long, the image so powerful, that it obliges even the
 288 TH E Y A LO M R EA DE R

most naive observer of human nature to wonder whether a man firmly

convinced of his identity would channel such a considerable proportion
of his life energy into a search for masculine fulfillment. Since the earli-
est reviews of his works, a stream of Hemingway critics have pointedly
noted his need to assert again and again a brute virility."
Before we examine the image itself, let us test its boundaries. Was
the Hemingway image a public image only, constructed by the author
and his publisher, in secret complicity, to hoodwink the public and to
increase revenue? Our research leads us to a most emphatic "No!" All
available evidence suggests that the public and private Herningways are
merged: the Hemingway of private conversations, of letters, and of
notebooks is identical with the Hemingway who careened across the
pages of ne\i\'spapers and journals and the many Hemingways who
fought, loved, and challenged death in his novels and stories.
Although he was a well-known raconteur, Hemingway never
laughed at himself, nor did he permit friends to question the Heming-
way image. General Lanham, his closest friend for the last quarter of his
life, once remarked to Hemingway's wife, Mary, that her husband was
"frozen in adolescence." Hemingway learned of the remark, remem-
bered it, and eventually rejoined: "Perhaps adolescence isn't such a bad
place to be frozen." On another occasion during World War II Lan-
12

ham's z znd infantry fought a hard battle to capture the town of Lan-
drecies, ultimately ending up 60 miles ahead of the entire First Army.
Lanham, scholar as well as soldier, sent Hemingway a bantering mes-
sage paraphrasing Voltaire, which read, "Go hang thyself, brave Hem-
ingstein. We have fought at Landrecies and you were not there.'!"
Responding as if to a dare, Hemingway sped through 60 miles of
German-infested territory, at great personal risk, in order to flourish
his panache in front of Lanham. l
Both publicly and privately Hemingway invested inordinate psychic
energy in fulfilling his idealized image. The investment was not pr i-
marily a conscious, deliberate one, for many of Hemingway's life activi-
l
ties were overdetermined; he acted often not through free choice but
because he was driven by some dimly understood internal pressure
whose murky persuasiveness only shammed choice. He fished, hunted,
and sought danger not only because he wanted to but because he had to,
in order to escape some greater internal danger. In "The Snows of Kili-
 Psychology Informing Literature 289

manjaro" Hemingway suggested that he needed to kill to stay alive."

The years following World War II were not genera1l y good ones for the
writer and man, and Hemingway complained of the emptiness and
meaninglessness of his life without war.
Who does not have an idealized image? Who does not formulate a
set of personal aspirations and self-expectations? But Hemingway's ide-
alized image was more, much more. Rather than expectations, he
forged a set of restrictive demands upon himself, a tyrannical and inex-
orable decalogue which pervaded all areas of his inner world. Many
personality theorists have dealt with the construct of the idealized im-
age, but none so cogently as Karen Horney. For a complete exposition
of her personality theory we refer the reader to her last book, Neurosis
and Human Grou/th," To summarize drastically, a child suffers from ba-
sic anxiety, an extremely dysphoric state of being, if he has parents
whose own neurotic conflicts prevent them from providing the basic ac-
ceptance necessary for the development of the child's autonomous be-
ing. During early life when the child regards the parents as omniscient
and omnipotent, he can only conclude, in the face of parental disap-
proval and rejection, that there is something dreadfully wrong with
him. To dispel basic anxiety, to obtain the acceptance, approval, and
love he requires for survival, the child perceives he must become some-
thing else; he channels his energies away from the realization of his real
self, from his own personal potential, and develops a construct of an ide-
alized image-a way he must become in order to survive and to avoid
basic anxiety. The idealized image may take many forms, all of which
are designed to cope with a primitive sense of badness, inadequacy, or
unlovability. Hemingway's idealized image crystallized around a search
for mastery, for a vindictive triumph which would lift him above oth-
ers.
The development at an early age of an idealized image and the chan-
neling of energies away from fulfillment of one's actual potential has ex-
tremely far-reaching ramifications on the developing personality. The
individual experiences great isolation as chasms arise between himself
and others. He places increasingly severe demands upon himself (a
process which Horney calls the "tyranny of the shoulds"), he develops a
complete pride system that defines which feelings and attitudes he can
permit and which he must squelch in himself In short, he must shape
 290 THE Y ALOM READER

himself according to a predesigned form rather than allow himself to

unfold and to enjoy the experience of gradually discovering new and
rich parts of himself.
When the idealized image is severe and unattainable, as it was for
Hemingway, tragic consequences may result: the individual cannot in
real life approximate the superhuman scope of the idealized image, real-
ity eventually intrudes, and he realizes the discrepancy between what he
wants to be and what he is in actuality. At this point he is flooded with
self-hatred, which is expressed through a myriad of self-destructive
mechanisms from subtle forms of self-torment (the tiny voice which
whispers, "Christ, you're ugly!" when one gazes at a mirror) to total an-
nihilation of the self.
Considering only the broad brush strokes of Hemingway's life, one
might assume that he approximated his idealized image, that in every
way he became what· he most wanted to be. Yet throughout his life
Hemingway judged himself, found himself wanting, and experienced
recurrent cycles of extreme self-doubt and self-contempt.
Consider the quality of self-sufficiency upon which the Hemingway
man is predicated: he must be true only to himself, to perhaps an elite
cadre of friends, and impervious to the opinions of all others. Yet Hem-
ingway was exceedingly dependent on praise from all quarters and
highly sensitive to any critical judgment. He bore his critics vengeance
and, in a paranoid way, considered anything but unqualified praise as
conspiracy against him." He was so tormented by adverse criticism of
his writing that only a foolhardy friend would dare offer anything re-
sembling authentic appraisal.
The lack of war decorations immediately following World War II
was another ignominious affront to the Hemingway ego. He often
lamented to Lanham that the Distinguished Service Cross, rightfully
his for fighting in Rambouillet, was given to another. (Though Hem-
ingway fought valiantly in the war, he was ineligible for citation as a
soldier since he was a correspondent and not officially permitted to
carry weapons in World War II.) In 1947 "he was glad enough to accept
I
a Bronze Star ... for 'meritorious service' as a war correspondent.?" He
wrote plaintively to Lanham of his fear that twenty years after his death
"they" would deny he was in the war. Later this was shortened to "ten
 Psychology Informing Literature 291

years" and finally to the fear that before his death "they'll" deny he ever
saw action.
His relationship to Lanham was often highly inconsistent with the
Hemingway image. The letters to Lanham reveal childlike admiration
for the professional soldier, with whom Hemingway simultaneously
compares himself unfavorably and attempts to identify. He wrote to
Lanham that others were "always jealous" of people like them, that he
"hurt" when Lanham "hurt," that The Old Afan and the Sea had in it
everything in which they both believed. He wrote also in a period of de-
pression that he was just killing time wishing he were a soldier like
Lanham instead of a "chickenshir writer." He demeaned his own ac-
complishments by suggesting that he would get into history only be-
cause of his close association with Lanham when Lanham commanded
the zznd infantry."
In his relationship to the women in his life, Hemingway assumes a
curiously paradoxical pose, scorning them as much as he loves them. He
is at once the celebrated champion of romantic love and the misogynist.
Yet to be written is the storv' of his innumerable love affairs and four
marriages, wherein he undoubtedly demonstrated tenderness, sensitiv-
ity, and a capacity for caring, as well as the erotic feats of which he pub-
licly and privately boasted. Baker's biography gives numerous examples
of thoughtful attentions to his wives-s-Hadley, Pauline, Martha, and
Mary. But despite Baker's tactful presentation of Hemingway the lover,
there are numerous incidents of the unkindness, ugliness, and patent
unfaithfulness which were invariably served to the Hemingway
women; the menages a trois to which Hadley and Pauline were sub-
jected with their respective successors, and which Mary endured with
younger rivals, are cases in point." Lanham tells us that Hemingway
was notoriously rude to his friends' wives, some of whom served as
models for the "bitches" he described in his fiction. He rewarded
Gertrude Stein, his early mentor and friend, with some vicious pages in
A Moveable Feast (a not uncommon treatment of his fellow authors,
whether they had befriended him or not). Hemingway once wrote that
the things he loved were in the following order: "good soldiers, animals
and women. "iv
In his fiction, which includes some of the most moving love stories
 292 TH E Y A LO M R EA D ER

in contemporary literature, there is scarcely a single example of a suc-

cessful male-female egalitarian relationship." The Sun Also Rises de-
scribes the relationship of an impotent man, Jake Barnes, with the
seductive, promiscuous Brett Ashley. In For Whom the Bell Tolls the
worldly American Robert Jordan and the young ingenuous Maria
come together like teacher and pupil. This disparity is even more pro-
nounced in Across the River and Into the Trees, where the ro-vear-old
girl Renata is called "daughter" by her lover, the 50-year-old Colonel
Cantwell. In To Have and Have Not Harry's wife, Marie, is an unfemi-
nine, blowsy ex-prostitute. In "The Snows of Kilimanjaro" Harry is
married to a rich, intrusive woman who feeds on his vitality, and in
"The Short Happy Life of Francis Macomber" the protagonist's wife
infantilizes him until he begins to discover his authentic self, where-
upon she manages to kill him by accident. The couple in A Farewell to
Arms are perhaps Hemingway's most fulfilled lovers, yet their relation-
ship appears unconvincing; Catherine Barkley, Frederick's former
nurse, is an extraordinarily selfless, fleshless being who lives only for
Frederick and dies rather pointlessly following childbirth by caesarian
section (the novel, incidentally, was written immediately after Hem-
ingway's second wife, Pauline, was delivered of his second child by cae-
sarian section).
If Hemingway avoids depicting egalitarian male-female relation-
ships, he is indeed inventive in creating alternatives. It is as though his
attempts to portray a satisfying love-sex relationship are thwarted by a
number of powerful counterforces, many of which Hemingway recog-
nizes. Looming large in such works as "The Snows of Kilimanjaro,"
"The Short Happy Life of Francis Macomber," "Now I Lay Me," "The
Three-Day Blow," "Mr. and Mrs. Elliot," "Out of Season," "Hills Like
White Elephants," and "Cat in the Rain" is the danger of emasculation.
Though the narrative varies, the outcome in each is the same-an en-
during union with a woman results in a devitalized man. The father
in "Now I Lay Me" observes, powerlessly, while his wife burns his
treasured belongings. In "Hills Like White Elephants" another devital-
ized and dependent husband pleads with his pregnant wife to have
an abortion because he cannot bear the thought of competition for her
attention.
 Psychology Informing Literature 293

Even closer to home was the decline of Hemingway's own father

from the able doctor and legendary huntsman immortalized in the
Nick Adams stories to the wasted figure who visits his son some months
before his death like a pre1nature ghost whose life force had been ab-
sorbed by Hemingway's mother, looming beside him, "a picture of
ruddy health.'?' Believing that his mother's aggressive bullying had dri-
ven his father to suicide, Hemingway modeled the parents of Robert
Jordan in For Whom the Bell Tolls upon his own parents; like Ernest,
Robert calls his father a coward because he did not resist his wife and fi-
nally resorted to suicide-the weakest act of all.
Throughout his life Hemingway considered love between man and
woman as detrimental to other, truer types of relationships, such as
friendship between males or man's communion with nature. When he
fell in love with Hadley, he castigated himself for no longer caring about
the two or three streams he had loved better than anything else in the
world." In "Cross Country Snow" the impending marriage of a young
man threatens to destroy his deep relationship with a skiing comrade.
The two speak wistfully of skiing again in the place to which one must
move, but both know that "the mountains aren't much .... They're too
rocky. There's too much timber and they're too far away.""
Another risk inherent in an adult love relationship is the potential
rejection by the woman and the ensuing insult to one's narcissism.
While recovering from his wound in the First World War, Hemingway
fell deeply in love, probably for the first time, with Agnes von
Kurowsky, one of the nurses who tended him. When Agnes finally
chose another man, Hemingway was plunged into despair. That this
emotional injury was profound and enduring is indicated by the fact
that Hemingway returned to it in four separate works: "A Very Short
Story," "The Snows of Kilimanjaro," The Sun Also Rises, and A Farewell
to Anns.
To love another is to expose oneself to the risk of painful separation
or loss, a risk against which Hemingway admonished in "In Another
Country":"

"Wh y must not a man marry. ?"

"He cannot marry, he cannot marry," he said angrily.
 294 TH E Y A LO ~ R EA D ER

"If he is to lose everything he should not place himself in a posi-

tion to lose. He should find things he cannot lose."

Still another counterforce to mature Jove arose from a deeply based fear
of women stemming from Oedipal conflicts. Literary critics are some-
times more intrepid than psychiatrists in offering highly inferential in-
terpretations; Young, for example, in a study which Hemingway tried
to block during his lifetime, suggested that Hemingway was psycholog-
ically crippled by castration anxiety, and that his major works derive
from this source." Freudian developmental theory holds that the male
child in his early years experiences libidinal desires toward his mother;
these libidinal impulses are, as Freud reminds us, not clearly sexual but
of the stuff from which sex will come." They beget conflicted feelings
toward the father, at first competitive and then destructive, which may
take the guise of stark death wishes; these hostile feelings rapidly evoke
another constellation of feelings-fears of retribution which may as-
sume the amorphous form of global annihilation or the specific form of
castration. A successful resolution of this conflict involves identification
with the father and repression or relinquishment of the incestuous de-
sire for the mother.
If resolution does not occur, the child does not attain psychosexual
maturity, and a number of adverse outcomes may ensue. Sexual en-
counters with women become symbolic recapitulations of the relation-
ship with the mother, with its attendant feelings of desire, repulsion,
and the anticipation and dread of catastrophe; sexual intercourse be-
comes an inchoate nightmare. Some methods of coping involve the
abandonment of women as sexual objects, with the individual seeking
refuge in alternative outlets. More common yet is the splitting of
women into sexual and nonsexual categories; one a voids intercourse
with "pure" women of one's age, intelligence, and class; one goes to bed
with an unequal partner, a woman obviously inferior in education and
social status.
The evidence that castration anxiety played an important role in
Hemingway's conflicted attitude toward women is meager, and there
are, as we have indicated, a number of other dynamics operating. Nev-
ertheless, the theory of castration anxiety gains support as we consider
Hen1ingway's reaction to significant physical trauma-one final area in
 Psychology Informing Literature 29,) ...

which he experienced a marked discrepancy between his idealized and

his real self. The idealized Hemingway courts danger and endures
physical injury with little self-concern, heals quickly with no functional
or psychological residue, and returns, untrammeled, to the fray. The
real Hemingway did indeed court danger and did indeed suffer injury.
The inventory of Hemingway's physical injuries rivals a list of his pub-
lished works; it includes several spectacular plane and automobile
crashes resulting in brain concussions, hemorrhages, rn ulti pie fractures,
severe cuts, and burns, and a lifeti1ne of minor accidents, 1nany associ-
ated with hunting, fishing, boxing, and skiing. Lanham remarked that
his body was crisscrossed with scars. Yet it seems that Hemingway's
wounds seared his mind rnore harshly and more indelibly than they
ever cauterized his flesh. Indeed, the big wound, the one suffered in
Fossalra di Piave, Italy, in July 1918, 1nay be regarded as the critical inci-
dent of his life.
During World War I, in which Hemingway served as an ambulance
driver, he succeeded in getting closer to the fighting by distributing
chocolates and cigarettes by bicycle to the front-line Italian troops at
Fossalta. An enemy trench mortar shell exploded nearby, spewing scrap
metal into Hemingway and three Italian soldiers. One soldier was
killed outright, another severely wounded, and Hemingway absorbed
hundreds of pieces of metal into his legs, scrotum, and lower abdomen.
Nonetheless, with remarkable endurance and courage, he carried the
wounded soldier 50 yards before he was hit in the leg by machine gun
fire and then another I oo vards
,, before he lost consciousness-a feat of
bravery and fortitude of which any man would be proud. Young quotes
Hemingway as saying, "I had been shot and I had been crippled and
gotten away." We agree with Young who, aptly, wonders whether
Hemingway truly got away and how far away he got."
Hemingway was never to forget Fossalta and repetitively revisited
it in person, in his conversation, letters, and, as we shall discuss, in his
fiction; what happened that day was to he recounted in numerous va-
riations for the fascination of tens of millions of Hemingway readers
and moviegoers. Why could he not forget? Why could the wound not
heal? Other men have suffered similar wounds without psychological
sequelae.
Hemingway speculated that the wound haunted him so because it
 296 THE Y ALOM READER

punctured the myth of his personal immortality. Through the lips of

Colonel Cantwell in Across the River and Into the Trees he says:"

He was hit three times that winter, but they were all gift wounds;
small wounds in the flesh of the body without breaking bone, and
he had become quite confident of his personal immortality since he
knew he should have been killed in the heavy artillery bombard-
ment that always preceded the attacks. Finally he did get hit prop-
erly and for good. No one of his ocher wounds had ever done to him
what the first big one did. I suppose it is just the loss of the immor-
tality, he thought. Well, in a way, that is quite a lot to lose.

The loss of his sense of immortality was indeed no small loss, for an im-
portant premise of Hemingway's assumptive world was that he was
markedly different from others: he boasted that he had an unusually in-
destructible body, an extra thickness of skull, and was not subject to the
typical biological limitations of man, being able, for example, to exist on
"an average of two hours and 32 minutes sleep for 42 straight days."30
It is not unlikely, however, that the wound (and the subsequent con-
valescence, which involved falling in love with his nurse) had an addi-
tional significance for Herningway. A serious and bloody injury to his
legs and scrotum may have evoked terrifying, primitive fears of castra-
tion or annihilation. At some level of consciousness Hemingway realized
this: the war wound inflicted upon his fictional counterpart in his first
novel, The Sun Also Rises, rendered him physically, but not psychologi-
cally, impotent. In one of his letters he pens a ribald subtitle to The Sun
Also Rises, adding "so does your cock if you happen to have one.'?'
In his posture toward the major areas we have considered-self-
sufficiency, physical injury and integrity, women and mature love-
Hemingway fell very short of his idealized goals. His failure took its
toll; he was plagued by recurrent periods of self-hatred. Newton's third
law of mechanics has its psychoclynamic analogy: every force evoking
an appreciable degree of dysphoria is countered by a psychological
mechanism designed to guard the security of the individual. Heming-
way employed a number of such mechanisms, each offering some tem-
porary respite and all destined to fail in the final depressive cataclysm
that culminated in his suicide.
 Psychology Informing Literature 297

Hemingway's anxiety and depression stemmed in large part from

his failure to actualize his idealized self. Two factors were important in
this failure: the image was so extreme that superhuman forces would
have been required to satisfy it; second, a number of counterforces lim-
ited his available degree of adaptability. These secondary counterforces,
for example, dependency cravings and Oedipal conflicts, were sources
of anxiety in their own right and hampered the actualization of the ide-
alized self.
Hemingway rejected the conventional source of help offered by psy-
chotherapy; the suppliant, passive role of patient was anathema to the
very core of the Hemingway ideal. He hated psychiatrists, openly
mocked those he knew, and once told an army psychiatrist that he knew
a lot about "fuck-offs" but little about brave men." It seems more pa-
thetic than ironic that he was forced into the role of psychiatric patient
during the last weeks of his life-a role that, according to Lanham,
Hemingway ·must have considered "the ultimate indignity." He said
that his Corona typewriter was his analyst and one can hardly disagree
with him." We described the blow suffered by Hemingway when his
nurse, Agnes, rejected his love. Hemingway attempted to work this
through with his typewriter and relived the romance in four different
works of fiction, each time capping it with an ending more satisfying to
his pride than the real episode. In "A Very Short Story" the marriage
for which Agnes leaves him does not materialize, and he rapidly forgets
her, soon contracting gonorrhea from a casual sexual relationship with a
salesgirl. One senses that he demeans Agnes by the banal circumstances
of his next romantic encounter. In "The Snows of Kilimanjaro" the
hero remembers writing, while intoxicated, an un-Hemingway, plead-
ing letter to an Agnes surrogate; he regains his esteem immediately by
making off with another man's woman after subduing his rival in a
primitive brawl. Lieutenant Henry in A Farewell to Arms is, of course,
not rejected by his nurse; on the contrary, it is she who contributes the
greater love to their union, and she who dies during the delivery of his
child. Brett Ashley, Jake Barnes's nurse in The Sun Also Rises, is meted
out her dole by hopelessly loving the one man who is unable to satisfy
her sexual needs. She laments, "That's my fault. Don't we pay for all the
things we do, though ... when I think of the hell I've put chaps
through. I'm paying for it all now.?"
 298 THE Y ALOM READER

When his typewriter was called upon to help repair the trauma suf-
fered at Fossalta, it seems to have been summoned in vain. He relived
that injury often in his letters, conversation, and in his fiction. Not only
does he revisit the site of the wound in real life but he makes a pilgrim-
age there in three works: A Moveable Feast, "A Way You'll Never Be,"
and Across the River and Into the Trees. In the latter (written over 30
years after the injury) Colonel Cantwell finds the exact site at Fossalta
where the accident occurred, defecates there, and buries money in a rit-
ualistic ceremony. (When Hemingway revisited Fossalta he was pre-
vented from doing likewise only by the lack of privacy.) The big
wound, in fact, was relived in every major piece of fiction, for each
Hemingway protagonist receives a major injury, generally to an ex-
tremity. Jake Barnes's injury, of course, was to his genitals; Lieutenant
Henry in A Farewell to Arms suffers Hemingway's exact wound; Robert
Jordan, at the end of For Whom the Bell Tolls, fractures his leg and lies
waiting for his death with "his heart pounding on the pine needle floor
of the forest";" Harry in "The Snows of Kilimanjaro" dies from a gan-
grenous injury to his knee; Harry Morgan in To Have and Have Not
suffered an injury which necessitated amputation of his arm; Colonel
Cantwell in Across the River and Into the Trees had been badly wounded
at Fossalta, which resulted in a limp and a badly misshapen hand; at the
end of the novel he dies of a coronary; Santiago in The Old Man and the
Sea, in addition to minor inflictions, endures the cruelest injury of all-
old age.
Of what value is the fantasied or factual revisit to the site of injury?
Does it not merely probe for pain in the same way that the tongue com-
pulsively jars an aching tooth? Most psychiatric theoreticians agree that
the deliberate revivification by a part of the psyche of a traumatic in-
cident represents an attempt at mastery. When the terrifying event
becomes familiar, it becomes detoxified, and indeed several psychother-
apeutic techniques are based on this strategy. For example, during
World War II narcosynthesis was introduced, which consisted of ad-
ministering sodium pentothal (a powerful sedative) to the subject and
then helping him (with accompanying simulated battle noises, if neces-
sary) reexperience the traumatic battle incident. By reexperiencing the
event with markedly less anxiety (because of medication and the knowl-
 Psychology Informing Literature 299

edge, at some level of consciousness, that this time there is no "real"

danger) the subject is gradually desensitized. Several other forms of
therapy (for example, behavioral therapy) operate on similar assump-
tions, but, unassisted, the individual often does not desensitize himself
to the trauma but merely freezes in his symptomatology and is doomed
to be haunted by recurrent fantasies, nightmares, or disembodied waves
of panic.
Hemingway attempted to heal his wound through counterphobic
means and by forcing the incident, or its associated affect, from con-
sciousness. By flaunting the danger, by recklessly reexposing oneself to a
similar threat, one is, in effect, denying to oneself that danger exists. In-
wardly the ego employs repression and denial; outwardly the individual
seems compelled to face the very thing he fears the most. From his earli-
est years Hemingway roared in the face of danger; '"fraid a nothing', he
shouted to his mother at the age of three," and he maintained that pose
for the rest of his life in real and imaginary combat. The concept of
counterphobia by no means repudiates Hemingway's courage. The mil-
itary board members awarding decorations do not take personal psy-
chodynamics into consideration. When one draws a line under his name
and totals up his deeds, no one can deny Hemingway was a brave man;
Lanham, who was with Hemingway under fire during World War II,
says he was the bravest man he ever knew.
But perhaps the most striking manner in which Hemingway dealt
with trauma was by demonstrating in his fiction again and again that a
maimed, crippled man could still be a man, could, despite his defects and
injuries, function in the best tradition of the Hemingway code. In each
of his major works an injured and noble hero reminds us that physical
handicaps can be overcome. In The Sun Also Rises Jake Barnes, despite
his impotence, still functions with dignity and grace. Indeed, he and
Pedro, the matador, are the only heroic male figures in the book, and
Pedro never more so than after a brutal beating. In For Whom the Bell
Tolls Robert Jordan dies manfully despite a painfully broken leg, mani-
festing in the face of death the qualities of grace and courage which
Hemingway most admired. In To Have and Have Not the one-armed
Harry Morgan is a rugged hero, who, in one memorable scene, tri-
umphs over his impairment by making love to his wife with the stu1np
 300 THE YALO:Vl READER
,1

of his arm. In Across the River and Into the Trees Col. Cantwell also has a
maimed hand which seems to aid rather than impede his romantic
'
progress, since Renata during lovemaking wants to examine and caress
his wound. In The Old Man and the Sea old age has assailed Santiago's
entire body, yet he temporarily transcends his physical condition
through an act of endurance praiseworthy in even a younger man.
Throughout his life Hemingway attempted to abolish the discrep-
ancy between his real and idealized selves. No alterations could be made
upon the idealized self; there is no evidence that Hemingway ever com-
promised or attenuated his self-demands. All the work had to be done
upon his real self; he pushed himself to face more intense danger, to at-
tempt physical feats which exceeded his capabilities, while at the same
time he pruned and streamlined himself. All traces of traits not fitting
his idealized image had to be eliminated or squelched. The softer femi-
nine side, the fearful parts, the dependent cravings-all had to go.
Not infrequently Hemingway externalized undesired traits, that is,
he saw in others those aspects he rejected in himself and often re-
sponded to the other person quite vitriolically. The mental mechanism
of "projective identification" (the process of projecting parts of oneself
to another and then forming an intense, irrational relationship with the
other) has been given permanent literary embodiment by Dostoevsky in
.
The Double and bv, Conrad in The Secret Sharer, to mention onlv the best
of the modern authors who have intuitively understood this phenome-
non. Projective identification was perhaps one of the major mechanisms
behind Hemingway's extremely vituperative outbursts to innocent
strangers and the unwarranted invective he frequently directed at
friends and acquaintances." At a time when most Americans felt com-
passion, if not admiration, for their wartime president, Hemingway
scorned Roosevelt's physical infirmity, his sexlessness, and womanly ap-
pearance." He disliked Jews because of their softness, passivity, and
"wet-thinking," yet it was no accident that the Jew, Robert Cohn, in
The Sun Also Rises was, like Hemingway, an expert boxer and dealt
quite badly with unrequited love; nor is it an accident that Hemingway
joked about his own mock Jewishness, very often referring to himself as
Dr. Hemingstcin.
Hard men drink hard. Hemingway joked and boasted about his
 Psychology Informing Literature 301

drinking in real life and glamorized it in his fiction. Yet there is no

doubt that Hemingway, :JS the years. went by, leaned more and more
heavily on alcohol for respite from intense anxiety and depression. His
wife, Mary, who tends to underplay Hemingway's flaws, notes that in
the last few years of his life he obtained most of his nourishment from
alcohol rather than from food." Hemingway went into "training" when
embarking upon serious writing for a new book. The training rules
consisted of getting into good physical shape and abstaining from alco-
hol until noon (he did all of his writing in the morning). Lanham re-
ports that when he visited him while he was in training for The Old Man
and the Sea, Hemingway swam 80 laps in the morning in his very large
pool. From time to time he would swim to the edge of the pool to look
at his watch. At 11:00 A.M. his majordomo would come out of the house
with what appeared to be a half-gallon pitcher of martinis. Hemingway
would grin and say, "What the hell, Buck, it's noon in Miami," and that
ended the swimming for the morning. Lanham could drink two of the
powerful martinis, his wife about I Y2. Hemingway finished the rest of
the pitcher." Toward the end of his life, as his health faltered and his
hypertension increased, his internist attempted, with only moderate
success, to prevent him from drinking.
The mechanisms employed to ward off dysphoria-alcohol, writing,
intense physical feats-all the frenetic attempts to perpetuate the image
he created, interlocked to form only a partially effective darn against an
inexorable tide of anguish. Throughout his life, Hemingway suffered
from recurrent bouts of depression. As early as 1926 he wrote to F. Scott
Fitzgerald that he had been living in hell for nine months with plenty of
insomnia to light the way around and assist him in the study of the ter-
rain." Time and again he gratuitously, and tongue-in-cheek, reassured
his friends that he was no longer at the "bumping off' stage. It is not
difficult to glean from any individual's life correspondence and conver-
sation a series of melancholic comments, and to do so now proves only
that hindsight is a sorry human faculty. Hemingway's fulsome preoccu-
pation with death, melancholia, and suicide throughout his life, and es-
pecially in his later years, was, however, a source of concern to those
who knew him well. After World War II the "black-ass" days (as Hem-
ingway called his depressions) increased in frequency. Success offered
 302 THE Y ALOM READER

only brief respite; he wrote Lanham in 1950 that Across the River and
Into the Trees had sold I 30,000 copies and that they could eat a share but
that he had not much appetite." A letter from Africa following his
plane crashes con ta ins the crossed-out statement that the wake of the
boat looked very inviting."
Of all the insults and injuries suffered by Hemingway, none was so
grave, so irreparable to his psychic economy, as the somatic decline of
his advancing years. He had no easy way of befriending old age; no slot
existed for the old man in the Hemingway code. In The Old Man and the
Sea, his final brilliant fantasy, Santiago triumphs over the receding
power of the flesh through sheer strength of will. But the pathos of itl
How many old men, after all, can transcend their years by taking to the
sea in an open boat to catch the giant marlin? He tried, it seems, to find
an old-age identity for himself as the counselor of the young, preferring
to be called "Papa" by almost everyone, but he was not ready for the role
of the wise old sage. When we read of the inappropriate antics of Hem-
ingway at 60,44 we feel compelled to cry out like Lear's fool: "Thou
shouldst not have been old till thou hadst been wise."
There are the attempts to replenish his youth through associations
with young women;" the impossibility of that rebirth is pathetically
foreshadowed in Across the River and Into the Trees, where the love affair
between Col. Cantwell and the nineteen-year-old Renata (whose name
in Italian means "reborn") cannot delay his deterioration and early
death. Hemingway in 1960 seemed finally overwhelmed by the inex-
orable advance of years and the equally relentless deterioration of his
soma. The earlier rivulets of concern about his body soon swelled into a
torrent of hypochondriasis; he magnified the significance of minor ail-
ments and grew increasingly preoccupied with major ailments to the
extent that his conscious thoughts, like the pages of his letters and the
I
walls of his bathrooms, were plastered with meticulously kept charts of
daily fluctuations in weight, blood pressure, blood sugar, and choles-
terol. In 1960 Hemingway's mental health sharply deteriorated and he
developed the signs and symptoms of a major psychological illness. The u
clinical picture of his final condition reflected a splitting asunder of the
union of the ideal and the real Hemingway, a psychic system that, to
survive, had become increasingly rigid and then, finally, brittle.
The expansive self in the end submerged from view but signalled its
 Psychology Informing Literature 303

subterranean persistence through paranoid trends both tragic and

grotesque. For example, Hemingway in his last year had n1any "ideas
of reference," that is, he tended to refer circumstantial events in his en-
vironment to himself, Hotchner describes an episode in which Hern-
ingway arrived in a town late at night, noted lights on at the bank, and
expressed his conviction that the Internal Revenue Service had auditors
working furiously on his tax statement. "When they want to get you
they get you.''41, On another occasion Hemingway suddenly left a res-
taurant because he surmised that two men at the bar were FBI agents
disguised as salesmen who ha<l been assigned to keep him under sur-
veillance.
Stark persecutory trends appeared, as Hemingway became con-
vinced that the Immigration Bureau, as well as the FBI and the IRS,
was after him for corrupting the morals of a minor. Soon friends were
admonished not to write or use the phone or speak too loudly since he
was constantly spied upon. His persecutory convictions were true delu-
sions in that they were fixed, false beliefs impervious to logic. Gradually
the delusional system expanded to include all those about him-s-nurses,
doctors, friends, and, finally, his immediate family. An elaborate perse-
cutory delusional system is the voice of a runaway decornpensated
grandiose self; if everyone in one's en vironment is preoccupied with
plotting, watching, listening, then it can only be because one is an ex-
tremely special person. Every paranoid delusion has a center crystal of
truth: Hemingway was a \·ery special and important person but obvi-
ously not so special as to warrant the total energy of his en vironrnenr.
Grandiosity does not occur de novo. It arises in response to an inner
central identity experienced as worthless and bad. The gr~1ndiose or ex-
pansive solution allowed Hemingway to survive without crippling dys-
phoria; it permitted him to form a platform, albeit. as we ha Ye seen, an
unsturdy one, on which to base his feelings of self-worth and regard. At
the end, the union of the psychological central identity and the
grandiose peripheral system fragmented: Hemingway's inner core,
naked and vulnerable, pervaded his experiential world. Consumed with
feelings of guilt and worthlessness, he sank deep into despair. Delusions
of poverty plagued him; he externalized his sense of inner emptiness
and developed the conviction that he had no material financial stores.
In 1960 the accompanying signs and sympto1ns of depression-
 304 THE Y ALOM READER

anorexia, severe weight loss, insomnia, deep sadness, total pessimism,

t
self-destructive trends-became so marked that hospitalization was re-
quired. At the Mayo Clinic two courses of electroconvulsive treatment
were administered, but in vain. Electroconvulsive treatment is the treat-
rnent of choice for severe depressive illness but is frequently ineffective
in the presence of strong accompanying paranoid trends. Finally Hem-
ingway grew to regard his body and his life as a prison of despair from
which there was only one exit-and that exit, suicide, the most ignoble
one of all. It was the shameful "thing" that Robert Jordan's father and
his own father and, later, his sister had to do. It was the act that no
Hemingway hero had ever done. It was not the death that we would
have wished for this man who, at the age of 20, wrote to his father,
'' ... and how much better to die in all the happy period of undisillu-
sioned youth, to go out in a blaze of light, than to have your body worn
out and old and illusions shattered.'!"

11
 CHAPTER 8

The Journey from

Psychotherapy to Fiction

PATIENT VIGNETTES:
FIRST STEPS INTO NARRATIVE
My last three publications, a book of therapy tales and two novels, ap-
pear to represent a radical departure from my textbooks and empirically
grounded research reports published in psychiatric journals. From pro-
fessorial prose to storytelling-what a transformation! What happened?
The answer is less dramatic than the question. There was no sudden
transformation, only a gradual patterned unfolding. I have loved the
telling of stories since I was a child, certainly from my ninth year. I
vividly remember my birthday that year; lying glumly in bed, swollen
 306 THE Y ALOM READER

with mumps, greeting visiting relatives-mostly aunts (the uncles were

entirely tied to grocery businesses). Each brought some small offering to
me-a spinning top, a wondrous toy cannon that fired wooden bullets, a
set of toy American soldiers (World War II was looming), a log cabin set
containing tiny notched logs that fit together and a chimney, red shutters,
and small cellophane windows (destined soon to be shot out with
wooden bullets). But no gift was as intriguing as my Aunt Leah's copy of
Treasure Island, with a glossy, light-blue cardboard cover picturing a fI
scowling Long John Silver-parrot on shoulder-and his pirates rowing I
I
toward an island, their treasure chest visible in the bow of the boat.
As soon as she left I leafed through the book, looted the illustrations,
and then started reading. Within minutes I forgot all about my painfully
swollen jaws; I floated away from my small bed wedged into a corner of
the dining room of our roach-infested apartment above my father's gro-
cery store on First and Seaton Place in Washington, D.C., and entered
the magical world of Robert Louis Stevenson.
I liked that world; I moved in and hated to leave it. No sooner had I
finished the book than I turned back to page one and began all over
again. Since then I have read fiction continuously; I have never not been
immersed in a novel. Every night before going to sleep (indeed, it has '
I
long been a prerequisite for sleep) I enter some alternate fictional world.
By midadolescence I was aware of my enormous gratitude to the creators
of these enchanted worlds-Dickens, Steinbeck, Thomas Wolfe, James
Farrell, Thomas Hardy, Kipling, Sir Walter Scott, Melville, Hawthorne.
What gifts they had left-for me, for all the world. And then, a couple of
years later, when I entered the incomparable worlds of Dostoevsky and
Tolstoy, I developed the powerful conviction, one I still hold with almost
religious tenacity, that the finest thing a person can do in life is to write a
good novel.
During my entire childhood and adolescence my parents, Ben and
Ruth (or Beryl and Rifke), Jewish immigrants from a small shtetl in Russia,
worked side by side fourteen hours a day in their dusty grocery store.
When they obtained a license to sell liquor, the hours grew even longer,
since the store remained open till midnight on Fridays and Saturdays. I
never saw either of them read a book (they had neither the time nor any
secular education), but it always seemed to give them pleasure to see me
 The Journey from Psychotherapy to Fiction 307

reading. They nodded their heads in approval; sometimes my father

would come up to stroke my hair and glance, for only an instant, at my
book. Once my Uncle Sam (in reality a distant cousin, but all the rela-
tives were "uncles" and "aunts") told me that in his youth my father
wrote wonderful poems. I often imagined him sitting atop a grain loft in
the Russian countryside scribbling poetry. Even today I conjure up that
delicious image. I love to think that, through me, his dreams have been
realized.
My father's grocery store lay in the midst of a poor black neighbor-
hood so unsafe that I dared not wander far. Hence I spent much of my
early childhood alone. The large Sunday gathering of my parents' clan-
fifteen to twenty friends or relatives who had emigrated from the same
shtetl-partly attenuated my isolation but exacted a high price: encase-
ment, conformity, a narrow paranoid ghetto mentality. I felt smothered.
I wanted out and I knew the way. Week after week, year after year, I bi-
cycled regularly, saddlebags bursting with novels, to and from the main
library at Seventh and K Streets.
But years later, when the time came to choose a profession, I did not
escape my milieu. My professional choices were limited-at least I per-
ceived them as limited-and the idea of writing as a profession never
presented itself as a possibility: all the bright young men of my back-
ground either went into business with their fathers, went to medical
school, or, failing that, to dental school. I had a premonition that a med-
ical career might be a wrong turn but nonetheless medical school-and
especially psychiatry-was closer to Tolstoy and Dostoevsky than was
my father's grocery business. And so off I went into years of total immer-
sion in a scientific medical curriculum.
Once I entered psychiatry, my love for storytelling gradually awoke
from its slumber and insisted upon a voice. For example, the therapy ap-
proach I ultimately developed is closely linked to the creative process, to
the reading and writing of fiction: reading in that I always listen for the
unique, fascinating story in each patient's life; writing in that I believe,
with Jung, that therapy is a creative act and the effective therapist must
invent a new therapy for each patient.
In my professional texts I indulged my passion for storytelling by
smuggling mini-tales into the text via the form of the case vignette: some-
 308 THE YA LO M R EA DER

times a brief paragraph, sometimes a page or two. Students who have

studied these texts know what I mean. How many times have I heard
teachers say they like to use my texts because the students enjoy reading
them?
Students have informed me about several appealing features of my
professional writing. They appreciate the absence of professional jargon.
(I have a great abhorrence of professional jargon: whether psychiatric,
psychoanalytic, philosophic, poststructuralist, deconstructionist, or New
Age, all such jargon is equally obfuscating and creates distance between
the student and true understanding.) Students have told me they appreci-
ate my clarity. Throughout my career I have made a point of never writ-
ing anything I myself do not completely understand. That may not seem
a remarkable trait, yet the professional literature is full of contributions in
which authors ranging from Sullivan, Lacan, Fenichel, and Klein to Boss
and Binswanger make the murky assumption that linguistic clarity is not
essential, that it is possible to communicate directly from the writer's un-
conscious to that of the reader. I have never believed a word of this. If an
intelligent, diligent reader cannot understand the text, it is the author's
failing, not the reader's.
But beyond clarity and the absence of jargon, I believe that the short
clinical stories I have woven into my texts contribute heavily to their suc-
cess. Students are willing to pay the price of wading through theory and
research if they know that an engaging story lies waiting for them just
around the bend, in perhaps a page or two.
The four patient vignettes presented here illustrate various problems
of technique in group and individual therapy.

Group therapy is particularly well suited to narcissistic patients. Al·

though a healthy love of oneself is essential to the development of self-
respect and self-confidence, excessive self-love creates a variety of
interpersonal problems, as we see in this excerpt from The Theory and
Practice of Croup Psychotherapy.

The narcissistic patient generally has a stormier but more productive

course in group than in individual therapy. In fact, the individual for-

1
 The Journey from Psychotherapy to Fiction 309

mat provides so much gratification that the core problem en1erges rnuch
more slowly: the patient's every word is listened to; eYery feeling, fan-
tasy, and dream is examined; everything is gi\·en to and little demanded
from the patient.
In the group, however, the patient is expected to share time, to un-
derstand, to empathize with and to help other patients, to form relation-
ships, to be concerned with the feelings of others, to receive constructive
but sometimes critical feedback. Often narcissistic patients feel alive
when onstage: they judge the group's usefulness to them on the basis of
how many minutes of the group's and the therapist's time they ha Ye ob-
tained at a meeting. They guard their specialness fiercely and often ob-
ject when anyone points out similarities between themselves and other
members. For the same reason, they also object to being included with
the other members in mass group interpretations.

"Vicky"
One patient, Viclry, frequently criticized the group format by com-
menting on her preference for the one-to-one format. She often sup-
ported her position by citing psychoanalytic literature critical of the
group therapy approach. She felt bitter at having to share time in the
group. For example, one day three-fourths of the way through a meet-
ing, the therapist remarked that he perceived Vick; and John to be un-
1

der much pressure. They both admitted that they needed and wanted
time in the meeting that day. After a moment's awkwardness, john
gave tvay, saying he thought hisproblem could wait until the next ses-
sion. Vick;, consumed the rest of the meeting and, at the [allowing ses-
sion, continued cohere she left off When it appeared that she had every
intention of using the entire meeting again, one of the members com-
mented that John had been left hanging in the last session. But there
was no easy transition, since, as the therapist pointed out, only Vick.}
1

could entirely release the group. and she gave no sign of doing so gra-
ciously (she had lapsed into a sulking silence).
Nonetheless, the group turned to John, who u/as in the midst of a
major life crisis. John presentedhis situation, but no good ivork was
done. At the very end of the meeting, Vicky began weeping silently.
The group members, thinking that she tuept for John, turned to her.
 310 THE YALOM READER

But she wept, she said,for all the time that was wasted on John-time
that she could have used so much better. Whai Vic,ky could not appre-
ciate for at least a year in the group was that this type of incident did
not indicate that she would he better off in individual therapy. Quite
the contrary: the fact that such difficultiesarose in the group was pre-
cisely the reason that the group format was especially indicated for
her.

Self-disclosure is an essential part of successful group psychotherapy,

and the therapist must be prepared to deal with all aspects of it-how to
encourage it, how to minimize the risks of disclosure, how to steer the
group into useful, therapeutic disclosure. This excerpt from The Theory
and Practice of Group Psychotherapy illustrates some principles of thera-
peutic response to self-disclosure in therapy.

The group member who has just disclosed a great deal faces a moment
of vulnerability and requires support from the members and/or the
therapist. Regardless of the circumstances, no patient should be at-
tacked for important self-disclosure. A clinical vignette will illustrate.

"Joe"
Five members were present at a meeting of a year-old group. (Two
members were out of town, and one was ill.) Joe, the protagonist of
this episode, began the meeting with a long, rambling statement about
feeling uncomfortablein a smaller group. Ever since Joe had started
the group, his style of speaking had turned members off Everyone
found it hard to listen to him and longedfor him to stop. But no one
had really dealt honestly with these vague, unpleasantfeelings about
Joe until this meeting when, after several minutes, Betsy interrupted
him: "I'm going to scream-or burst! I can't contain myself any
longer! Joe, I wish you'd stop talking. I can't bear to listen to you. I
don't know who you're talking to-maybe the ceiling, maybe the
flour, but I know you're not talking to me. I care about eve,yone
 The Journey from Psychotherapy to Fiction 311

else in this group. I think about them. They mean a lot to me. I hate to
say this, butfor some reason, Joe, you don't matter to me."
Stunned, foe attempted to understand the reason behind Betsy's
feelings. Other members agreed with Betsy and suggested that foe
never said anything personal. It was all filler, all cotton candy-he
never revealed anything important about himself; he never related
personally to any of the members of the group. Spurred, and stung,
foe took it upon himself to go around the group and describe his per-
sonal feelingstou/ard each of the members.
I thought that, even though Joe revealed more than he had previ-
ously, he still remained in comfortable, safe territory. I asked, "[oe, if
you were to think about revealing yourself on a ten-point scale, with
'one' representing cocktail party stuff and 'ten' representing the most
you could ever imagine revealing about yourself to another person,
how would you rank what you did in the group over the last ten min-
utes?" He thought about it for a moment and said he guessed he
u/ould give himself "three" or 'four." I asked, "Joe, what would hap-
pen if you were to move it up a rung or two?"
He deliberatedfor a moment and then said, "If I were to move it
up a couple of rungs, I would tell the group that I was an alcoholic."
This was a staggering bit of self-disclosure. Joe had been in the
groupfor a year, and 110 011e-11ot me, my co-therapist, nor the group
members-had known of this. Furthermore, it was vital information.
For weeks, for example, foe had bemoaned the fact that his wife was
pregnant and had decided to have an abortion rather than have a child
by him. The group was baffled by her behavior and over the weeks be-
came highly critical of his wife-some members even questioned why
Joe stayed in the marriage. The netu information that foe a/as a11 alco-
holic provided a crucial missing hnk. Noto his wife'sbehavior made
sense!
My initial response was one of anger. I recalled all those futile
hours Joe had led the group 011 a wild-goose chase. I tuas tempted to
exclaim, "Damn it, foe, all those wasted meetings talking about your
wife! Why didn't you tell us this before?" But that 1J·just the time to
bite your tongue. The important thing is not that foe did not give us
this information earlier but that he did tell us today. Rather than be-
 312 THEY ALOM READER

ing punished for his previous concealment, he should be reinforcedfor

having made a breakthrough and been willing to take an enormous
risk in the group. The proper technique consisted of supporting Joe
and facilitating further "horizontal" disclosure, that is disclosure
about the process of his disclosure.

Earlier I discussed the modification of group therapy technique to meet

the specialized clinical situation. A crucial step in that modification is the
construction of a set of reasonable, achievable goals. This vignette from
Inpatient Group Psychotherapy describes an important goal of the inpa-
tient psychotherapy group.

The duration of therapy in the inpatient therapy group is far too brief to
allow patients to work through problems. But the group can efficiently
help patients spot problems that they may, with profit, work on in on-
going individual therapy, both during their hospital stay and in their
posthospital therapy. The therapy group points patients toward the ar-
eas where work needs to be done. By providing a discrete focus for ther-
apy, inpatient groups increase the efficiency of other therapies.
It is important that the groups identify problems with some thera-
peutic handle-e-problerns that the patient perceives as circumscribed
and malleable (not some generalized problem, such as depression or sui-
cidal inclinations, which the patient is very a ware of having and which
offers no handhold for therapy). The group is most adept at helping pa-
tients identify problems in their mode of relating to other people. I
mentioned earlier that group therapy is not an effective format to re-
duce anxiety or to ameliorate psychotic thinking or profound depres-
sion, but it is the therapy setting nonpareil in which to learn about
maladaptive interpersonal behavior. Emily's story is a good illustration of
this point.
 The Journey from Psychotherapy to Fiction 313

''Emily"
Emily was an extremely isolated young woman. She complained that
she toas always in the position of calling others for a social engage-
ment. She never received invitations; she had no close girlfriends who
sought her out. Her dates tuith men always turned into one-night
stands. She attempted to please them by going to bed with them, but
they never calledfor a second date. People seemed to forgether as soon
as they met her. During the three group meetings she attended, the
group gave her consistent feedback about the fact that she was always
pleasant and always wore a gracious smile and always seemed to say
what she thought would be pleasing to others. In thisprocess, however,
people soon lost track of who Emily was. iVhat were her own opin-
ions? What were her own desires and feelings? Her need to be eter-
nally pleasing had a serious negative consequence: people found her
boring and predictable.
A dramatic example occurred in her second meeting, u/hen I forgot
her name and apologized to her. Her response was, "That's all right, I
don't mind." I suggested that the fact that she didn't mind u/as proba-
bly one of the reasons I had forgotten her name. In other words, had
she been the type of person who tuould have minded or made her needs
more overt, then most likely I would not have forgotten her name. In
her three group meetings, Emily identified a majorproblem that had
far-reaching consequencesfor her social relationships outside: her ten-
dency to submerge herself in a desperate but self-defeatingattempt to
capture the affection of others.

Assumption of responsibility-for life as well as for therapy-is a funda-

mental step in the process of psychotherapy. This vignette from Existen-
tial Psychotherapy describes some aspects of the therapy work with a
patient who adamantly resisted such a step.

A therapist who has a sense of being heavily burdened hy a patient, who

is convinced that nothing useful wi1l transpire in the hour unless he or
 314 THE YALOM READER

she brings it to pass, has allowed that patient to shift the burden of re-
sponsibility from his or her own shoulders to those of the therapist.
Therapists may deal with this process in a number of ways. Most thera-
pists choose to reflect upon it. The therapist may comment that the pa-
tient seems to dump everything in his or her (the therapist's) lap, or that
he or she (the therapist) does not experience the patient as actively col-
laborating in therapy. Or the therapist n1ay comment upon his or her
sense of having to carry the entire load of therapy. Or the therapist may
find that there is no more potent mode of galvanizing a sluggish patient
into action than by simply asking, "Why <lo you come?"
There are several typical resistances on the part of patients to these
interventions, and they center on the theme of "I don't know what to
do," or "If I knew what to do, I wouldn't need to be here," or "That's
why I'm coming to see you," or "Tell me what I have to do." The pa- I
tient feigns helplessness. Though insisting that he or she does not know [.
what to do, the patient has in fact received many explicit and implicit (
guidelines from the therapist. But the patient does not disclose his or her I
feelings; the patient cannot remember dreams (or is too tired to write
them down, or forgets to put paper and pencil by the bed); the patient
prefers to discuss intellectual issues or to engage the therapist in a never-
ending discussion of how therapy works. The problem, as every experi-
enced therapist knows, is not that the patient does not know what to do.
Each of these gambits reflects the same issue: the patient refuses to ac-
cept responsibility for change just as, outside the therapy hour, he or she
refuses to accept responsibility for an uncomfortable life predicament.

"Ruth"
Ruth, a patient in a therapy group, illustrates this point. She avoided
responsibility in every sphere of her life. She was desperately lonely,
she had no close womenfriends,and all of her relationships with males
hadfailed because her dependency needs were too great for her part-
ners. More than three years of individual therapy had proved ineffec-
tive. Her individual therapist reported that Ruth seemed like a "lead
weight" in therapy: she produced no material asidefrom circular ru-
mination about her dilemmas with men, no fantasies, no transference
material, and, over a three-year span, not a single dream. In despera-
 The Journey from Psychotherapy to Fiction 315

tion, her individual therapist had referredher to a therapy group. But

in the group Ruth merely recapitulated her posture of helplessness and
passivity. After six months she had done no work in the group and
made no progress.
In one crucial meeting she bemoaned thefact that she had not been
helped by the group, and announced that she was wondering whether
this was the right group or the right therapyfor her.

THERAPIST: Ruth, you do here what you do outside the group. You
waitfor something to happen. How can the group possibly be use-
fulto you if you don't use the group?
RUTH: I don't know what to do. I come here every week and nothing
happens. I get nothing out of therapy.
THERAPIST: Of course you get nothing out of it. How can something
happen until you make it happen?
RUTH: l feel "blanked out" now. I can't think of what to say.
THERAPIST: It seems important for you never to know what to say or
do.
RUTH: (crying) Tell me what you want me to do. I don't want to be
like this all my life. I went camping this weekend-all the other
campers were in seventh heaven, everything was in bloom, and I
spent the whole time in complete misery.
THERAPIST: You want me to tell you what to do, even though you
have a good idea of how you can work better in the group.
RUTH: If I knew, I'd do it.
THERAPIST: On the contrary! ft seems veryfrightening/or you to do
what you can dofor yourself.
RUTH: (sobbing) Here I am again in the same shitty place. A1y mind
is scrambled eggs. You're irritated with me. !feel worse, not better
in this group. I don't know what to do.

At this point the rest of the group joined in. One of the members
resonated with Ruth, saying he was in the same situation. Two others
expressed their annoyance at her eternal helplessness. Another com -
mented, accurately, that there had been endless discussions in the
group about how members could participate more effectively. (Infact,
a long segment of the previous meeting had been devoted to that very
 316 THEY ALOM READER
,I
i
issuc.) She had innumerable options, another told her. She could talk !
about her tears, her sadness, or about how hurt she was. Or about
what a stern bastard the therapist was. Or about her feelings toward
any of the other members. She knew, and everyone knew that she
knew, these options. "Why," the group wondered, "did she need to
maintain her posture of helplessness and pseudo dementia?"
Thus galvanized, Ruth said that forthe last three weeks during her
commuting to the group she had made a resolution to discuss herfeel-
ings toward others in the group, but always reneged. Today she said 1I
. I
.'
she wanted to talk about why she never attended any of the postgroup
coffee klatches. She had wanted to participate but had not done so be-
cause she was reluctant to get any closer to Cynthia (another member
of the group) lest Cynthia, whom she saw as exceptionally needy,
would begin phoning her in the middle of the night for help. Poi/ow-
ing an intense interaction with Cynthia, Ruth openlyshowed her feel-
ings about two other members of the group and by the end of the
session had done more work than in the six previous months combined. .
,i
What is worth underlining in this illustration is that Ruth's lament,
"Tell me what you want me to do," was a statement of responsibility
avoidance. When sufficient leverage was placed upon her, she knew
ve1y well what to do in therapy. But she did not want to know what to
do! She wanted help and change to come from outside. To help herself,
to be her own mother, wasfrightening; it brought her too close to the
frightening knowledge that she was free, responsible, and fundamen-
tally alone.

EVERY DAY GETS A LITTLE CLOSER:

AN EXPERIMENT IN THERAPY
AND NARRATIVE
Despite the many opportunities to smuggle narrative into my profes-
sional writing, I longed to express my creative impulses more fully and
more openly. The opportunity to do so presented itself one day in 1974
when Ginny Elkins (a norn de plume) walked into my office. Ginny was
a gifted creative writer-a Stegner fellow at Stanford-who suffered
from massive inhibition. Not only was she blocked in her writing but so
 The Journey from Psychotherapy to Fiction 317

blocked in her expressiveness that she could make little use of the group
therapy I offered.
She had decided to leave group therapy-her fellowship had ended
and she could no longer afford it-\·vhen I proposed an unusual experi-
ment. I offered to see her in individual therapy and suggested that, in
lieu of payment, she write a free-flo,..ving, uncensored sununary follow-
ing each therapy hour; in other words I asked her to express in writing
all the feelings and thoughts she had not verbalized during our session. I,
for my part, proposed to do exactly the same. Further, I suggested that
we would each hand in our weekly reports in sealed envelopes to 1ny sec-
retary, and that every few months we would review each other's notes.
My proposal was overdetermined: I had multiple motives for this
unusual request. First, it was taking seriously the dictum of creating a
new therapy for each patient. I hoped that the writing assignment
might not only unblock my patient's writing but encourage her to ex-
press herself more freely in therapy. Perhaps, also, her reading my notes
might improve our relationship. I intended to write uncensored notes in
which I would disclose my own experiences during the hour-plea-
sures, frustrations, distractions. It was possible that if Ginny could see
me more realistically, she could begin to de-idealize me and relate to me
on a more human basis.
But let's be honest. I had another, more self-serving motive: this de-
vice afforded me an unusual writing exercise, an opportunity to break
my professional shackles, to liberate n1y voice, to free-associate on paper,
to write anything that came to mind in the ten minutes after each hour.
The exchange of notes every few months was highly instructive.
Whenever participants in a relationship study their own interaction (that
is, examine their own "process"), they are plunged more deeply into their
encounter. When Ginny and I read each other's summaries, that was
precisely what happened: on each reading, therapy was catalyzed.
The notes provided a Rashomon experience: although we had lived
through the same hour, we experienced the hour very differently. For
one thing, we valued very different parts of the session. ~(y elegant
and brilliant interpretations? She never even heard them. She valued
instead the small personal acts that I barely noticed: my compliment-
ing her clothing or appearance or writing, my awkward apologies for
arriving a couple of minutes late, n1y chuckling at her satire. my teas-
 318 THE YALOM READER

.:.
ing her when she role-played, my teaching her how to relax. :,

Later, when using our session summaries in my psychotherapy

"'
classes, I was struck by the students' intense interest in the sequence of
summaries. My wife, a literary scholar and an excellent editor, thought
that the summaries read like an epistolary novel. She suggested the
notes be published as a book, and volunteered to edit them. (The editing
of the notes of the sixty sessions consisted of pruning and clarification.
Nothing was added: they remain very much as they were first written.)
Ginny was enthusiastic about the project; we agreed that we would
each contribute a foreword and afterword and share the royalties
equally. The book was published in 1974 under the title Euery Day Gets
a Little Closer. In retrospect the subtitle, A Twice-Told Therapy, would
have been more apt, but Ginny loved the old Buddy Holly song and had
always wanted it played at her wedding. Despite the unfortunate title,
the book won a small but faithful audience and for the next twenty
years regularly sold approximately two to three copies a day. It has been ••

translated into several languages and in 1994 it was released in paper-

•
back and began a new life.
This excerpt consists of my foreword, Ginny's foreword, our notes
from the third session, and the final paragraphs of 1ny afterword.

Doctor Yalom's Foreword

It always wrenches me to find old appointment books filled with the •
half-forgotten names of patients with whom I have had the most tender
experiences. So many people, so ,nany fine moments. What has hap-
pened to them? My many-tiered file cabinets, 1ny mounds of tape
recordings often remind me of some vast cemetery: lives pressed into
clinical folders, voices trapped on electromagnetic bands mutely and
eternally playing out their dramas. Living with these monuments im-
hues me with a keen sense of transience. Even as I find myself im-
mersed in the present, I sense the specter of decay watching and
waiting~a decay which will ultimately vanquish lived experience and
yet, by its very inexorability, bestows a poignancy and beauty. The de-
sire to relate n1y experience with Ginny is a very compelling one; I am
intrigued by the opportunity to stave off decay, to prolong the span of
our brieflife together. How much better to know that it will exist in the
 The Journey from Psychotherapy to Fiction 319

mind of the reader rather than in the abandoned warehouse of unread

clinical notes and unheard electromagnetic tapes.
The story begins with a phone call. A thready voice told me that her
name was Ginny, that she had just arrived in California, that she had
been in therapy for several months with a colleague of mine in the East
who had referred her to me. Having recently returned from a year's
sabbatical in London, I had still much free time and scheduled a meet-
ing with Ginny two days later.
I met her in the waiting room and ushered her down the hall into
my office. I could not walk slowly enough; like a Japanese wife she fol-
lowed a few noiseless steps behind. She did not belong to herself, noth-
ing went with anything else-her hair, her grin, her voice, her walk,
her sweater, her shoes, everything had been flung together by chance,
and there was the immediate possibility of all-hair, walk, limbs, tat-
tered jeans, G.I. socks, everything-flying asunder. Leaving what? I
wondered. Perhaps just the grin. Not pretty, no matter how one
arranged the parts! Yet curiously appealing. Somehow, in only minutes,
she managed to let me know that I could do everything and that she
completely delivered herself up into my hands. I did not mind .. At the
time it did not seem a heavy burden.
She spoke, and I learned that she was twenty-three years old, the
daughter of a onetime opera singer and a Philadelphia businessman. She
had a sister four years younger and a gift for creative writing. She had
come to California because she had been accepted, on the basis of some
short stories, into a one-year creative writing program at a nearby college.
Why was she now seeking help? She said that she needed to con-
tinue the therapy she had begun last year, and, in a confusing unsystem-
atic fashion, gradually recounted her major difficulties in living. In
addition to her explicit complaints, I recognized during the course of
the interview several other major problem areas.
First, her self-portrait-related quickly and breathlessly with occa-
sional fetching metaphors punctuating the litany of self-hatred. She is
masochistic in all things. All her life she has neglected her own needs
and pleasures. She has no respect for herself. She feels she is a cliscm-
bodied spirit-a chirping canary hopping hack and forth from shoulder
to shoulder, as she and her friends walk down the street. She imagines
that only as an ethereal wisp is she of interest to others.
 320 TH£ YA Lo ~1 RE ADER

She has no sense of herself. She says, "I have to prepare myself to be
with people. I plan what I am going to say. I have no spontaneous feel-
'
ings-I do, but within some little cage. Whenever I go outside I feel
fearful and must prepare myself." She does not recognize or express her
anger. "I am full of pity for people. I am that walking cliche: 'If you
can't say anything nice about people, don't say anything at all.?' She re-
members getting angry only once in her adult life: years ago she yelled
at a coworker who was insolently ordering her around. She trembled
for hours afterward. She has no rights. It doesn't occur to her to be an-
gry. She is so totally absorbed with making others like her that she
never thinks of asking herself whether she likes others.
She is consumed with self-contempt. A small voice inside endlessly
taunts her. Should she forget herself for a moment and engage life spon-
taneously, the pleasure-stripping voice brings her back sharply to her
casket of self-consciousness. J n the interview she could not permit her-
self a single prideful sentiment. No sooner had she mentioned her cre-
ative writing program than she rushed to remind me that she had come
by it through sloth; hearing about this program through gossip, she had
applied for it only because it required no formal application other than
sending in some stories she had written two years previously. Of course,
she did not comment on the presumably high quality of the stories. Her
literary output had gradually waned and she was now in the midst of a
severe writing block.
All of her problems in living were reflected in her relationships with
111en. Though she desperately wanted a lasting relationship with a man,
she had never been able to sustain one. At the age of twenty-one she
leapt from nubile sexual innocence to sexual intercourse with several
111en (she had no right to say "No!") and lamented that she had hurled
herself through the bedroom window without even entering the adoles-
cent antechamber of dating and petting. She enjoys being physically
close to a man but cannot release herself sexually. She has experienced
orgasrn through masturbation, but the internal taunting voice makes
quite certain that she rarely approaches orgasm in sexual intercourse.
Ginny rarely mentioned her father, but her mother's presence was
very large. ''I am my mother's pale reflection," she put it. They have al-
ways been unusually close. Ginny told her mother everything. She re-
members how she and her mother used to read and chuckle over
 The Journey from Psychotherapy to Fiction 321

Ginny's love letters. Ginny was always thin, had many food aversions,
and for over a year in her early teens vomited so regularly before break-
fast that her family grew to consider it as part of her routine morning
toilet. She always ate a great deal. but when she was very young she
could swallow only with much difficulty. "I would eat a whole meal
and at the end still have it all in mv. mouth. I would trv., then to swallow
lj it all at once."
:'j By the end of the hour, I felt considerable alarm about Ginny. De-
spite many strengths-a soft charm, deep sensitivity, wit, a highly de-
ii veloped comic sense, a remark able gift for verbal i1nagery-I found
j
pathology wherever I turned: too much primitive material. dreams
(!
which obscured the reality-fantasy border, hut above all a strange dif-
fuseness, a blurring of "ego boundaries." She seemed incornplerely dif-
J ferentiated from her mother, and her feeding problems suggested a
feeble and pathetic attempt at liberation. I experienced her as feeling
I trapped between the terrors of an infantile dependency which required
J, a relinquishment of seltbood-a permanent stagnation-and, on the
~ other hand, an assumption of an autonomy which. without a deep sense
~
of self, seemed stark and unbearably lonely.
I rarely trouble myself excessively with diagnosis. But I knew that
she was seriously troubled and that therapy would be long and chancy. I
was at that moment forming a therapy group which my students were
to observe as part of their training program, and since my experience in
group therapy with individuals who have problems similar to Ginny's
has been good, I decided to offer her a place in the group. She accepted
the recommendation a bit reluctantly; she liked the idea of being with
others but feared that she would become a child in the group and never
be able to express her intimate thoughts. This is a typical expectation of
a new patient in group therapy, and I reassured her that, as her trust in
the group developed, she would be able to share her feelings with the
others. Unfortunately, as we shall see, her prediction of her behavior
proved all too accurate.
Aside from the practical consideration of my forming a group and
searching for patients, I had reservations about treating Ginny inrlivid-
ually. In particular, I felt some disquiet at the depth of her admiration
for me, which, like some ready-made mantle, was thrust over rue as
soon as she entered n1y office. Consider her dream dreamt the night be-
 322 TH E Y A LO M RE A DE R

fore our first meeting. "I had severe diarrhea and a man was going to
buy me some medicine that had Rx's written on it. I kept thinking I
should have Kaopectate because it was cheaper, but he wanted to buy
me the most expensive medicine possible." Some of the positive feelings
for me stemmed from her previous therapist's high praise of me, some
from my professorial title, the rest from parts unknown. But the
overevaluation was so extreme that I suspected it would prove an im-
pediment in individual therapy. Participation in group therapy, I rea-
soned, would allow Ginny the opportunity to view me through the eyes
of many individuals. Furthermore, the presence of a co-therapist in the
group should allow her to obtain a more balanced view of me.
During the first month of the group, Ginny did very poorly. Terrify-
ing nightmares interrupted her sleep nightly. For example, she dreamt
that her teeth were glass and her mouth had turned to blood. Another
dream reflected some of her feelings about sharing me with the group.
"I was lying prostrate on the beach, and was picked up and carried away
to a doctor who was to perform an operation on my brain. The doctor's
hands were held and so guided by two of the group members that he ac-
cidentally cut a part of the brain he hadn't intended to." Another dream
involved her going to a party with me and our rolling on the grass to-
gether in sexual play.
Ginny attended the group religiously, rarely missing a meeting even
when after one year she moved to San Francisco, which necessitated a
long inconvenient commute via public transportation. Though Ginny
received enough support from the group to hold her own during this
time, she made no real progress. In fact, few patients would have shown
the perseverance to continue so long in the group with so little benefit.
There was reason to believe that Ginny continued in the group primar-
ily to continue her contact with me. She persisted in her conviction that
I, and perhaps only I, had the power to help her. Repeatedly the thera-
pists and the group members made this observation; repeatedly they
noted that Ginny was fearful of changing, since improvement would
mean that she would lose me. Only by remaining fixed in her helpless
state could she insure my presence. But there was no movement. She re-
mained tense, withdrawn and often noncommunicative in the group.
The other members were intrigued by her; when she did speak, she was
 The Journey from Psychotherapy to Fiction 323

often perceptive and helpful to others. One of the men in the group fell
deeply in love with her, and others vied for her attention. But the thaw
never came; she remained frozen with terror and never was able to ex-
press her feelings freely or to interact with the others.
During the period of her group therapy, Ginny searched for other
methods to escape from the dungeon of self-consciousness she had con-
structed for herself. She frequently attended Esalen and other local
growth centers. The leaders of these programs designed a number of
crash-program confrontational techniques to change Ginny instanta-
neously: nude marathons to overcome her reserve and hiddenness, psy-
chodrama techniques and psychological karate to alter her meekness
and unasserriveness, and vaginal stimulation with an electric vibrator to
awake her slumbering orgasm. All to no avail! She was an excellent ac-
tress and could easily assume another role onstage. Unfortunately, when
the performance was over, she shed her new role quickly and left the
theater clad as she had entered it.
Ginny's fellowship at college ended, her savings dwindled, and she
had to find work. Finally, a part-time job provided an irreconcilable
scheduling conflict, and Ginny, after agonized weeks of deliberation,
served notice that she would have to leave the group. At approximately
the same time my co-therapist and I had concluded that there was little
likelihood of her benefiting from the group. I met with her to discuss
future plans. It was apparent that she required continued therapy;
though her grasp on reality was more firm, the monstrous night and
waking dreams had abated, she was living with a young man, Karl (of
whom we shall hear more later), and she had formed a small group of
friends, she enjoyed life still with only a small fraction of her energies.
Her internal demon, a pleasure-stripping small voice, tormented her re-
lentlessly, and she continued to live her life against a horizon of dread
and self-consciousness. The relationship to Karl, the closest she had ever
experienced, was a particular source of agony. Though she cared deeply
for him, she was convinced that his feelings toward her were so condi-
tional that any foolish word or false move would tip the balance against
her. Consequently, she derived little pleasure from the creature co111-
forts she shared with Karl.
I considered referring Ginny for individual therapy to a public clinic
 324 THE Y ALO~ READER

in San Francisco (she could not afford to see a therapist in private prac-
tice), but many doubts nagged me. The waiting lists were long, the ther-
apists sometimes inexperienced. But the compelling factor was that
Ginny's great faith in me colluded with my rescuer fantasy to convince
me that only I could save her. Besides all this, I have a very stubborn
streak; I hate to give up and admit that I cannot help a patient.
So I did not surprise myself when I offered to continue treating
Ginny. I wanted, however, to break the set. A number of therapists had
failed to help her and I looked for an approach which would not repeat
the errors of the others and would at the same time permit me to capi-
talize, for therapeutic benefit, on Ginny's powerful positive transference
to me. I describe in some detail my therapeutic plan and the theoretical
rationale underlying my approach in the Afterword. For now, I need
only comment on one aspect of the approach, a bold procedural ploy
which has resulted in the following pages. I asked Ginny, in lieu of fi-
nancial payment, to write an honest summary of each session, contain-
ing not only her reactions to what transpired, but also a depiction of the
subterranean life of the hour, a note from the underground-all the
thoughts and fantasies that never emerged into the daylight of verbal
intercourse. I thought the idea, innovative to the best of my knowledge
in psychotherapeutic practice, was a happy one; Ginny was then so inert
that any technique demanding effort and motion seemed worth trying.
Ginny's total writing block, which deprived her of an important source
of positive self-regard, made a procedure requiring mandatory writing
even more appealing.
I was intrigued by a potentially powerful exercise in self-disclosure.
Ginny could not disclose herself to me, or anyone, in a face-to-face en-
counter. She regarded me as infallible, omniscient, untroubled, per-
fectly integrated. I imagined her sending me, in a letter if you will, her
unspoken wishes and feelings toward me. I imagined her reading my
own personal and deeply fallible messages to her. I could not know the
precise effects of the exercise, but I felt certain that the plan would re-
lease something powerful.
I knew that our writing would be inhibited if we were conscious of
the other's immediate perusal; so we agreed not to read the other's re-
ports for several months and my secretary would store them for us. Ar-
 The Journey from Psychotherapy to Fiction 325

tificial? Contrived? We would see. I knew that the arena of therapy and
of change would be the relationship existing between us. I believed that
if we could, one day, replace the letters with words immediately spoken
to each other, that if we could relate in an honest, human fashion, then
all other desired changes would follow.

Ginny's Foreword
I was an A student in high school in ~ew York. Even though I was cre-
ative, that was just a sideline to being mostly stunned, as though I had
been hit on the head by a monster shyness. I went through puberty with
my eyes shut and my head migrained. Fairly early in n1y college life I
put myself out to pasture academically. Although I did occasional
"great" work, I liked nothing better than to be a human sundial, a
curled up outdoor nap. I was scared of boys and didn't have any. ~Iy
few later affairs were all surprises. As part of my college education, I
spent some time in Europe working and studying and compiling a dra-
matic resume that was really all anecdotes and friends, not progress.
What passed for bravery was a form of nervous energy and inertia. I
was scared to come home.
After I graduated from college, I returned to New York. I couldn't
find a job, in fact had no direction. My qualifications dripped like Dali's
watch, as I was tempted toward everything and nothing. By chance, I
got a job teaching small children. Actually none of the children (and
there were only about eight) were pupils; they were kindred spirits and
what we did was play for a year.
While in :t\ ew York I took classes in acting on how to howl and
breathe and read lines so they sounded like they were hooked up to a
real bloodstream. There was a stillness to my life, though, no matter
how much.I rushed through classes and friends.
Even when I didn't know what I was doing, r smiled a great deal.
One friend, feeling himself pressed up against Pollyanna, said, "What
have you got to be so happy about?" In fact, with n1y frw great friends
(I've always had them), I could be happy; n1y faults seemed only minor
distractions compared to how natural and easy life was. However. rny
grin was stifling. My mind was filled with a jangling carousel of words
 THE YALOM READER
l
that rotated constantly around moods and aromas, only occasionally
dropping out into my voice or onto paper. I was not too good when it
came to facts.
I lived alone in New York. My contact with the outside world, ex-
cept for classes and letters, was minimal, I began to masturbate for the
first time, and found it frightening, just because it was something pri-
vate happening in my life. The transparent quality of my fears and hap-
piness had always made me feel light and silly. A friend said, "I can read
you like a book." I was someone like Puck, who didn't need any respon-
sibility; who never did anything more serious than vomit. And suddenly
I was starting to act differently. Quickly I began to immerse myself in
therapy.
The therapist was a woman and in the five months I was with her,
twice a week, she tried to make my grin go away. She was convinced
that my whole objective in therapy was to get her to like me. In theses-
sions she pounded away at my relationship with my parents. It had al-
ways been ridiculously loving and open and ironic.
I was afraid in therapy because I was sure there was some horrible se-
cret that 1ny mind was withholding from me. Some explanation of why
my life felt like one of those children's drawing boards: when you lift up
the paper, the easy funny faces, the squiggly lines, are all erased, leaving
no traces. At that time no matter how much I did, how 1nany best friends
I loved, I was dependent on others to give me my setting and pulse. I was
both vibrant and dead. I needed their push; I could never be self-starting.
And my memory was mostly deadly and derogatory.
I was progressing in therapy to the point where both me and my
feelings were sitting in the same leather chair. Then an unusual circum-
stance change<l 1ny life, or at least 1ny location. I had applied on a whim
to a writing program in California and was accepted. My therapist in
New York was not happy with the news; in fact, was against my going.
She said I was stuck, took no responsibility for 1ny life, and no amount
of fellowship was going to get me out. However, I could not act adult
about it and write to the grant people saying, "Please postpone my
miraculous stipend while I try to find my emotions and feel confident
and human." No, as with everything else, I waded into the new envi-
ronment, even though I was afraid that my therapist's words were cor-
 The Journey from Psychotherapy to Fiction 327

rect and that I was just leaving at the beginning. risking my life for a
guaranteed year of sun. But I could not refuse experience, since that was
my alibi, my backdrop for feeling. my way of thinking. of moving. Al-
ways the scenic view rather than the serious. thoughtful route.
!I My therapist in the end ga\·e me her blessing, convinced that I could
get excellent help from a psychiatrist she knew in California. I left :\'e\\'
1 York, and as always there was something thrilling about leaving. ~o
j
matter how many valuables you have left behind, you still have your en-
l ergy and your eyes. and right before I left. my grin. like a permanent
logo, came back, with the exhilaration of getting out. I gambled that the
psychological pot would still be waiting for me when I arr ived in Cali-
fornia, and I wouldn't ha Ye to start from scratch as a child star.
~
Because of the intensive and heroic work I had done in ~ew York
~ with acting, therapy. and loneliness. I made it to California with all my
I•
I
limited, padded feelings still intact. It was a great time in my life be-
cause I had a guaranteed future, plus no men whom I had to try and
1
• stretch myself for and be judged by. I hadn't had any boyfriend since
college. I found a small cottage. with an orange tree in front: I never
even thought of picking the oranges off the tree till a friend said I could.
I substituted tennis for acting. And made my usual quota of one great
girlfriend. At the college I did okay. though I acted like an ingenue.
I went from one therapist to another in coming from ~ew York to
Mountain View.
In a teetering frame of mind, teething on Chekhov and Jacques Brel
and other sweet and sour sadnesses. I first went to see Dr. Yalorn. Ex-
pectations, which are an important part of my lot, were great~ since he
had been recommended by my ~ew York therapist. As I went into his
room vulnerable and warm, maybe even Bela Lugosi could have done
the trick, but I doubt it. Dr. Yalorn was special.
That first interview with him, my soul became infatuated. I could
talk straight; I could cry. I could ask for help and not be ashamed.
There were no recriminations waiting to escort me home .. All his ques-
tions seemed to penetrate past the mush of 1ny brain. Corning into his
room I seemed to have license to he rnvself I trusted Dr. Ynlorn. He was
Jewish-and that day, I was too. He seemed familiar and natural with-
out being a Santa Claus psychiatrist type.
 r
328 THE YALOJ\t READER

Dr. Yalorn suggested I join his group therapy that he conducted with
another doctor. It was like signing up for the wrong course-I wanted
Poetry and Religion on a one-to-one visitation and instead I got begin-
ning bridge (and with no good chocolate mix either). He sent me to the
co-leader of the group. In my preliminary interview with the other doc-
tor there were no tears, no truths, just the subtext of an impersonal tape
recorder breathing.
Group therapy is really hard. Especially if the table is stacked with in-
ertia as ours was. The group of about seven patients plus two doctors met
at a round table with a microphone dangling from the ceiling; on one
side there was a wall of mirrors like a glassy web where my face would
get caught every once in a while looking at itself. A group of resident
doctors sat on the other side and looked in the window mirror. It really
didn't bother me, Although I am shy, I am also a little exhibitionist, and
I removed myself accordingly and "acted" like a stuffed Ophelia. The
table and chair put you in a posture where it was difficult to get going.
Many of us had the same problems-s-an inability to feel, unjelled
anger, love troubles. There were a few miraculous days when one or the
other of us caught fire and something would happen. But the time
boundaries on either side of the hour and a half usually doused any big
breakthroughs. And by the next week we had subsided into our usual
psychological rigor morris.
I was beginning to feel lifeless again and pretentious, so I sought arti-
ficial respiration from encounter groups, which were indigenous to the
area. They were held in people's lush forest homes-s-on rugs, on straw
mats, in Japanese baths, at midnight. I enjoyed the milieu even more
than the content. Physicists, dancers, middle-aged people, boxers would
show up with their skills and problems. There would be stage lights and
Bob Dylan coaching from the corner of a hi-fi, you know something is I
happening, but you don't know what it is.
This fonn of theater with your soul auditioning appealed to me.
There were tears and screaming and laughter and silence-all energiz-
ing. Fear, real hits on the back, and friendships staggered up out of the
midnight slime. Marriages dissolved before your eyes; white-collar jobs
were slashed. I gladly signed up for these judgrnent days and resurrec-
tions since I'd had nothing like it in 1ny life.
 The Journey from Psychotherapy to Fiction 329

Sometimes you would only be brought down though, without any

upward sweep and salvation. You were supposed to be able to follow a
certain ritual rhythm and beat, from fear and panic to howling insight,
confession, and acclamation. And if that failed you were supposed to be
able to say, "Well, I'm a schmuck, I'm hopeless, so what? I'm going to
go on from there," and dance out your stomach cran1ps.
Eventually, though, I realized I was straddling two opposite salva-
tions-the impacted, solid, sluggish, constant, patient group therapy
which was just like n1y life; and the medieval carnivals of the mind and
heart of the psychodramas. I knew Dr. Yalom disapproved of my en-
counters, especially one particular group leader who was inspired and
brilliant but with no credentials other than magic, I never really chose
my side but continued both forms of therapy, diminishing all the while.
Finally in group therapy I got to feel as though I dragged my cocoon in,
fastened it onto the chair each week, held on for an hour and a half, and
left. Refusing to be born.
I was bloated from the many months of group therapy, but was
making no move to get out of the situation. M y life was happy and yet as
usual I felt somewhat submerged and foggy. Through friends I'd met a
boyfriend named Karl who was intelligent and dynamic. He had his
own book business, which I helped him with, learning no skills but
managing to ply him with my jokes and getting stirred up inside. I was
at first, however, not naturally attracted to him, which worried me.
There was something about his eyes that seemed a little fierce and alien.
But I enjoyed being with him even though I had some doubts, because
unlike my few other loves, Karl was not an immediate crush, not some-
one I would have chosen from afar.
After a few terrific weeks of dalliance, we settled into a livable non-
chalance. One day, almost as an aside, he told me there was an apart-
ment he knew of where we could live together, and I moved from
Mountain View into the city. Karl once said, holding me, that I brought
humanity into his life, but he wasn't given to many love declarations.
We began living together easily and enjoying ourselves. It was the
beginning of our life together and there were plenty of new green
shoots-movies, books, walks, talks, embraces, meals, making our
friends mutual and giving up some. I remember I had a physical around
 330 TH E Y A LO M R EA DE R

then at a free clinic and they wrote: "A twenty-five-year-old white fe-
male in excellent health."
I had left psychodrama by then, and the group therapy was just a
habit that I dared not give up. I was waiting as usual to see what would
happen in therapy rather than choose my own fate. One day Dr. Yalom
called and asked if I would like to have private, free therapy with him
on condition that we would both write about it afterward. It was one of
those wonderful calls from out of the blue that I am susceptible to. I said
yes, overjoyed.
When I began therapy as a private patient with Dr. Yalom, two
years had gone by since my first fertile interview with him. I had re-
placed acting with tennis, looking for someone with being with some-
one, experiencing loneliness with trying to recall it. Inside I had a
feeling that I had skipped out on my problems and that they would all
be waiting for me at the ambush of night, some night. The critics, such
as my New York therapist, and loves, whom I carried around with me,
would have said that there was hard work to be done. That I had suc-
ceeded too easily without deserving it, and that Karl, who had started
calling me "babe," really didn't know my name. I tried to get him to call
me by my name-Ginny-and whenever he did, my life flowed. Some-
times, though, in deference to my blond hair and nerves, he called me
the Golden Worrier.
Eighteen months of hibernation in group therapy had left me groggy
and soiled. I began private therapy with only vague anxieties.

THIRD SESSION
Dr. Yalom's Notes

Retter today. What was better? I was better. In fact, I was very good
today. It's almost as though I am performing in front of an audience.
The audience that will read this. No, I guess that isn't completely
true-now I'm doing the very thing I accuse Ginny of doing, which
is to negate the positive aspects of myself. I was being good for Ginny
today. I worked hard and I helped her get at some things, although I
wonder if I wasn't just trying to impress her, trying to make her fall
 The Journey from Psychotherapy to Fiction 331

in love with me. Good Lord! Will I never be free of that? No, it's
still there, I have to keep an eye on it-the third eye, the third ear.
What do I want her to love me for? It's not sexual-Ginny doesn't
stir sexual feelings in n1e-no, that's not completely true-she does,
but that's not really important. Is it that I want to be known by
Ginny as the person who cultivated her talent? There is some of that.
At one point I caught myself hoping chat she would notice that some
of the books in 1ny bookcases were nonpsychiatric ones, O'Neill
plays, Dostoevsky. Christ, what a cross to bear! The ludicrousness of
it. Here I am trying to help Ginny with survival problems and I'n1
still burdened down with my own petty vanities.
Think of Ginny-how was she? Pretty sloppy today. Her hair
uncombed, not even a straight part, worn-out jeans, shirt patched in
a couple of places. She started off by telling me what a bad night she
had had last week when she was unable to achieve orgasm, and then
couldn't sleep the entire night because she feared rejection from
Karl. And then she started to go back to the image of herself as the
same body of a little girl who used to lie awake all night when she
was in junior high school, hearing the same bird crying at three in
the morning, and suddenly there I was again with Ginny, back in a
hazy, clouded, mystical magical world. How fetching it all is, how
much I would like to stroll around in that pleasant mist for a while,
but ... contraindicated. That would really be selfish of me. So, I
tackled the problem. We went back to the sexual act with her
boyfriend and talked about some obvious factors that prevent her
from reaching orgas1n. For example, there are some clear things that
Karl could do to help arouse her to reach climax, but she is unable to
ask him, and then we went into her inability to ask. It was all so ob-
vious that I almost feel Ginny was doing it on purpose to allow me to
demonstrate how perceptive and helpful I can be.
So, too, with the next problem. She described how she had met
two friends on the street and how she had made, as usual, a fool of
herself. I analyzed that with her, and we got into some areas that
perhaps Ginny hadn't quite expected. She behaved with them in a
chance meeting on the street in such a way, she says, as to leave thern
walking away saying, "Poor pathetic Ginny." So I asked, "What
 332 THE YALOM READER

could you have said that would have made them feel you were rather
hearty?" In fact, I proved to her there were some constructive things
she could have mentioned. She's trying out for an improvisational
acting group, she has done some writing, she has a boyfriend, she
spent an interesting summer in the country, but she can never say
anything positive about herself since it would not call forth the re-
sponse "Poor pathetic Ginny," and there is a strong part of her that
wants just that reaction.
She does the same thing with me in the session, as I pointed out to
her. For example, she had never really conveyed to me the fact that
she is good enough to work with a professional acting troupe. Her
self-effacing behavior is a pretty pervasive theme, going back to her
behavior in the group. I shocked her a bit by telling her that she
looked intentionally like a slob, that some day I'd like to see her I

looking nice, even to the extent of putting a comb through her hair. I II

tried to de-reflect her self-indulgent inner gaze by suggesting that

maybe her core isn't in the midst of her vast inner emptiness, that
maybe her core is as much outside of herself, even with other people.
I also pointed out to her that although it is necessary for her to look
inside to write, sheer introspection without writing or some other
fonn of creation is often a barren exercise. She did say that she has
done considerably more writing during the last week. That makes
me very happy. It may be that she is just giving me a gift, something
to keep me anticipating improvement.
I tried to get her to discuss her notion of my expectations for her,
since this is a genuine blind spot for me. I suspect I have great expec-
tations for Ginny; am I really exploiting her writing talent so that she
will produce something for me? How much of my asking her to
write instead of paying is sheer altruism? How much is selfish? I
want to keep urging her to talk about what she thinks I'm expecting
of her; I must keep this in focus-the Almighty God "Countertrans-
ference"-thc more I worship it the less I give to Ginny. What I
must not do is try to fill her sense of inner void with my own Pyg-
malion expectations.
She's a fetching, likable soul, Ginny is. Though a doctor's
dilemma. The more I like her as she is, the harder it will be for her to
 The Journey from Psychotherapy to Fiction 333

change; yet for change to occur, I have to show her that I like her,
and at the same time convey the message that I also want her to
change.

THI RO SESSIO!\;
Ginny's Note.

Something might happen if I were more natural looking. So I left

my glasses on. Something might not happen though.
I spoke about that bad Tuesday night which turned out to have
had a bad Tuesday beginning. The idea of a hearty, robust me,
which you suggested and asked for, was very encouraging. fv1y usual
register of "success" is how much I have been released and done dif-
ficult things, like crying or thinking straight without fantasizing.
And you pushed me in that direction.
I had fun at the session and before that could disturb me I en-
joyed the sensation, the buoyancy. I seemed to see alternatives to my
way of acting. This lasted even when I went on the ca1npus after-
wards. Though during the session and later I was obviously ques-
tioning this optimistic feeling. Surely happiness must be harder?
Could I end it as a hearty wench?
I was looking at your way of treating me, like an adult. I wonder
if you think I am pathetic or, if not, a hypocrite, or just an old maga-
zine that you read in a doctor's office. Your methods are very com-
forting and absurd. You still seem to think that you can ask me
questions that I will answer helpfully or with insight. You treat me
with interest.
I think during the session that I am bragging, trying to show my-
self off good. I am dropping little self-indulgent hints and facts, like
me being pretty (a real static fact), like the acting group, like the
good sentence I wrote (treading water in front of your face). I know
these are a waste of time since they don't do me any good and are
things that go through my head every day with or without you. Even
when you say, "I don't quite understand," that is a kin<l of flattery to
my worst old habits of being elusive in word and deed. And inside
 334 THE YAL0~1 READER

me I don't understand either. God knows, I know the difference be-

tween the things I say and the things I feel. And 111y sayings are not
satisfying most times, The few times in therapy when I react in a
fashion not predestined by my mind, I feel alive in an eternal way.
So yesterday's experience was strange. I usually distrust the
things that are said. Parent pep talk. I give it to rnysclf regularly.
But I didn't feel down when the session was over, or let down. It
was funny to hear you talk about n1y hair and dress. Kind of like my
father but not quite. Of course maybe you think Franny dressed
good. To me she looked attractive but always seemed an arm's
length away. I look like a badly bent hanger with the clothes slipping
off. I like to look heroic, like I've just done something. Though I
wish I didn't have such an uncanny burlesque instinct in dressing.
Sometimes I try and still look schleppy.
The night after the session I couldn't sleep at all. There was such
a rush of blood in rny chest and stomach and I could feel my heart
beating all night. Was it because there was no release in the session
or that I couldn't wait for a new day to begin? I was raring to go. I
arn saying this now 'cause I don't want to say it in the next session.
I think it is wrong in therapy for me to be too self-conscious, to
say things like "I a111 feeling something in n1y leg." Those are proba-
bly cheap asides left over from sensory awareness afternoons that
stop the direction you are heading me in. You must get sick of them,
infliction, indulgence. • I
!

It was funny when you said I couldn't make a career out of schiz- '
I I
ophrenia. (I still think catatonia is right up my sleeve.) In a sense this I
takes away a lot of the romance I have been flirting with. I feel awk-
ward and lacking and can't connect in social situations. There must
I
I
be another way. With Dr. wl.-I think he thought the things I said
were "far-out," weird, and that they should be recorded for their nu-
ances. I think you know they're shit. I was always watching him
write down things. I'm not aware of your face too much except that
it seems to be sitting over there waiting for something. And you
seem to have a lot of patience. I don't like to look at your face 'cause I
·i
know I haven't said anything. If it did light up at the wrong places,
I'd begin to distrust you.
 The Journey from Psychotherapy to Fiction 335

In these first fe\\, sessions I think I can be as bad as I want, so later

the transition will seem lovely.

Excerpt from Dr. Yalom's Afterword

... So much for the theory behind my therapy with Ginny, for the tech-
niques and their rationale. I have delayed as long as I can. What about
the therapist, me, the other actor in this drama? In my office I hide be-
hind my title, interpretations, n1y Freudian beard, penetrating gaze,
and posture of ultimate helpfulness; in this book, behind my explana-
tions, my thesaurus, my reportorial and belletristic efforts. But this time
I have gone too far. If I do not step gracefully out of my sanctum sane-
torum, almost certainly my analytic colleagues and reviewers will yank
me out.
The issue, of course, is countertransference. During our life together
Ginny often related to me irrationally, on the basis of a very unrealistic
appraisal of me. But what of n1y relationship to her? To what extent did
my own unconscious or barely conscious needs dictate my perception of
Ginny and my behavior toward her?
It is not entirely true that she was the patient and I the therapist. I
first discovered that a few years ago when I spent a sabbatical year in
London. I had no claims on my time and had planned to do nothing but
work on a book on group therapy. Apparently that was not enough; I
grew depressed, restless, and finally arranged to treat two patients-
more for my sake than for theirs. Who was the patient and who the
therapist? I was more troubled than they and, I think, benefited more
than they from our work together.
For over fifteen years, I have been a healer; therapy has become a
core part of my self-image; it provides me meaning, industry, pride,
mastery. Thus, Ginny helped me hy allowing me to help her. But I had
to help her a great deal, a very great deal. I was Pygmalion, she my
Galatea. I had to transform her, to succeed where others had failed, and
to succeed in an astonishingly hricf period of time. (Though the notes of
our sessions may seem lengthy, sixty hours is a relatively short course of
therapy.) The miracle worker. Yes, I own that, and the need was not
 336 TH E Y A LO M RE ADER

silent in therapy: I pressured her relentlessly, I gave voice to my frustra-

tion when she rested or consolidated for even a few hours, I improvised
continuously. "Get well," I shouted at her, "get well for your sake, not
for your mother's sake or for Karl's-v-get well for yourself." But, very
softly, I also said, "Get well for me, help rne be a healer, a rescuer, a mir-
acle worker." Did she hear me? I scarcely heard myself.
In still another more evident way the therapy was for me. I became
Ginny and treated myself She was the writer I always wanted to be-
come. The pleasure I obtained from reading her sentences transcended
sheer aesthetic appreciation. I struggled to unlock her, to unlock myself.
How rnany times during therapy did I go back twenty-five years to my
high school English class, to old frayed Miss Davis who read my compo-
sitions aloud to the class, to my embarrassing notebooks of verse, to my
never-begotten Thomas Wolfe-ian novel. She took me back to a cross-
road, to a path I never dared take for myself I tried to take it through
her. "If only Ginny could have been deeper," I said to myself. "Why did
she have to be content with satire and parody? What I could have done
'·
with that talent!" Did she hear me? I
I I
The healer-patient, the rescuer, Pygmalion, the miracle worker, the
great unrealized writer. Y cs, all these. And there is more. Ginny devel-
oped a strong positive transference toward me, She overvalued my wis-
dom, my potency. She fell in love with me. I tried to work with that
transference, to "work through" it, to resolve it in a therapeutically ben-
eficial way. But I had to work against myself as well. I u/ant to appear
wise and omnipotent. It is important that attractive women fall in love
with me. And so in my office we were many patients sitting in many
j
chairs. I struggled against parts of myself, trying to ally with parts of
Ginny in the conflict against other parts. I had to monitor myself con-
l
tinuously. How many times did I silently ask myself, "Was that for me
or for Ginny?" Often I caught myself engaging or about to engage in a
seduction that would do nothing but foster Ginny's exaltation of me.
How rnany times did I elude my own watchful eye? ·~

I became far more important to Ginny than she to me. It is so with 'I
every patient, how could it be otherwise? A patient has only one thera-
pist, a therapist many patients. And so Ginny dreamt about me, held
imaginary conversations with me during the week (just as I used to con-
 The Journey from Psychotherapy to Fiction 337

verse with my analyst, old Olive Smith-bless her staunch heart), or

imagined I was there at her elbow watching her every action. And yet
there is more to it. True, Ginny rarely entered my fantasy life. I did not
think about her between sessions, I never dreamt about her, yet I know
that I cared deeply about her. I think I did not permit myself full
knowledge of my feelings and so I must awkwardly deduce these things
about myself. There were many clues: my jealousy toward Karl; my dis-
appointment when Ginny missed a session; my snug, cozy feelings
when we were together C'snug" and "cozy" are just the right words-
not clearly sexual but by no means ethereal). All these are self-evident, I
expected and recognized them, but what was unexpected was the erup-
tion of my feelings when n1y wife, editor of our notes, moved into my
relationship with Ginny. Earlier I described our social meeting in Cali-
fornia after the end of therapy. When Ginny left I was morose, diffusely
irritated, and sullenly refused n1y wife's invitations to talk about our
meeting. Though my phone conversations with Ginny were generally
brief and impeccably professional, I was invariably uneasy at my wife's
presence in the room, It is even possible that I invited, ambivalently, my
wife into our relationship to help me with my countertransference. (I
am not sure, though; my wife generally edits my work.) All these reac-
tions become explicable if one concludes that I was in the midst of a
heavily sublimated affair with Ginny.
Ginny's positive transference complicated therapy in many ways.
I wrote earlier that she was in therapy in large part to be with me. To
get well was to say good-bye. "And so she remained suspended in
a great selfless wasteland, not so well as to lose me, not so sick as to
drive me away in frustration." And I? What did I do to prevent Ginny
from leaving me? Our book has insured that Ginny never will become
a half-forgotten name in my old appointment book or a lost voice on an
electromagnetic band. In both a real and symbolic sense we have de-
feated termination. Would it be going too far to say that our affair has
been consummated in this shared work?
Add, then, Lothario, lover, to the list of healer-patient, rescuer, Pyg-
malion, unborn writer, and still there is more which I cannot or will not
see. Countertransference was always present, like a gauzed veil through
which I attempted to see Ginny. To the best of my ability I tugged at it,
 338 TH E YA LO 1\I RE ADER

I stared through it, I refused, as best I could, to allow it to obstruct our

work. I know that I did not always succeed, nor am I convinced that the
total subjugation of my irrational side, needs, and wishes would have J
promoted therapy; in a bewildering fashion countertransference sup-
plied much of the energy and humanity that made our venture a suc-
cessful one.
Was therapy successful? Has Ginny undergone substantial change?
Or do we see "a transference cure," she having merely learned how to
behave differently, how to appease and please the now-internalized Dr.
Yalom? The Readers shall have to judge for themselves. I feel satisfied
with our work and optimistic about Ginny's progress. There are re-
maining areas of conflict, yet I regard them with equanimity; I have
long ago lost the sense that I as the therapist have to do it all. What is
important is that Ginny is unfrozen and can take an open posture to
new experiences. I have confidence in her ability to continue changing,
and my view is supported by most objective measures.

l
She has now terminated a relationship with Karl which, with retro-
spective wisdom, was growth retarding for both parties; she is actively
writing and, for the first time, functioning well in a responsible and
I
challenging job (a far cry fron1 the playground worker or the placard- /.
I

carrying traffic guard); she has established a social circle and a more sat-
isfying relationship with a new man. Gone are the night panics, the
frightening dreams of disintegration, the migraines, the petrifying self-
consciousness and self-effacement.
But I would have been satisfied even without these observable mea-
sures of outcome. I wince as I confess that, since I have devoted much
of my professional career to a rigorous, quantifiable study of the out-
come of psychotherapy. It is a paradox hard to embrace, even harder to
banish. The "art" of psychotherapy has for me a dual meaning: "art" in
that the execution of therapy requires the use of intuitive faculties not
derivable from scientific principles and "art" in the Keatsian sense, in
that it establishes its own truth transcending objective analysis. The
truth is a beauty that Ginny and I experienced. We knew each other,
touched each other deeply, and shared splendid moments not easily
come by.
 The Journey from Psychotherapy to Fiction 339

LOVE'S EXECUTIONER:
CASE HISTORIES INTO SHORT STORIES

After The Theory and Practice of Group Psychotherapy was published in

1970, I joined the ranks of textbook writers who find, much to their
surprise, that they have enlisted for a lifetime mission. I learned that the
demands on a textbook writer are severe: I kept current with the profes-
sional literature, allowing no significant group therapy article to escape
my purview; I continued my own group therapy research; I kept a record
of illuminating episodes from my own clinical practice; and I spent many
years preparing revisions-a second, third, fourth edition.
The job description of a university professor and academician calls
for staying abreast of one's field and continuing to contribute signifi-
cantly to it. I knew how to do that in the area of group psychotherapy: it
was a matter of continuing my clinical research and revising my group
therapy textbook. But how was I to contribute to my second field of in-
terest, existential psychotherapy? That was far more problematic for a
number of reasons. (Lack of desire was never a factor: although I was
very visible in the large field of group therapy, I always considered the
world of existential therapy as my true home.) A major reason was that
the standard activity of medical academicians-the empirical investiga-
tive study-was not available because the subject matter of an existential
approach does not lend itself to empirical investigation.
Another reason was my uncertainty concerning how to write about
existential therapy. Long after my text Existential Psychotherapy was
published, I continued to search for a deeper understanding of existen-
tial ideas and for methods of applying them more effectively in my
everyday therapy practice. I read widely in relevant philosophical texts.
I audited philosophy and religious studies courses at Stanford. I co-
taught courses with colleagues in the philosophy and English depart-
ments. I centered my clinical practice on patients who faced existential
issues: life-threatening illness, bereavement, midlife crisis, separation,
divorce.
I considered revising Existential Psychotherapy but in the end rejected
that plan-there was no tradition of an evolving literature, no research to
update and review. Besides, it seemed silly to update a book that pur-
ported to deal with timeless elements of the human condition.
 340 TH F. YA LO M RE A DER

Nor did the prospect of writing some other professional text seem at-
tractive. More and more I had begun to feel that formal psychiatric or
philosophic prose was hopelessly inadequate to describe the true exis-
tential dilemma, the human, all-too-human, flesh-and-blood, deeply
subjective experience. Ever since Freud posited psychoanalysis as a sci-
ence subject to the same rules of procedure and observation as the nat-
ural sciences, the field of psychiatry has struggled to fit itself into that
framework. But case histories written in precise, frosty scientific lan-
guage simply fail to communicate the complexity, the passion, and the
pain of the emotional dilemmas facing each human being.
So I began searching in earnest for a more evocative method of com-
municating these sentiments. My quest rendezvoused quickly with my
storytelling inclinations, and it was not long before I began experiment-
ing with a frankly literary conveyance. Of course, I'm hardly the first to
employ this method. There exists a long skein of existential thinkers who
decided that the deep experience they wished to depict was better done
through literature than through formal philosophical prose-think of
Camus, Sartre, Unamuno, Kierkegaard, Nietzsche, Ortega y Gasset, de
Beauvoir. In psychiatry there exist no similar models, aside from some of
Freud's own cases and Robert Lindner's collection of tales about hyp-
notherapy, The Fifty-Minute Hout; published over forty years before.
All these considerations informed the shape and the meter of my next
project, Love's Executioner. I had two purposes in writing Love's Execu-
tioner: to teach the fundamentals of a clinical existential approach and to
express my literary aspirations. I decided that, in this book, I would re-
verse my earlier strategy of smuggling illustrative stories into the midst of
theoretical material: instead I would give the story center stage and allow
theoretical material to emanate from it.
I had an abundance of material. From the beginning of my psychiatric
career I have kept a journal of illuminating therapy events-epiphanies
in a Joycean sense, that is, clarifying moments of luminous insight, some
event, phrase, or dream that contains a preternatural amount of informa-
tion about the essence, the "whatness" or "whyness," of a state of being.
I write these notes immediately after therapy sessions and have always
scheduled fifteen or twenty minutes between patients (instead of the tra-
ditional five or ten) expressly for this purpose.
 The Journey from Psychotherapy to Fiction 341

My first plan for Love's Executioner was based on the model of Lewis
Thomas's The Lives of a Cell. That book, a thoughtful, graceful work, is a
series of three- to four-page essays, each consisting of a description of an
arresting biological phenomenon followed by a brief discussion of the
broader implications of the phenomenon for human behavior. I hoped,
then, to do something analogous for psychotherapy: I would describe a
therapy event in a page or two and then, in the next few pages, explore
its implications for the understanding of psychotherapy. A collection of
thirty or forty of these brief expositions would constitute a book-length
manuscript.
And so off I went on a year-long round-the-world sabbatical with a
laptop and my notes. The first vignette involved a purse snatching that
traumatized an elderly widow, Elva, and confronted her with her own or-
dinariness. Although Elva had lost her husband eighteen months before,
she had never really come to terms with his death. To shield herself from
the full impact of her loss, she had wrapped herself in denial and
dwelled in an in-between state in which she knew he was dead, but at
the same time also believed in his continued existence and abi I ity to pro-
tect her from life's unpleasantness. And then came the shattering purse-
snatching experience, which confronted her with the reality of both her
husband's death and her own personal finiteness.
That was the essential part of the story. I wrote a three-page vignette
followed by a discussion of some relevant aspects of grief; for example,
how the death of the other serves, if it is not resisted, to confront one with
one's own finiteness. I wrote also about the major psychological devices
we employ in the service of death denial, including, in Elva's case, the be-
lief in some ultimate rescuer, embodied in her husband, Albert: in life he
had been a fixer, and in death, a pervasive presence watching over her,
protecting her, always there to pull her back from the edge of the abyss.
When I reread the story I felt unsatisfied. Elva was a flat character and
demanded more roundness, but the more I gave, the more she de-
manded. Even when she seemed fully realized, the story itself seemed
truncated and demanded a more complete resolution. So I stitched to it
another journal vignette-an interaction with Elva that occurred a few
weeks after the purse snatching. I had been bantering with her about car-
rying such a large purse and suggested she would soon have to put
 342 THE Y ALOM REA DER

wheels on it to carry it around. She insisted she needed everything in it. I

challenged that statement and then, heads bent close together, we emp-
tied her purse and examined every item of its contents. This process
turned out to be an extraordinarily intimate act; it drew us more closely
together and ultimately persuaded Elva that she had not lost her capacity
for intimacy-even in a world without her husband.
The odd language I've just used-f/va demanded more roundness ...
the story demanded ... -accurately reflects my experience. I had, from
the start, planned that the stories should be organic: in other words, they
should evolve as they were being written. Thus the story had one foot in
fact, another in fiction. Was it historically correct? For example, did I ac-
curately describe the contents of her purse? I hardly remember. What dif-
ference does it make?
Even the selection of stories was organic. I began the book with no
preconception of which of my many vignettes I would use, nor in which
order. Nor, when writing one story, did I know which I would select next.
I had the remarkable writerly experience of my unconscious taking over.
As I was approaching the end of one story, I would find another unac-
countably wafting into my mind: it was as though I didn't choose the
story-the story chose me. In fact, the process soon reversed itself in an
odd manner-the first appearance of the next story in my mind informed
me that the present one was nearing its end.
The word "organic" thus denotes that the story grew in nondeter-
mined ways, autonomously, as if it were writing itself. But even more
striking examples of literary organicity were in store for me. Again and
again I created characters-partly based on patients but largely fictional-
ized to disguise identity-who were willful, rebellious, who took on a
life of their own and would not comply with my scheme for the story.
Although these phrases-"the story demanded," "the story chose
me," lithe characters took on a fife of their own"-may appear fanciful or
precious, they describe a well-known phenomenon. E. M. Forster noted:
"The characters arrive when evoked, but full of the sense of mutiny ...
they 'run away,' they 'get out of hand': they are creations within a cre-
ation and often inharmonious towards it; if they are given complete free-
dom they kick the book to pieces, and if they are kept too sternly in
check, they revenge themselves by dying, and destroy it by intestinal
decay."
 The journey from Psychotherapy to Fiction 343

A story is told of the nineteenth-century novelist Thackeray, who

emerged from his studio one day, weary from long hours of writing. His
wife asked him how the day had gone and he replied, "Terrible. Penden-
nis [one of his fictional characters] made a fool of himself and there was
nothing J could do to stop him."
Although Elva was resistive, I managed, nonetheless, to close her
story ("I Never Thought It Would Happen to Me") in eight pages (rather
than the three or four I had originally planned). But with each succeed-
ing story, closure became more difficult. Soon I was forced to jettison the
idea of writing thirty or forty short pieces: each story demanded more
and more space. Ten stories added up to a book-length manuscript.
It was also part of my original plan to write a theoretical afterword to
each story in Love's Executioner. But each afterword I wrote seemed
stilted and unnecessary. I kept two of the afterwords and eliminated the
other eight-these I would incorporate into a lengthy theoretical fore-
word to the book.
But the publisher vehemently disagreed. Phoebe Hoss, my long-term
editor at Basic Books, insisted that the stories were sufficient and that less
was more. We had a lengthy battle: each time I sent a prologue she, with
remarkable consistency, red-penciled out 70 to 80 percent of it. U lti-
mately I understood that I could not give just lip service to the idea that
literature could convey powerful, otherwise inexpressible, thoughts: I
had to pack all I wanted to say within the narrative and save nothing for
a separate pedagogical overview. Eventually Love's Executioner was
published with an eight-page prologue and no afterword. It took me four-
teen months to write the three hundred pages of my ten stories: I strug-
gled over the ten-page prologue for four months. But it was a watershed
personal struggle that permitted me to abandon the didactic mode and
let the story speak for itself.
In the following pages, the prologue and the second story, "If Rape
Were Legal ... ," are reproduced.

Love's Executioner: The Prologue

Imagine this scene: three to four hundred people, strangers to one an-
other, are told to pair up and ask their p:irtner one single question,
"What do you want?" over and over and over again.
 344 THEY ALOM READER

Could anything be simpler? One innocent question and its answer.

And yet, time after time, I have seen this group exercise evoke unex-
pectedly powerful feelings. Often, within minutes, the room rocks with
emotion. Men and women-and these are by no means desperate or
needy, but successful, well-functioning, well-dressed people who glitter
as they walk-are stirred to their depths. They call out to those who are
forever lost-dead or absent parents, spouses, children, friends: "I want
to see you again." "I want your love." "I want to know you're proud of
me." "I want you to know I love you and how sorry I am I never told
you." "I want you back-I am so lonely." "I want the childhood I never
had." "I want to be healthy-to be young again. I want to be loved, to be
respected. I want my life to mean something. I want to accomplish
something. I want to matter, to be important, to be remembered."
So much wanting. So much longing. And so much pain, so close to
the surface, only minutes deep. Destiny pain. Existence pain. Pain that is
always there, whirring continuously just beneath the membrane of life.
Pain that is all too easily accessible. Many things-a simple group exer-
I'
cise, a few minutes of <leep reflection, a work of art, a sermon, a personal
crisis, a loss-remind us that our deepest wants can never be fulfilled:
our wants for youth, for a halt to aging, for the return of vanished ones,
for eternal love, protection, significance, for immortality itself.
It is when these unattainable wants come to dominate our lives that
we turn for help to family, to friends, to religion-sometimes to psy-
chotherapists.
In this book I tel1 the stories of ten patients who turned to therapy,
and in the course of their work struggled with existence pain. This was I
nor the reason they came to me for help; on the contrary, all ten were 1
suffering the common problems of everyday life: loneliness, self-
conten1pt, impotence, migraine headaches, sexual compulsivity, obesity,
hypertension, grief, a consuming love obsession, mood swings, depres-
sion. Yet somehow (a "somehow" that unfolds differently in each story),
I'
l

therapy uncovered deep roots of these everyday problems-roots

stretching down to the bedrock of existence.
"I want! I want!" is heard throughout these tales. One patient cried,
"I want my dead darling daughter back," as she neglected her two liv-
ing sons. Another insisted, "I want to fuck every woman I see," as his
lymphatic cancer invaded the crawlspaces of his body. And another
 The Journey from Psychotherapy to Fiction 345

pleaded, "I want the parents, the childhood I never had," as he agonized
over three letters he could not bring himself to open. And another de-
clared, "I want to be young forever," as she, an old woman, could not
relinquish her obsessive love for a man thirty-five years younger.
I believe that the primal stuff of psychotherapy is always such exis-
tence pain-and not, as is often claimed, repressed instinctual strivings
or imperfectly buried shards of a tragic personal past. In my therapy
with each of these ten patients, my primary clinical assurnption-c-an as-
sumption on which I based n1y technique-is that basic anxiety emerges
from a person's endeavors, conscious and unconscious, to cope with the
harsh facts of life, the "givens" of existence.
I have found that four gi\·ens are particularly relevant to psychother-
apy: the inevitability of death for each of us and for those we love; the
freedom to make our lives as we will; our ultimate aloneness; and, fi-
nally, the absence of any obvious meaning or sense to life. However
grim these givens n1ay seem, they contain the seeds of wisdom and re-
demption. I hope to demonstrate, in these ten tales of psychotherapy,
that it is possible to confront the truths of existence and harness their
power in the service of personal change and growth.
Of these facts of life, death is the most obvious, most intuitively ap-
parent. At an early age, far earlier than is often thought, we learn that
death will come, and that from it there is no escape. Nonetheless,
"everything," in Spinoza's words, "endeavors to persist in its own be-
ing." At one's core there is an ever-present conflict between the wish to
continue to exist and the awareness of inevitable death.
To adapt to the reality of death, we are endlessly ingenious in devis-
ing ways to deny or escape it. When we are young, we deny death with
the help of parental reassurances and secular and religious myths; later,
we personify it by transforming it into an entity, a monster, a sandman,
a demon. After all, if death is some pursuing entity, then one n1ay yet
find a way to elude it; besides, frightening as a death-bearing monster
may be, it is less frightening than the truth-that one carries within the
spores of one's own death. Later, children experiment with other ways
to attenuate death anxiety: they detoxify death by taunting it, challenge
it through daredevilry, or desensitize it by exposing themselves, in the
reassuring con1pany of peers and warm buttered popcorn, to ghost sto-
ries and horror films.
 346 TH E Y A LO M R EA D ER

As we grow older, we learn to put death out of mind; we distract

ourselves; we transform it into something positive (passing on, going
home, rejoining God, peace at last); we deny it with sustaining myths;
we strive for immortality through imperishable works, by projecting
our seed into the future through our children, or by embracing a reli-
gious system that offers spiritual perpetuation.
Many people take issue with this description of death denial. "Non-
sense!" they say. "We don't deny death. Everyone's going to die. We
know that. The facts are obvious. But is there any point to dwelling
on it?"
The truth is that we know but do not know. We know about death,
intellectually we know the facts, but we-that is, the unconscious por-
tion of the mind that protects us from overwhelming anxiety-have
split off, or dissociated, the terror associated with death. This dissocia-
tive process is unconscious, invisible to us, but we can be convinced of its
existence in those rare episodes when the machinery of denial fails and
death anxiety breaks through in full force. That may happen only
rarely, sometimes only once or twice in a lifetime. Occasionally it hap-
pens during waking life, sometimes after a personal brush with death,
or when a loved one has died; but more commonly death anxiety sur-
faces in nightmares.
A nightmare is a failed dream, a dream that, by not "handling" anxi-
ety, has failed in its role as the guardian of sleep. Though nightmares
differ in manifest content, the underlying process of every nightmare is
the same: raw death anxiety has escaped its keepers and exploded into
consciousness. The story "In Search of the Dreamer" offers a unique
backstage view of the escape of death anxiety and the mind's last-ditch
attempt to contain it: here, amidst the pervasive, dark death imagery of
Marvin's nightmare, is one life-promoting, death-defying instrument-
the glowing white-tipped cane with which the dreamer engages in a
sexual duel with death.
The sexual act is seen also by the protagonists of other stories as a tal-
isman to ward off diminishment, aging, and approaching death: thus,
the compulsive promiscuity of a young man in the face of his killing
cancer ("J f Rape Were Legal ... "); and an old man's clinging to yellow-
ing thirty-year-old letters from his dead lover ("Do Not Go Gentle").
In my many years of work with cancer patients facing imminent
 The Journey from Psychotherapy to Fiction 347

death, I have noted two particularly powerful and cornmon methods of

allaying fears about death, two beliefs, or delusions, that afford a sense
of safety. One is the belief in personal specialness; the other, the belief in
an u1timate rescuer. While these are delusions in that they represent
"fixed false beliefs," I do not employ the term delusion in a pejorative
sense: these are universal beliefs which, at some level of consciousness,
exist in all of us and play a role in several of these tales.
Specialness is the belief that one is invulnerable, inviolable-beyond
the ordinary laws of human biology and destiny. At some point in life,
each of us will face some crisis: it may be serious illness, career failure,
or divorce; or as happened to Elva in "I Never Thought It Would Hap-
pen to Me," it may be an event as simple as a purse snatching, which
suddenly lays bare one's ordinariness and challenges the common as-
sumption that life will always be an eternal upward spiral.
While the belief in personal specialness provides a sense of safety
from within, the other major mechanism of death denial-belief in an
ultimate rescuer-permits us to feel forever watched and protected by an
outside force. Though we may falter, grow ill, though we may arrive at
the very edge of life, there is, we are convinced, a looming, omnipotent
servant who will al ways bring us back.
Together these two belief systems constitute a dialectic-two dia-
metrically opposed responses to the human situation. The human being
either asserts autonomy by heroic self-assertion or seeks safety through
fusing with a superior force: that is, one either emerges or merges, sepa-
rates or embeds. One becomes one's own parent or remains the eternal
child.
Most of us, most of the time, live comfortably by uneasily avoiding
the glance of death, by chuckling and agreeing with Woody Allen when
he says, "l 'm not afraid of death. I just don't want to be there when it
happens." But there is another way-a long tradition, applicable topsy-
chotherapy-that teaches us that full awareness of death ripens our wis-
dom and enriches our life. The dying words of one of my patients (in "If
Rape Were Legal ... ") demonstrate that though the fact, the physical-
ity, of death destroys us, the idea of death may save us.

Freedom, another given of existence, presents a dilemma for several of

these ten patients. When Betty, an obese patient, announced that she
 348 THE YA LO .vt RE A DER

had binged just before coming to see me and was planning to binge
again as soon as she left my office, she was attempting to give up her
freedom by persuading me to assume control of her. The entire course
of therapy of another patient (Thelma in "Love's Executioner") re-
volved around the theme of surrender to a fonner lover (and therapist)
and my search for strategies to help her reclaim her power and freedom.
Freedom as a given seems the very antithesis of death. While we
dread death, we generally consider freedom to be unequivocally positive.
Has not the history of Western civilization been punctuated with yearn-
ings for freedom, even driven by it? Yet freedom from an existential per-
spective is bonded to anxiety in asserting that, contrary to everyday
experience, we do not enter into, and ultimately leave, a well-structured
universe with an eternal grand design. Freedom means that one is re-
sponsible for one's own choices, actions, one's own life situation.
Though the word responsible n1ay be used in a variety of ways, I pre-
fer Sartre's definition: to be responsible is to "be the author of," each of
us being thus the author of his or her own life design. We are free to be
anything but unfree: we are, Sartre would say, condemned to freedom.
Indeed, some philosophers claim much more: that the architecture of
the human mind makes each of us even responsible for the structure of
external reality, for the very form of space and time. It is here, in the
idea of self-construction, where anxiety dwells: we are creatures who
desire structure, and we are frightened by a concept of freedom which
implies that beneath us there is nothing, sheer groundlessness.
Every therapist knows that the crucial first step in therapy is the pa-
tient's assumption of responsibility for his or her life predicament. As
long as one believes that one's problems are caused by some force or
agency outside oneself, there is no leverage in therapy. If, after all, the
problem lies out there, then why should one change oneself? It is the
outside world (friends, job, spouse) that m ust be changed--or ex-
changed. Thus, Dave (in "Do Not Go Gentle"), complaining bitterly of
being locked in a mar ital prison by a snoopy, possessive wife-warden,
could not proceed in therapy until he recognized how he himself was
responsible for the construction of that prison.
Since patients tend to resist assuming responsibility, therapists must
develop techniques to make patients aware of how they themselves cre-
ate their own problems. A powerful technique, which I use in many of
 The Journey from Psychotherapy to Fiction 349

these cases, is the here-and-now focus. Since patients tend to re-create in

the therapy setting the same interpersonal problems that bedevil them in
their lives outside, I focus on what is going on at the moment between a
patient and me rather than on the events of his or her past or current
life. By examining the details of the therapy relationship (or, in a ther-
apy group, the relationships among the group members), I can point out
on the spot how a patient influences the responses of other people.
Thus, though Dave could resist assuming responsibility for his marital
problems, he could not resist the immediate data he himself was gener-
ating in group therapy: that is, his secretive, teasing, and elusive behav-
ior was activating the other group members to respond to him much as
his wife did at home.
In similar fashion, Betty's ("Fat Lady") therapy was ineffective as
long as she could attribute her loneliness to the flaky, rootless California
culture. It was only when I demonstrated how, in our hours together,
her impersonal, shy, distancing manner re-created the same impersonal
environment in therapy that she could begin to explore her responsibil-
ity for creating her own isolation.
While the assumption of responsibility brings the patient into the
vestibule of change, it is not synonymous with change. And it is change
that is always the true quarry, however much a therapist may court in-
sight, responsibility assumption, and self-actualization.
Freedom not only requires us to bear responsibility for our life
choices but also posits that change requires an act of will. Though will is
a concept therapists seldom use explicitly, we nonetheless devote much
effort to influencing a patient's will. We endlessly clarify and interpret,
assuming (and it is a secular leap of faith, lacking convincing empirical
support) that understanding will invariably beget change. When years
of interpretation have failed to generate change, we n1ay begin to make
direct appeals to the will: "Effort, too, is needed. You have to try, you
know. There's a time for thinking and analyzing but there's also a time
for action." And when direct exhortation fails, the therapist is reduced.
as these stories bear witness, to employing any known means by which
one person can influence another. Thus, I rnay advise, argue, badger,
cajole, goad, implore, or simply endure, hoping that the patient's neu-
rotic worldview will crumble away from sheer fatigue.
It is through willing, the mainspring of action, that our frecdrnn is
 350 THE YALOM READER

enacted. I see willing as having two stages: a person initiates through

wishing and then enacts through deciding.
Some people are wish-blocked, knowing neither what they feel nor
what they want. Without opinions, without impulses, without inclina-
tions, they become parasites on the desires of others. Such people tend to
be tiresome. Betty was boring precisely because she stifled her wishes,
and others grew weary of supplying wish and imagination for her.
Other patients cannot decide. Though they know exactly what they
want and what they must do, they cannot act and, instead, pace tor-
mentedly before the door of decision. Saul, in "Three Unopened Let-
ters," knew that any reasonable man would open the letters; yet the fear
they invoked paralyzed his will. Thelma ("Love's Executioner") knew
that her love obsession was stripping her life of reality. She knew that
she was, as she put it, living her life eight years ago; and that, to regain
it, she would have to give up her infatuation. But that she could not, or
would not, do, and she fiercely resisted all my attempts to energize her
will.
Decisions are difficult for many reasons, some reaching down into
the very socket of being. John Gardner, in his novel Grendel, tells of a
wise man who sums up his meditations on life's mysteries in two simple
but terrible postulates: "Things fade: alternatives exclude." Of the first
postulate, death, I have already spoken. The second, "alternatives ex-
clude," is an important key to understanding why decision is difficult.
Decision invariably involves renunciation: for every yes there must be a
no, each decision eliminating or killing other options (the root of the
word decide means "slay," as in homicide or suicide). Thus, Thelma
clung to the infinitesimal chance that she might once again revive her
relationship with her lover, renunciation of that possibility signifying
!
.,
diminishment and death.

Existential isolation, a third given, refers to the unbridgeable gap be-

tween self and others, a gap that exists even in the presence of deeply
gratifying interpersonal relationships. One is isolated not only from
other beings hut, to the extent that one constitutes one's world, from the
world as well. Such isolation is to he distinguished from two other types
of isolation: interpersonal and intrapersonal isolation.
 The Journey from Psychotherapy to Fiction 351

One experiences interpersonal isolation, or loneliness, if one lacks the

social skills or personality style that permits intimate social interactions.
lntrapersonal isolation occurs when parts of the self are split off, as when
one splits off emotion [rom the n1en1ory of an event. The most extreme,
and dramatic, form of splitting, the multiple personality, is relatively
rare (though growing more widely recognized); when it does occur, the
therapist may be faced, as was I in the treatment of Marge ("Therapeu-
tic Monogamy"), with the bewildering dilemma of which personality to
cherish.
While there is no solution to existential isolation, therapists must dis-
courage false solutions. One's efforts to escape isolation can sabotage
one's relationships with other people. Many a friendship or marriage
has failed because, instead of relating to, and caring for, each other, one
person uses another as a shield against isolation.
A common, and vigorous, attempr to solve existential isolation,
which occurs in several of these stories, is fusion-the softening of one's
boundaries, the melting into another. The power of fusion has been
demonstrated in subliminal perception experiments in which the mes-
sage "Mommy and I are one," flashed on a screen so quickly that the
subjects cannot consciously see it, results in their reporting that they feel
better, stronger, more optimistic-and even in their responding better
than other people to treatment (with behavioral modification) for such
problems as smoking, obesity, or disturbed adolescent behavior.
One of the great paradoxes of life is that self-awareness breeds anxi-
ety. Fusion eradicates anxiety in a radical fashion-by eliminating self-
awareness. The person who has fallen in love, and entered a blissful
state of merger, is not self-reflective because the questioning lonely I
(and the attendant anxiety of isolation) dissolve into the we. Thus one
sheds anxiety but loses oneself.
This is precisely why therapists do not like to treat a patient who has
fallen in love. Therapy and a state of love-merger are incompatible be-
cause therapeutic work requires a questioning self-awareness and an
anxiety that will ultimately serve as guide to internal conflicts.
Furthermore, it is difficult for me, as for most therapists. to form a
relationship with a patient who has fallen in love. In the story "Love 's
Executioner," Thelma would not, for example, relate to me: her energy
 352 THE Y AL0:'\1 READER

was completely consumed in her love obsession. Beware the powerful

exclusive attachment to another; it is not, as people sometimes think, ev-
idence of the purity of the love. Such encapsulated, exclusive love-
feeding on itself, neither giving to nor caring about others-is destined
to G1,·e in on itself. Love is not just a passion spark between two people;
there is infinite difference between falling in love and standing in love.
Rather, love is a vvay of being, a "giving to," not a "falling for"; a mode
of relating at large, not an act limited to a single person.
Though we try hard to go through life two by two or in groups,
there are times, especially when death approaches, that the truth-that
we are born alone and must die alone-breaks through with chilling
clarity. I have heard many dying patients remark that the most awful
thing about dying is that it must be done alone. Yet, even at the point of
death, the willingness of another to be fully present may penetrate the
isolation. As a patient said in "Do Not Go Gentle," "Even though you're
alone in your boat, it's always comforting to see the lights of the other
boats bobbing nearby."

Now, if death is inevitable, if all of our accomplishments, indeed our

entire solar system, shall one day lie in ruins, if the world is contingent
(that is, if everything could as well have been otherwise), if human be-
ings must construct the world and the human design within that world,
then what enduring rneaning can there be in life?
This question plagues con tern porary men and women, and many
seek therapy because they feel their lives to be senseless and aimless. We · I
. I
are meaning-seeking creatures. Biologically, our nervous systems are
organized in such a way that the brain automatically clusters incoming
stimuli into configurations. Meaning also provides a sense of mastery:
feeling helpless and confused in the face of random, unpatterned events,
we seek to order them and, in so doing, gain a sense of control over
them. Even more important, meaning gives birth to values and, hence,
to a code of behavior: thus the answer to why questions (Why do I live? )
supplies an answer to how questions (How do I live.").
There are, in these ten tales of psychotherapy, few explicit discussions
of meaning in life. The search for meaning, much like the search for
pleasure, must be conducted obliquely. Meaning ensues from meaning-
 The Journey from Psychotherapy to Fiction 353

ful activity: the more we deliberately pursue it, the less likely are we to
find it; the rational questions one can pose about meaning will always
outlast the answers. In therapy, as in life, meaningfulness is a by-product
of engagement and commitment, and that is where therapists must
direct their efforts-not that engagement provides the rational answer
to questions of meaning, but it makes these questions not matter.
This existential dilemma-a being who searches for meaning and
certainty in a uni verse that has neither-has tremendous relevance for
the profession of psychotherapist. In their everyday work, therapists, if
they are to relate to their patients in an authentic fashion, experience
considerable uncertainty. Kot only does a patient's confrontation with
unanswerable questions expose a therapist to these same questions, but
also the therapist must recognize, as I had to in "Two Smiles," chat the
experience of the other is, in the end, unyieldingly private and un-
knowable.
Indeed, the capacity to tolerate uncertainty is a prerequisite for the
profession. Though the public may believe that therapists guide patients
systematically and sure-handedly through predictable stages of therapy
to a foreknown goal, such is rarely the case: instead, as these stories bear
witness, therapists frequently wobble, improvise, and grope for direc-
tion. The powerful temptation to achieve certainty through embracing
an ideological school and a tight therapeutic system is treacherous: such
belief may block the uncertain and spontaneous encounter necessary for
effective therapy.
This encounter, the very heart of psychotherapy, is a caring. deeply
human meeting between two people, one (generally, but not always, the
patient) more troubled than the other. Therapists have a dual role: they
must both observe and participate in the lives of their patients. As ob-
server, one must be sufficiently objective to provide necessary rudirncn-
tary guidance to the patient. As participant, one enters into the life of
the patient and is affected and sometimes changed hy the encounter.
In choosing to enter fully into each patient's life, I, the therapist, not
only am exposed to the same existential issues as are 111y patients hut
must be prepared to examine them with the same rules of inquiry. I
must assume that knowing is better than not knowing, venturing than
not venturing; and that magic and illusion, however rich, however al-
 354 THE Y ALOM READER

luring, ultimately weaken the human spirit. I take with deep serious-
ness Thomas Hardy's staunch words "If a way to the Better there be, it
exacts a full look at the Worst."
The dual role of observer and participant demands much of a thera-
pist and, for me in these ten cases, posed harrowing questions. Should I,
for example, expect a patient, who asked me to be the keeper of his love
letters, to deal with the very problems that I, in my own life, have
avoided? Was it possible to help him go further than I have gone?
Should I ask harsh existential questions of a dying man, a widow, a be-
reaved mother, and an anxious retiree with transcendent dreams-
questions for which I have no answers? Should I reveal my weakness
and rny limitations to a patient whose other, alternative personality I
found so seductive? Could I possibly form an honest and caring rela-
tionship with a fat lady whose physical appearance repelled me? Should
I, under the banner of self-enlightenment, strip away an old woman's
irrational but sustaining and comforting love illusion? Or forcibly im-
pose my will on a man who, incapable of acting in his best interests, al-
lowed himself to be terrorized by three unopened letters?
Though these tales of psychotherapy abound with the words patient
and therapist, do not he misled by such terms: these are everyman, every-
woman stories. Patienthood is ubiquitous; the assumption of the label is
largely arbitrary and often dependent more on cultural, educational,
and economic factors than on the severity of pathology. Since therapists,
no less than patients, must confront these givens of existence, the profes-
sional posture of disinterested objectivity, so necessary to scientific
method, is inappropriate. We psychotherapists simply cannot cluck
with sympathy and exhort patients to struggle resolutely with their
problems. We cannot say to them you and your problems. Instead, we
must speak of us and our problems, because our life, our existence, will
always be riveted to death, love to loss, freedom to fear, and growth to
separation. We are, all of us, in this together.

"If Rape Were Legal ... "

"Your patient is a dumb shit and I told him so in the group last night-
in just those words." Sarah, a young psychiatric resident, paused here
and glared, daring me to criticize her.
 The Journey from Psychotherapy to Fiction 355

Obviously something extraordinary had occurred. Not every day

does a student charge into my office and, with no trace of chagrin-in-
deed, she seemed proud and defiant-tell me she has verbally assaulted
one of my patients. Especially a patient with advanced cancer.
"Sarah, would you sit down and tell me about it? I've got a few min-
utes before my next patient arrives."
Struggling to keep her composure, Sarah began, "Carlos is the gross-
est, most despicable human being I have ever met!"
"Well, you know, he's not my favorite person either. I told you that
before I referred him to you." I had been seeing Carlos in individual
treatment for about six months and, a few weeks ago, referred him to
Sarah for inclusion in her therapy group. "But go on. Sorry for stopping
you. "
"Well, as you know, he's been generally obnoxious-sniffing the
women as though he were a dog and they bitches in heat, and ignoring
everything else that goes on in the group. Last night, Martha-s-she's a
really fragile borderline young woman, who has been almost mute in
the group--started to talk about having been raped last year. I don't
think she's ever shared that before-certainly not with a group. She was
so scared, sobbing so hard, having so much trouble saying it, that it was
incredibly painful. Everyone was trying to help her talk and, rightly or
wrongly, I decided it would help Martha if I shared with the group that
I had been raped three years ago."
"I didn't know that, Sarah."
"No one else has known either!"
Sarah stopped here and dabbed her eyes. I could see it was hard for
her to tell me this-but at this point I couldn't be sure what hurt worse:
telling me about her rape, or how she had excessively revealed herself to
her group. (That I was the group therapy instructor in the program
must have complicated things for her.) Or was she most upset by what
she had still to tell me? I decided to remain matter-of-fact about it.
"And then?"
"Well, that's when your Carlos went into action."
My Carlos? Ridiculous! I thought. As though he's 1ny child and I
have to answer for him. (Yet it was true that I had urged Sarah to take
him on: she had been reluctant to introduce a patient with cancer into
her group. But it was also true that her group was down to five, and she
 356 THE Y ALOM READER

needed new members.) I had never seen her so irrational-and so chal-

lenging. I was afraid she'd be very embarrassed about this later, and I
didn't want to make it worse by any hint of criticism.
"What did he do?"
"He asked Martha a lot of factual questions-when, where, what,
who. At first that helped her talk, but as soon as I talked about my at-
tack, he ignored Martha and started doing the same thing with me.
Then he began asking us both for more intimate details. Did the rapist
tear our clothing? Did he ejaculate inside of us? Was there any moment
when we began to enjoy it? This all happened so insidiously that there
was a time lag before the group began to catch on that he was getting off
on it. He didn't give a damn about Martha and me, he was just getting
his sexual kicks. I know I should feel more compassion for him-but he
is such a creep!"
"How did it end up?"
"Well, the group finally wised up and began to confront him with
his insensitivity, but he showed no remorse whatsoever. In fact, he be-
came more offensive and accused Martha and me (and all rape victims)
of making too much of it. 'What's the big deal?' he asked, and then
claimed he personally wouldn't mind being raped by an attractive
woman. His parting shot to the group was to say that he would wel-
come a rape attempt by any woman in the group. That's when I said, 'If
you believe that, you're fucking ignorant!'"
"I thought your therapy intervention was calling him a dumb shit?"
That reduced Sarah's tension, and we both smiled.
"That, too! I really lost my cool."
I stretched for supportive and constructive words, but they came out
more pedantic than I'd intended. "Remember, Sarah, often extreme sit-
uations like this can end up being important turning points if they're
worked through carefully. Everything that happens is grist for the mill
in therapy. Let's try to turn this into a learning experience for him. I'm
meeting with him tomorrow, and I'll work on it hard. But I want you to
be sure to take care of yourself. I'm available if you want someone to
talk to-later today or anytime this week."
Sarah thanked me and said she needed time to think about it. As she
.1
left my office, I thought that even if she decided to talk about her own
 The Journey from Psychotherapy to fiction 357

issues with someone else, I would still try to meet with her later when
she settled down to see if we could make this a learning experience for
her as well. That was a hell of a thing for her to have gone through, and
I felt for her, but it seemed to me that she had erred by trying to bootleg
therapy for herself in the group. Better, I thought, for her to have
worked on this first in her personal therapy and then, even if she still
chose to talk about it in the group-and that was problemnric-s-she
would have handled it better for all parties concerned.
Then my next patient entered, and I turned 1ny attention to her. Rut
I could not prevent myself from thinking about Carlos and wondering
how I should handle the next hour with him. It was not unusual for him
to stray into my mind. He was an extraordinary patient; and ever since I
had started seeing him a few months earlier, I thought about him far
more than the one or two hours a week I spent in his presence.
"Carlos is a cat with nine lives, but now it looks as if he's coming to
the end of his ninth life." That was the first thing said to me by the on-
cologist who had referred him for psychiatric treatment. He went on to
explain that Carlos had a rare, slow-growing lymphoma which caused
problems more because of its sheer bulk than its 1nalignancy. For ten
years the tumor had responded well to treatment but now had invaded
his lungs and was encroaching upon his heart. His doctors were run-
ning out of options: they had given hi111 maximum radiation exposure
and had exhausted their pharrnacopeia of chemotherapy agents. How
honest should they be? they asked me. Carlos didn't seem to listen.
They weren't certain how honest he was willing to be with himself
They did know that he was growing deeply depressed and seemed to
have no one to whom he could turn for support.
Carlos was indeed isolated. Aside from a seventeen-year-old son and
daughter-dizygotic twins, who lived with his ex-wife in South Arner-
ica-Carlos, at the age of thirty-nine, found himself virtually alone in the
world. He had grown up, an only child, in Argentina. His mother had
died in childbirth, and twenty years ago his father succumbed to the
same type of lymphoma now killing Carlos. He had never had a male
friend. "Who needs them?" he once said to me, "I've never met anyone
who wouldn't cut you dead for a dollar, a job, or a cunt." He had been
married only briefly and had had no other significant relationships with
 ,
358 THE Y ALOM READER

women. "You have to be crazy to fuck any woman more than once!" His
aim in life, he told me without a trace of shame or self-consciousness, was
to screw as many different women as he could.
No, at my first meeting I could find little endearing about Carlos's
character-or about his physical appearance. He was emaciated,
knobby (with swollen, highly visible lymph nodes at elbows, neck, be-
hind his ears) and, as a result of the chemotherapy, entirely hairless. His
pathetic cosmetic efforts-a wide-hrirnrned Panama hat, painted-on
eyebrows, and a scarf to conceal the swellings in his neck-succeeded
only in calling additional unwanted attention to his appearance.
He was obviously depressed-with good reason-and spoke bitterly
and wearily of his ten-year ordeal with cancer. His lymphoma, he said,
was killing him in stages. It had already killed most of him-his energy,
his strength, and his freedom (he had to live near Stanford Hospital, in
permanent exile from his own culture).
Most important, it had killed his social life, by which he meant his
sexual life: when he was on chemotherapy, he was impotent; when he
finished a course of chemotherapy, and his sexual juices started to flow,
he could not make it with a woman because of his baldness. Even when
his hair gre\Y back, a few weeks after chemotherapy, he said he still
couldn't score: no prostitute would have him because they thought his
enlarged lymph nodes signified AIDS. His sex life now was confined
entirely to masturbating while watching rented sadomasochistic video-
tapes.
It was true-he said, only when I prompted hi1n-that he was iso-
lated and, yes, that did constitute a problem, but only because there were
times when he was too weak to care for his own physical needs. The idea
of pleasure deriving from close human (nonsexual) contact seemed alien
to him. There was one exception-his children-and when Carlos
spoke of them real emotion, emotion that I could join with, broke
through. I was moved by the sight of his frail body heaving with sobs as
he described his fear that they, too, would abandon him: that their
mother would finally succeed in poisoning them against him, or that
they would become repelled by his cancer and turn away from him.
"What can I do to help, Carlos?"
"If you want to help rne-then teach me how to hate armadillos!"
 The Journey from Psychotherapy to Fiction 359

For a moment Carlos enjoyed my perplexity, and then proceeded to

explain that he had been working with visual imaging-a form of self-
healing many cancer patients attempt. His visual metaphors for his new
chemotherapy (referred to by his oncologists as BP) were giant B's and
P's-Bears and Pigs; his metaphor for his hard cancerous lymph nodes
was a bony-plated armadillo. Thus, in his meditation sessions, he visual-
ized bears and pigs attacking the arrnad illos. The problem was that he
couldn't make his hears and pigs be vicious enough to tear open and de-
stroy the arrnadillos.
Despite the horror of his cancer and his narrowness of spirit, I was
drawn to Carlos. Perhaps it was generosity welling out of n1y relief that
it was he, and not I, who was dying. Perhaps it was his love for his chil-
dren or the plaintive way he grasped my hand with both of his when he
was leaving my office. Perhaps it was the whimsy in his request: "Teach
me how to hate armadillos."
Therefore, as I considered whether I could treat him, I minimized
potential obstacles to treatment and persuaded myself that he was more
unsocialized than malignantly antisocial, and that many of his noxious
traits and beliefs were soft and open to being modified. I did not think
through my decision clearly and, even after I decided to accept him in
therapy, remained unsure about appropriate and realistic treatment
goals. Was I simply to escort him through this course of chemotherapy?
(Like many patients, Carlos became deathly ill and despondent during
chemotherapy.) Or, if he were entering a terminal phase, was I to com-
mit myself to stay with him until death? Was I to be satisfied with offer-
ing sheer presence and support? (Maybe that would be sufficient. God
knows he had no one else to talk to!) Of course, his isolation was his
own doing, but was I going to help him to recognize or to change that?
Now? In the face of death, these considerations seerned immaterial. Or
did they? Was it possible that Carlos could accomplish something more
"ambitious" in therapy! No, no, no! What sense does it make to talk about
"ambitious" treatment with someone whose anticipated life span may be, at
best, a matter of months? Does anyone, do I, want to invest time and en-
ergy in a project of such evanescence?
Carlos readily agreed to meet with me. In his typical cynical mode,
he said that his insurance policy would pay ninety percent of my fee,
 1
I

360 THE Y ALOM READER

and that he wouldn't turn down a bargain like that. Besides, he was a
person who wanted to try everything once, and he had never before spo-
ken to a psychiatrist. I left our treatment contract unclear, aside from
saying that having someone with whom to share painful feelings and
thoughts always helped. I suggested that we meet six times and then
evaluate whether treatment seemed worthwhile.
To my great surprise, Carlos made excellent use of therapy; and after
six sessions, we agreed to meet in ongoing treatment. He came to every
hour with a list of issues he wanted to discuss-dreams, work problems
(a successful financial analyst, he had continued to work throughout his
illness). Sometimes he talked about his physical discomfort and his
loathing of chemotherapy, but most of all he talked about women and
sex. Each session he described all of his encounters with women that
week (often they consisted of nothing more than catching a woman's
eye in the grocery store) and obsessing about what he might have done
in each instance to have consummated a relationship. He was so preoc-
cupied with women that he seemed to forget that he had a cancer that
was actively infiltrating all the crawlspaces of his body. Most likely that
was the point of his preoccupation-that he might forget his infestation.
But his fixation on women had long predated his cancer. He had al-
ways prowled for women and regarded them in highly sexualized and
demeaning terms. So Sarah's account of Carlos in the group, shocking
as it was, did not astonish me. I knew he was entirely capable of such
gross behavior-and worse.
But how should I handle the situation with him in the next hour?
Above all, I wished to protect and maintain our relationship. We were
making progress, and right now I was his primary human connection.
But it was also important that he continue attending his therapy group.
I had placed him in a group six weeks ago to provide him with a com-
munity that would both help to penetrate his isolation and also, by iden-
tifying and urging him to alter some of his most socially objectionable
behavior, help him to create connections in his social life. For the first
five weeks, he had made excellent use of the group but, unless he
changed his behavior dramatically, he would, I was certain, irreversibly
alienate all the group members-s-if he hadn't done so already!
Our next session started uneventfully. Carlos didn't even mention
. the group but, instead, wanted to talk about Ruth, an attractive woman
 The Journey from Psychotherapy to Fiction 361

he had just met at a church social. (He was a member of a half-dozen

churches because he believed they provided him with ideal pickup op-
portunities.) He had talked briefly to Ruth, who then excused herself
because she had to go home. Carlos said good-bye but later grew con-
vinced that he had missed a golden opportunity by not offering to escort
her to her car; in fact, he had persuaded himself that there was a fair
chance, perhaps a ten to fifteen percent chance, he might have married
her. His self-recriminations for not having acted with greater dispatch
continued all week and included verbal self-assaults and physical
abuse-pinching himself and pounding his head against the wall.
I didn't pursue his feelings about Ruth (although they were so
patently irrational that I decided to return to her at some point) because
I thought it was urgent that we discuss the group. I told him that I had
spoken to Sarah about the meeting. "Were you," I asked, "going to talk
about the group today?"
"Not particularly, it's not important. Anyway, I'm going to stop that
group. I'm too advanced for it."
"What do you mean?"
"Everyone is dishonest and playing games there. I'm the only person
there with enough guts to tell the truth. The men are all losers-they
wouldn't be there otherwise. They're jerks with no cojones, they sit
around whimpering and saying nothing."
"Tell me what happened in the meeting from your perspective."
"Sarah talked about her rape, she tell you that?"
I nodded.
"And Martha did, too. That Martha. God, that's one for you. She's a
mess, a real sickie, she is. She's a mental case, on tranquilizers. What the
hell am I doing in a group with people like her anyway? But listen to
me. The important point is that they talked about their rapes, both of
them, and everyone just sat there silently with their mouths hanging
open. At least I responded. I asked them questions."
"Sarah suggested that some of your questions were not of the helpful
. ,,
varrety.
"Someone had to get them talking. Resides, I've always been curious
about rape. Aren't you? Aren't all men? About how it's done, about the
rape victim's experience?"
"Oh, come on, Carlos, if that's what you were after, you could have
 362 THE Y AL0Iv1 READER

read about it in a book. These were real people there-not sources of in-
formation. There was something else going on."
"Maybe so, I'll admit that. When I started the group, your instruc-
tions were that I should be honest in expressing my feelings in the
group. Believe me, I swear it, in the last meeting I was the only honest
person in the group. I got turned on, I admit it. It's a fantastic turn-on to
think of Sarah getting screwed. I'd love to join in and get my hands on
those boobs of hers. I haven't forgiven you for preventing me from dat-
ing her." When he had first started the group six weeks ago, he talked
at great length about his infatuation with Sarah-or rather with her
breasts-and was convinced she would be willing to go out with him.
To help Carlos become assimilated in the group, I had, in the first few
meetings, coached him on appropriate social behavior. I had persuaded
him, with difficulty, that a sexual approach to Sarah would be both fu-
tile and unseemly.
"Besides, it's no secret that men get turned on by rape. I saw the
other men in the group smiling at me, Look at the porno business!
Have you ever taken a good look at the books and videotapes about rape
or bondage? Do it! Go visit the porno shops in the Tenderloin-it'd be
good for your education. They're printing those things for somebody-
there's gotta be a market out there. I'll tell you the truth, if rape were le-
gal, I'd do it--once in a while."
Carlos stopped there and gave me a smug grin-or was it a poke-in-
the-arm leer, an invitation to take my place beside him in the brother-
hood of rapists?
I sat silently for several minutes trying to identify my options. It was
easy to agree with Sarah: he did sound depraved. Yet I was convinced
part of it was bluster, and that there was a way to reach something better,
something higher in him. I was interested in, grateful for, his last few
words: the "once in a while." Those words, added almost as an after-
thought, seemed to suggest some scrap of self-consciousness or shame.
"Carlos, you take pride in your honesty in the group-but were you
really being honest? Or only part honest, or easy honest? It's true, you
were more open than the other men in the group. You did express some
of your real sexual feelings. And you do have a point about how wide-
spread these feelings are: the porno business must be offering something
which appeals to impulses all men have.
 The Journey from Psychotherapy to Fiction 363

"But are you being completely honest? What about all the other feel-
ings going on inside you that you haven't expressed? Let me take a guess
about something: when you said 'big deal' to Sarah and Martha about
their rapes, is it possible you were thinking about your cancer and what
you have to face all the time? It's a hell of a lot tougher facing some-
thing that threatens your life right now than something that happened a
year or two ago.
"Maybe you'd like to get some caring from the group, but how can you
get it when you come on so tough? You haven't yet talked about having
cancer." (I had been urging Carlos to reveal to the group that he had can-
cer, but he was procrastinating: he said he was afraid he'd be pitied, and
didn't want to sabotage his sexual chances with the women members.)
Carlos grinned at me. "Good try, Doc! It makes a lot of sense.
You've got a good head. But I'll be honest-the thought of n1y cancer
never entered my mind. Since we stopped chemotherapy two months
ago, I go days at a time without thinking of the cancer. That's goddamn
good, isn't it-to forget it, to be free of it, to be able to live a normal life
for a while?"
Good question! I thought. Was it good to forget? I wasn't so sure.
Over the months I had been seeing Carlos, I had discovered that I could
chart, with astonishing accuracy, the course of his cancer by noting the
things he thought about. Whenever his cancer worsened and he was ac-
tively facing death, he rearranged his life priorities and became more
thoughtful, compassionate, wiser. When, on the other hand, he was in
remission, he was guided, as he put it, by his pecker and grew noticeably
more coarse and shallow.
I once saw a newspaper cartoon of a pudgy lost little man saying,
"Suddenly, one day in your forties or fifties, everything becomes
clear .... And then it goes away again!" That cartoon was apt for Car-
los, except that he had not one, but repeated episodes of clarity-and
they always went away again. I often thought that if I could find a way
to keep him continually a ware of his death and the "clearing" that death
effects, I could help him make some major changes in the way he re-
lated to life and to other people.
It was evident from the specious way he was speaking today, and a
couple of days ago in the group, that his cancer was quiescent again, and
that death, with its attendant wisdom, was far out of mind,
 364 T H E YA LO M RE A D E R

I tried another tack. "Carlos, before you started the group I tried to 1
explain to you the basic rationale behind group therapy. Remember
how I emphasized that whatever happens in the group can be used to
help us work in therapy?" He nodded.
I continued, "And that one of the most important principles of
groups is that the group is a miniature world-whatever environment
we create in the group reflects the way we have chosen to live? Remem-
ber that I said that each of us establishes in the group the same kind of so-
cial world we have in our real life?"
He nodded again. He was listening.
"Now, look what's happened to you in the group! You started with a
number of people with whom you might have developed close relation-
ships. And when you began, the two of us were in agreement that you
needed to work on ways of developing relationships. That was why you
began the group, remember? But now, after only six weeks, all the
members and at least one of the co-therapists are thoroughly pissed at
you. And it's your own doing. You've done in the group what you do
outside of the group! I want you to answer me honestly: Are you satis-
fied? Is this what you want from your relationships with others?"
"Doc, I understand completely what you're saying, but there's a bug
in your argument. I don't give a shit, not one shit, about the people in
the group. They're not real people. I'm never going to associate with
losers like that. Their opinion doesn't mean anything to me. I don't
want to get closer to them."
I had known Carlos to close up completely like this on other occa-
sions. He would, I suspected, be more reasonable in a week or two, and
under ordinary circumstances I would simply have been patient. But
unless something changed quickly, he would either drop out of the
group or would, by next week, have ruptured beyond repair his rela-
tionships with the other members. Since I doubted very much, after this
~
charming incident, whether I'd ever be able to persuade another group
therapist to accept him, I persevered.
I
J
"I hear those angry and judgmental feelings, and I know you really
feel them. But, Carlos, try to put brackets around them for a moment
and sec if you can get in touch with anything else. Both Sarah and
Martha were in a great deal of pain. What other feelings did you have
 The Journey from Psychotherapy to Fiction 365

about them? I'm not talking about major or predominant feelings, but
about any other flashes you had."
"I know what you're after. You're doing your best for me. I want to
help you, but I'd be making up stuff. You're putting feelings into my
mouth. Right here, this office, is the one place I can tell the truth, and
the truth is that, more than anything else, what 1 want to do with those
two cunts in the group is to fuck them! I meant it when I said that if
rape were legal, I'd do it! And I know just where I'd start!"
Most likely he was referring to Sarah, but I did not ask. The last
thing I wanted to do was enter into that discourse with him. Probably
there was some important Oedipal competition going on between the
two of us which was making communication more difficult. He never
missed an opportunity to describe to me in graphic terms what he
would like to do to Sarah, as though he considered that we were rivals
for her. I know he believed that the reason I had earlier dissuaded him
from inviting Sarah out was that I wanted to keep her to myself. But
this type of interpretation would be totally useless now: he was far too
closed and defensive. If I were going to get through, I would have to use
something more compelling.
The only remaining approach I could think of involved that one
burst of emotion I had seen in our first session-the tactic seemed so
contrived and so simplistic that I could not possibly have predicted the
astonishing result it would produce.
"All right, Carlos, let's consider this ideal society you're imagining
and advocating-this society of legalized rape. Think now, for a few
minutes, about your daughter. How would it be for her living in the
community-being available for legal rape, a piece of ass for whoever
happens to be horny and gets off on force and seventeen-year-old girls?"
Suddenly CarJos stopped grinning. He winced visibly and said sim-
ply, "I wouldn't like that for her."
"But where would she fit, then, in this world you're building?
Locked up in a convent? You've got to make a place where she can live:
that's what fathers do-they build a world for their children. I've never
asked you before-what do you really want for her?"
"I want her to have a loving relationship with a man and have a lov-
ing family."
 366 TH E YA LO M RE A DER

"But how can that happen if her father is advocating a world of

rape? If you want her to live in a loving world, then it's up to you to
construct that world-and you have to start with your own behavior.
You can't be outside your own law-e-that's at the base of every ethical
,,
system.
The tone of the session had changed. No more jousting or crudity.
We had grovvn deadly serious. I felt more like a philosophy or religious
teacher than a therapist, but I knew that this was the proper trail. And
these were things I should have said before. He had often joked about his
own inconsistency. I remember his once describing with glee a dinner-
table conversation with his children (they visited him two or three times
a year) when he informed his daughter that he wanted to meet and ap-
prove any boy she went out with. "As for you," he said, pointing to his
son, "you get all the ass you can!"
There was no question now that I had his attention. I decided to in-
crease my leverage by triangulation, and I approached the same issue
from another direction:
"And, Carlos, something else comes to n1y mind right now. Remem-
ber your dream of the green Honda two weeks ago? Let's go back over
. ,,
1 t.
He enjoyed working on dreams and was only too glad to apply him-
self to this one and, in so doing, to leave the painful discussion about his
daughter.
Carlos had dreamed that he went to a rental agency to rent a car, but
the only ones available were Honda Civics-his least favorite car. Of
several colors available, he selected red. But when he got out to the lot,
the only car available was green-his least favorite color! The most im-
portant fact about a dream is its emotion, and this dream, despite its he·
nign content, was full of terror: it had awakened him and flooded him
with anxiety for hours.
Two weeks ago we had not been able to get far with the dream. Car-
los, as I recall, went off on a tangent of associations about the identity of
the female auto rental clerk. But today I saw the dream in a different
light. Many years ago he had developed a strong belief in reincarnation,
a belief that offered him blessed relief from fears about dying. The
metaphor he had used in one of our first meetings was that dying is sim-
 The Journey from Psychotherapy to Fiction 367

ply trading in your body for another one-like trading in an old car. I
reminded him now of that metaphor.
"Let's suppose, Carlos, that the dream is more than a dream about
cars. Obviously renting a car is not a frightening activity, not something
that woul<l become a nightmare and keep you up all night. I think the
dream is about death and future life, and it uses your symbol of compar-
ing death and rebirth to a trade of cars. If we look at it that way, we can
make more sense of the powerful fear the dream carried. What do you
make of the fact that the only kind of car you could get was a green
Honda Civic?"
"I hate green and I hate Honda Civics. My next car is going to be a
Maserati."
"But if cars are dream symbols of bodies, why would you, in your
next life, get the body, or the life, that you hate above all others?"
Carlos had no option but to respond: "You get what you deserve, de-
pending on what you've done or the way you've lived your present life.
You can either move up or down."
Now he realized where this discussion was leading, and began to
perspire. The dense forest of crassness and cynicism surrounding him
had always shocked and dissuaded visitors. But now it was his turn to
be shocked. I had invaded his two innermost temples: his love for his
children and his reincarnation beliefs.
"Go on, Carlos, this is important-apply that to yourself and to your
. c .,
I ue.
He bit off each word slowly. "The dream is saying that I'm not living
right."
"I agree, I think that is what the dream is saying. Say some more on
your thoughts about Jiving right."
I was going to pontificate about what constitutes a good life in any
religious system-love, generosity, care, noble thoughts, pursuit of the
good, charity-but none of that was necessary. Carlos let me know I
had made my point: he said that he was getting dizzy, and that this was
a lot to deal with in one day. He wanted time to think about it during
the week. Noting that we still had fifteen minutes left, I decided to do
some work on another front.
I went back to the first issue he had raised in the hour: his belief that
 368 THE Y ALOM READER

he had missed a golden opportunity with Ruth, the woman he had met
briefly at a church social, and his subsequent head pounding and self-
recrimination for not having walked her to her car. The function that
this irrational belief served was patent. As long as he continued to be-
lieve that he was tantalizingly close to being desired and loved by an at-
tractive woman, he could buttress his belief that he was no different
from anyone else, that there was nothing seriously wrong with him, that
he was not disfigured, not mortally ill.
In the past I hadn't tampered with his denial. In general, it's best not
to undermine a defense unless it is creating more problems than solu-
tions, and unless one has something better to offer in its stead. Reincar-
nation is a case in point: though I personally consider it a form of death
denial, the belief served Carlos (as it does much of the world's popula-
tion) very well; in fact, rather than undermine it, I had always sup-
ported it and in this session buttressed it by urging that he be consistent
in heeding all the implications of reincarnation.
But the time had come to challenge some of the less helpful parts of
his denial system.
"Carlos, <lo you really believe that if you had walked Ruth to her car
you'd have a ten to fifteen percent chance of marrying her?"
"One thing could lead to another. There was something going on be-
tween the two of us. I felt it. I know what I know!"
"But you say that every week-the lady in the supermarket, the re-
ceptionist in the dentist's office, the ticket seller at the movie. You even
felt that with Sarah. Look, how many times have you, or any man,
walked a woman to her car and not married her?"
"O.K., O.K., maybe it's closer to a one percent or half percent chance,
hut there was still a chance-if I hadn't been such a jerk. I didn't even
thinle of asking to walk her to the car!"
"The things you pick to heat yourself up about! Carlos, I'm going to
be hlunt. What you're saying doesn't make any sense at all. All you've
told me about Ruth-you only talked to her for five minutes-is that
she's twenty-three with two small kids and is recently divorced. Let's be
very realistic-as you say, this is the place to be honest. What are you
going to tell her about your health?"
"When I get to know her better, I'll tell her the truth-that I've got
cancer, that it's under control now, that the doctors can treat it."
 The Journey from Psychotherapy to Fiction 369

"And?"
"That the doctors aren't sure what's going to happen, that there are
new treatments discovered every day, that I may have recurrences in the
future."
"What did the doctors say to you? Did they say may have recur-
rencesr..,"
"You're right-will have recurrences in the future, unless a cure is
found."
"Carlos, I don't want to be cruel, but be objective. Put yourself in
Ruth's place-twenty-three years old, two small children, been through
a hard time, presumably looking for some strong support for herself
and her kids, having only a layman's knowledge and fear of cancer--do
you represent the kind of security and support she's looking for? Is she
going to be willing to accept the uncertainty surrounding your health?
To risk placing herself in the situation where she might be obligated to
nurse you? What really are the chances she would allow herself to know
you in the way you want, to become involved with you?"
"Probably not one in a million," Carlos said in a sad and weary voice.
I was being cruel, yet the option of not being cruel, of simply humor-
ing him, of tacitly acknowledging that he was incapable of seeing real-
ity, was crueler yet. His fantasy about Ruth allowed him to feel that he
could still be touched and cared for by another human. I hoped that he
would understand that my willingness to engage him, rather than wink
behind his back, was my way of touching and caring.
All the bluster was gone. In a soft voice Carlos asked, "So where does
that leave me?"
"If what you really want now is closeness, then it's time to take all
this heat off yourself about finding a wife. I've been watching you beat
yourself up for months about this. I think it's time to let up on yourself.
You've just finished a difficult course of chemotherapy. Four weeks ago
you couldn't eat or get out of bed or stop vomiting. You've lost a lot of
weight, you're regaining your strength. Stop expecting to find a wife
right now, it's too much to ask of yourself. Set a reasonable goal-you
can do this as well as I. Concentrate on having a good conversation. Try
deepening a friendship with the people you already know."
I saw a smile begin to form on Carlos's lips. He saw my next sentence
coming: "And what better place to start than in the group?"
 3 70 TH E YA LO M R EA D ER

Carlos was never the same person after that session. Our next ap-
,
pointment was the day following the next group meeting. The first
thing he said was that I would not believe how good he had been in the
group. He bragged that he was now the most supportive and sensitive
member. He had wisely decided to bail himself out of trouble by telling
the group about his cancer. He claimed-and, weeks later, Sarah was to
corroborate this-that his behavior had changed so dramatically that
the members now looked to him for support.
He praised our previous session. "The last session was our best one
so far. I wish we could have sessions like that every time. I don't re-
member exactly what we talked about, but it helped me change a lot."
I found one of his comments particularly droll.
"I don't know why, but I'm even relating differently to the men in
the group. They are all older than me but, it's funny, I have a sense of
treating them as though they were my own sons!"
His having forgotten the content of our last session troubled me lit-
tle. Far better that he forget what we talked about than the opposite
possibility (a more popular choice for patients)-to remember precisely
what was talked about but to remain unchanged.
Carlos's improvement increased exponentially. Two weeks later, he
began our session by announcing that he had had, during that week,
two major insights. He was so proud of the insights that he had chris-
tened them. The first, he called (glancing at his notes) "Everybody has
got a heart." The second was "I am not my shoes."
First, he explained "Everybody has got a heart." "During the group
meeting last week, all three women were sharing a lot of their feelings,
about how hard it was being single, about loneliness, about grieving for
their parents, about nightmares. I don't know why, but I suddenly saw
them in a different way! They were like me! They were having the
same problems in living that I was. I had always before imagined
women sitting on Mount Olympus with a line of men before them and
sorting them out-this one to my bedroom, this one not!
"But that moment," Carlos continued, "I had a vision of their naked
hearts. Their chest wall vanished, just melted away, leaving a square •
•
blue-red cavity with rib-bar walls and, in the center, a liver-colored glis-
tening heart thumping away. All week long I've been seeing everyone's
heart beating, and I've been saying to myself, 'Everybody has got a
 The Journey from Psychotherapy to Fiction 371

heart, everybody has got a heart.' I've been seeing the heart in every-
one-a misshapen hunchback who works in reception, an old lady who
does the floors, even the men I work with!"
Carlos's comment gave me so much joy that tears came to my eyes. I
think he saw them but, to spare me embarrassment, made no comment
and hurried along to the next insight: "I am not n1y shoes."
He reminded me that in our last session we had discussed his great
anxiety about an upcoming presentation at work. He had always had
great difficulty speaking in public: excruciatingly sensitive to any criti-
cism, he had often, he said, made a spectacle of himself by viciously
counterattacking anyone who questioned any aspect of his presentation.
I had helped him understand that he had lost sight of his personal
boundaries. It is natural, I had told him, that one should respond ad-
versely to an attack on one's central core-after all, in that situation
one's very survival is at stake. But I had pointed out that Carlos had
stretched his personal boundaries to encompass his work and, conse-
quently, he responded to a mild criticism of any aspect of his work as
though it were a mortal attack on his central being, a threat to his very
survival.
I had urged Carlos to differentiate between his core self and other,
peripheral attributes or activities. Then he had to "disidentify" with the
non-core parts: they might represent what he liked, or did, or valued-
but they were not him, not his central being.
Carlos had been intrigued by this construct. Not only did it explain
his defensiveness at work, but he could extend this "disidenrification"
model to pertain to his body. In other words, even though his body was
imperiled, he himself, his vital essence, was intact.
This interpretation allayed much of his anxiety, and his work pre-
sentation last week had been wonderfully lucid and nondefensive.
Never had he done a better job. Throughout his presentation, a small
mantra wheel in his mind had hummed, "I am not mv, work." When he
finished and sat down next to his boss, the mantra continued, "I am not
my work. Not my talk. Not my clothes. None of these things." He
crossed his legs and noted his scuffed and battered shoes: "And I'm not
my shoes either." He began to wiggle his toes and his feet, hoping to at-
tract his boss's attention so as to proclaim to him, "I arn not rny shoes! ..
Carlos's two insights-the first of 1nany to con1e-were a gift to me
 3 72 TH E YA LO M RE A DER

and to my students. These two insights, each generated by a different

form of therapy, illustrated, in quintessential form, the difference be-
tween what one can derive from group therapy, with its focus on com-
munion between, and individual therapy, with its focus on communion
within. I still use many of his graphic insights to illustrate my teaching.
In the few months of life remaining to him, Carlos chose to continue
to give. He organized a cancer self-help group (not without some hu-
morous crack about this being the "last stop" pickup joint) and also was
the group leader for some interpersonal skills groups at one of his
churches. Sarah, by now one of his greatest boosters, was invited as a
guest speaker to one of his groups and attested to his responsible and
competent leadership.
But, most of all, he gave to his children, who noted the change in
him and elected to live with him while enrolling for a semester at a
nearby college. He was a marvelously generous and supportive father. I
have always felt that the way one faces death is greatly determined by
the model one's parents set. The last gift a parent can give to children is
to teach them, through example, how to face death with equanimity-
and Carlos gave an extraordinary lesson in grace. His death was not one
of the dark, muffled, conspiratorial passings. Until the very end of his
life, he and his children were honest with one another about his illness
and giggled together at the way he snorted, crossed his eyes, and puck-
ered his lips when he referred to his "lyrnphoooooooooooomma."
But he gave no greater gift than the one he offered me shortly before
he died, and it was a gift that answers for all time the question of
whether it is rational or appropriate to strive for "ambitious" therapy in
those who are terminally ill. When I visited him in the hospital he was
so weak he could hardy move, but he raised his head, squeezed my
hand, and whispered, "Thank you. Thank you for saving my life."
 CHAPTER 9

The Teaching Novel

In a manner I could never have anticipated, my unconscious played a key

role in the writing of Love's Executioner: as I approached the end of each
of the first nine stories, the next one mysteriously wafted into my mind, as
though I had unknowingly constructed in advance an outline and table of
contents. While I worked on the ending of the tenth story, "In Search of
the Dreamer," another surprise was in store for me: I found myself unac-
countably thinking not of another clinical tale, but of Friedrich Nietzsche.
I began rereading, with fascination, Nietzsche's work as well as several bi-
ographies of Nietzsche. Soon, even before Love's Executioner was fully
edited, I began work on a novel about Nietzsche and his relationship to
psychotherapy.
I never regarded the writing of Love's Executioner as a radical depar-
ture from my role as an academician. I was simply fulfilling the job de-
scription-making a contribution to the professional literature of my
field. I meant Love's Executioner to be a pedagogical device, a collection
of teaching tales to be used in psychotherapy training programs; that the
book became a best-seller surprised no one more than me.
It was with that same sentiment that I began When Nietzsche Wept.

373
 374 THE YALOM READER

My intention was to teach and my target audience was still the profes-
sional community-student and practicing psychotherapists. I planned,
through the use of a new pedagogical device, a teaching novel, to ex-
pose students to a fictionalized account of the conception and birth of
existential therapy.
The novel invites students to engage in a number of thought experi-
ments involving psychotherapy. They are asked, for example, to imagine
what type of psychotherapy might have evolved if Freud had never lived.
Or, in a more complex experiment: Suppose Freud had lived and left us
only his topographical model of the mind (that is, his posited structure of
the psyche, encompassing the dynamic unconscious and the mecha-
nisms of defense) without his psychoanalytic content-without the idea
of anxiety issuing from the vagaries of psychosexual development? And
imagine, further, the nature of psychotherapy if the content were based
on an existential model-that is, that anxiety issues from a confrontation
with the terrifying facts of life inherent in existence?
I knew I wanted to write fiction, but a special kind of fiction: fiction
that would serve a rhetorical, pedagogical purpose. While thinking about
the nature of this writing, I encountered a phrase in a novel by Andre
Gide, Lafcadio1s Adventures (also translated as The Vatican Swindle and
The Vatican Cellars). "History," Gide said, "is fiction that did happen.
Whereas fiction is history that might have happened."
Fiction is history that might have happened. Perfect! That was pre-
cisely what r wanted to write. I wanted to describe a genesis of psy-
chotherapy that might have happened, if history had rotated only slightly
on its axis. I wanted the events of When Nietzsche Wept to have had a
possible existence.
So although the novel is fiction, it is not, I think, an improbable ac-
count of how Friedrich Nietzsche might have invented psychotherapy.
Moreover, Nietzsche's relationship to therapy might well have been
more than that of sheer creator: he lived much of his life in deep despair
and could well have used therapy. Ultimately, I fashioned a plot that
consists of this central thought experiment:

Suppose that Nietzsche were placed in a historical situation that

would have enabled him to invent a psychotherapy, derived from
f I
 The Teaching Novel 375

his own published writings, that could have been used to heal
Nietzsche himself.

But why Nietzsche? First, the basic tenets of much of my thinking about
existential psychotherapy and the meaning of despair are to be found in
Nietzsche's writings. It is not that I read Nietzsche and deliberately set
about to develop clinical applications for his insights. I've never thought
or worked in that manner. Instead, my ideas about existential therapy
emerged from my clinical work; I then turned to philosophy as a way of
confirming and deepening this work.
In the process of writing the textbook Existential Therapy, I immersed
myself for years in the work of the great existential philosophers-Sartre,
Heidegger, Camus, Jaspers, Kierkegaard, Nietzsche. Of these thinkers, I
found Nietzsche to be the most creative, the most powerful, and the
most relevant for psychotherapy.
The idea of Nietzsche as a therapist may seem jarring to many of us
because we so often think of Nietzsche as a destroyer or nihilist. After all,
did he not describe himself as the philosopher who does philosophy with
a hammer? But Nietzsche, full of contradictions, revered destruction only
as a stage in the process of creation-often he said that one can build a
new self only on the ashes of the old
Many philosophers-the "gentle Nietzscheans"-have considered
Nietzsche not as a destroyer but as a healer, a man who aspired to be a
physician to his entire epoch. And the disease he hoped to treat? Ni~
hilism-the post-Darwinian nihilism that was creeping over Europe in
the late nineteenth century. In the wake of Darwin all the old traditional
religious values were crumbling. God was dead and a new secular hu-
manism squatted in the temple ruins. Nietzsche-Nietzsche the creator,
the seeker, not Nietzsche the destroyer-sought to use the death of God
as an opportunity to create a new set of values. Over a century ago he
said, "If we have our own 'why' of life we shall get along with almost any
'how."'1 But Nietzsche wanted the new "why," the new set of values, to
be based not on supernatural values but on human experience, and on
this life rather than on the illusion of some afterlife
Nietzsche's relevance for contemporary psychotherapy makes more
sense when one reviews the many ways in which Nietzsche anticipated
 3 76 TH E YA LO M R E AD ER

Freud. For example, consider Nietzsche's concept of the truly evolved

individual (the Ubetmensch, superman, or overman). Nietzsche believed
that the path to becoming an Ubetmensch lay not in the conquest or sub-
jugation of others but in a self-overcoming. The truly powerful man
never inflicts pain or suffering but, like the prophet Zarathustra, over·
flows with power and wisdom that he offers freely to others. His offer
emanates from a personal abundance, never from a sense of pity-that
would represent a kind of scorn. So the overman, then, is a life affirmer,
one who loves his fate, one who says yes to life.
In his life-celebratory stand, Nietzsche was much at odds with his first
hero, Socrates, who, just before taking his fatal draught of hemlock, said,
"I owe Asclepius a rooster." Why would Socrates owe the god of medi-
cine a rooster-a fee the Greeks offered a doctor when he cured a pa·
tient? Apparently Socrates meant that he was now cured of the disease of
life and its inherent, inescapable suffering. Nietzsche was at odds also
with the Buddhist view that life was suffering and that relief from suffer-
ing lay in the giving up of attachments. According to this view the final
goal of life is the detachment from individual consciousness, the end of
the cyclical wheel of individual ego, the attainment of Nirvana.
But not so for Nietzsche, who once said, "Was that life? Well, then,
once more!"2 Nietzsche's overman is one who, if offered the opportunity
to live life in precisely the same way, again and again and again, and for
all eternity, is able to say, "Yes, yes, give it to me. I'll take that life and I'll
live it again in precisely the same way." The Nietzschean overman loves
his fate, embraces his suffering, and turns it into art and into beauty. And
he is also a person who, in Nietzsche's view, overcomes the narcotic
need for some supernaturally imposed purpose. Once a man can do that,
Nietzsche said, he becomes an Ubetmensch. a philosophical soul, one
of those who represent the next stage of human evolution.
So Nietzsche urged us not to strive toward the conquest of others but
toward an interior, self-actualizing process, toward the realization of our
potential. Nietzsche's words were not lost to history: in the 1960s they
found expression again in the human potential movement. He offered a
new, nonsupernatural, humanistically-oriented purpose in life, namely,
that we are a bridge to something higher, that each of us is in the
process of becoming something more. Our task in life, Nietzsche said, is
to perfect nature and our own nature. And he offered instruction for the
 The Teaching :--,.:o,el 3 77

necessary inner work: his first "granite sentence" was-Become who

you are.
Despite Nietzsche's focus on the deep inner work of the individ-
ual, many of his words were twisted into Nazi slogans about world-
conquering Aryan supermen during World War II. To understand that
phenomenon one must draw a careful distinction between what Nietz-
sche really wrote and the vulgarized version of Nietzsche's philosophy
that was disseminated by his sister, Elisabeth, one of the great villainesses
of intellectual history.
Elisabeth, who ultimately became Nietzsche's literary executor, had
strong protofascist, anti-Semitic leanings, whereas Nietzsche vigorously
rejected these sentiments. He had a deeply ambivalent relationship to his
sister, at times closely attached to her, at times dismissing her as "an anti-
semitic goose.'? Much dismayed by her marriage in 1885 to Bernhard
Forster, a professional anti-Semitic agitator, Nietzsche was not altogether
sorry to see her emigrate with her husband to Paraguay to found Nueva
Germania, an Aryan colony built on soil "uncontaminated" by Jewish
presence.
Ultimately, due to Forster's ineptness and grandiosity, the Paraguay
project floundered. Bernhard Forster was accused of embezzlement and
ultimately committed suicide. Elisabeth, after an unsuccessful attempt to
salvage the colony, returned home to Europe just in time to take over her
ailing brother's estate. Seizing her one great chance to attain political
prominence, she set about distorting Nietzsche's writings in order to pro-
mulgate her Wagnerian-fascist ideas. So effectively did she do this that it
has taken a generation of scholars to separate Nietzsche's golden grain
from Elisabeth's chaff.
Nietzsche recoiled from the building of great philosophic systems,
like that of Hegel. He was more a brilliant gadfly whose remarkable in-
sights even now, a century later, continue to fuel philosophic investiga-
tions. Employing a penetrating, intuitive style, he preferred quick dips
into the cold pool of truth, which he mostly described aphoristically. He
even wrote an aphorism about aphorisms: "A good aphorism is too hard
for the tooth of time and is not consumed by all millennia, although it
serves every time for nourishment: thus it is the great paradox of litera-
ture, the intransitory amid the changing, the food that always remeins es-
teemed, like salt, and never loses its savor, as even that does."
 378 THE YA LOi\1 REA DER

Many fields-aesthetics, philosophy, ethics, history, philology, poli-

tics, music-have profited from Nietzsche's sparkling ideas. One of my
intentions in When Nietzsche Wept was to underscore the relevance of
Nietzsche's psychological insights to contemporary psychotherapy.
In many places he stressed the importance of coming to terms with
one's destiny, destiny in the deepest sense, not just an individualistic de-
velopmental destiny but the very condition of being human. It was the
task of the evolved human being, Nietzsche held, to look deeply into this
destiny. Looking deeply often incurs pain, he knew, but he believed that
we must train ourselves to bear the suffering of truth. Staring at the truth
is not easy, Nietzsche wrote: ''It makes one strain one's eyes all the time,
and in the end one finds more than one might have wished."5 Ultimately
suffering becomes the great liberator that permits us to plumb our deep-
est depths. Nietzsche's second granite sentence was: That which does
not ki II me makes me stronger.
Nietzsche's ability to stare unflinchingly at the truth, to break illusion,
was remarkable. "One must pay dearly for immortality," he said. "One
has to die several times while still alive."6 In other words, if one is to be-
come enlightened and worthy of immortality, one must face down the
terror of death and plunge into the vision of one's own dying many times
while still alive.
Although Nietzsche never explicitly addressed the field of medicine
or psychiatry, he nonetheless had thoughts about the training of healers:

Physician help thyself: thus you help your patients too. Let this be
his best help-that he, the patient, may behold with his eyes the
man who heals himself.7

You shall build over and beyond yourself, but first you must be
built yourself, perpendicular in body and soul. You shall not only
reproduce yourself, but produce something higher.8

Obviously these aphorisms, written a century ago, argue for the position
(to which almost all contemporary teachers of psychotherapy ascribe)
Ii
that a personal therapy is a sine qua non of the training of therapists. But !

another aphorism adds a moderating note: "Some cannot loosen their

 The Teaching Novel 3i9

own chains and can nonetheless redeem their friends;" In other words,
even though personal exploration and insight are needed, total enlight-
enment (that is, a full personal self-overcoming) may not be necessary
because therapists can take their patients farther than they themselves
have gone. Even the wounded therapist can still point the way to the pa-
tient-therapists are guides, not conveyor belts.
Nietzsche wrote on the nature of the healing relationship:

Here and there on earth we may encounter a kind of confirma-

tion of love in which this possessive craving of two people for
each other gives way to a new desire-a shared higher thirst for
an ideal above them. But who knows such love? Who has experi-
enced it? Its right name is triendship,"

"A shared higher thirst for an ideal above them ... its right name is
friendship." It might also be called psychotherapy-an authentic rela-
tionship, sharing a thirst for an ideal above, which emerges when all pos-
sessive cravings and transference distortions have dissipated.
How close a relationship? How distant? In a light piece of verse
Nietzsche advises that it be neither too distant nor too enmeshed. Per-
haps the best role for the healer is as a participant-observer:

Do not stay in the field

nor climb out of sight
the best view of the world
is from a medium height. 11

As I planned my novel I had to imagine what kind of therapist Nietz-

sche might have been. Ambitious, resolute, and uncompromising, I be-
lieve. He would have made no concessions, wou Id have expected his
clients to face the truth about themselves and their "situation" in exis-
tence. I grew convinced he would have been disdainful of simple symp-
tom relief or the limited goals of behavioral-cognitive modes. Listen:

I am a railing by the torrent: let those who can grasp me. A

crutch, however, I am not!12
 380 THE Y Al.OM READER

Or again:

For that is what I am through and through: reeling in, raising up,
raising, a raiser, cultivator, and disciplinarian, who once coun-
seled himself, not for nothing: Become who you erei"

Given even these few glimpses into Nietzsche's relevance for contempo-
rary psychotherapy, we may turn to the question of whether Nietzsche
has taken his deserved place in the history, theory, or practice of psy-
chotherapy. The answer is "absolutely not." Turn to history of psychiatry
or psychotherapy textbooks and you will find no mention of his name.
Why not? After all, Nietzsche lived in the right place at the right time,
that is, in the crucible of psychotherapy: central Europe, mid-nineteenth
century (he was born in 1844, twelve years before Freud). To answer the
question of why Nietzsche's name has been ignored in the psychother-
apy literature, we must turn to the relationship between Nietzsche and
Freud. I refer, of course, to the intellectual relationship: the two men
never met.
Nietzsche would not have known of Freud. By 1889, which marks
the end of Nietzsche's intellectual career, Freud had published nothing
in the field of psychiatry. (His first published article in psychiatry ap-
peared in 1893, and his first book, Studies in Hysteria, in 1895.) But did
Freud know Nietzsche's work? Here the record is contradictory. Some-
times Freud flatly denied he had ever read Nietzsche; at other times he
appeared to be intimately familiar with Nietzsche's writings.
Was it possible that Freud was ignorant of Nietzsche's work? How
prominent was Nietzsche at the end of the nineteenth century? During
his productive lifetime Nietzsche's writings were not well known. Thus
Spake Zarathustra, his best-known book and a standard undergraduate
text for later generations, sold only one hundred copies in its first year of
publication. In fact, so few copies of any of his books sold that Nietzsche
once claimed to know the owner of every copy. Yet Nietzsche's name
was not unknown during his lifetime; throughout Western Europe there
was an active underground Nietzsche appreciation movement, and
many artists and intellectuals were aware of his genius.
Nietzsche's death was no less remarkable than his life: in effect, he
 The Teaching Novel 381

died twice-in 1889 and eleven years later in 1900. In 1889 he suffered
a cataclysmic dementia and his great mind was gone forever. Most med-
ical historians have concluded that he suffered from tertiary syphilis-
paresis (general paralysis of the insane), a common incurable condition
of the era. After 1889 Nietzsche remained broken for the rest of his life,
unable to think clearly, barely able to formulate a coherent sentence. His
vacant husk lingered on for eleven more years until his corporeal death
in 1900.
How Nietzsche ever contracted syphilis remains a puzzle for histori-
ans, since he was believed to have led a chaste life. Unfounded specula-
tions abound, ranging from contact with the cigars of wounded soldiers
when Nietzsche served in an ambulance corps in the Franco-Prussian
War, to liaisons with prostitutes in Cologne, to medically prescribed
romps with Southern Italian peasant women, to (Jung's theory) visits to
gay brothels in Genoa.
When Nietzsche was incapacitated, his sister, Elisabeth, moved in to
take care of him and of his writings. A great self-promoter, she made the
most of her one possible vehicle for fame, her brother's philosophy, for
the rest of her life. Her political pandering was so successful that Hitler
funded her Nietzsche Archive at Weimar, visited her on her ninetieth
birthday bearing a huge bouquet of roses, and, a few years later, at-
tended her funeral and placed a laurel wreath on her casket.
Although Nietzsche was tittle known before his first death in 1889,
Elisabeth was to change that dramatically in the next ten years. As a re-
sult of her promotion, all of Nietzsche's work was republished. Before
long, copies of his books by the tens of thousands cascaded from the
great presses of Europe.
It is conceivable that Freud may have been unfamiliar with Nietz-
sche's writings during Nietzsche's productive lifetime, but it is highly im-
probable that he (or any educated middle European) would have been
unaware of the deluge of Nietzsche's books printed after 1900. We
know, also, that some of Freud's university friends (for example, Joseph
Paneth) became early devotees of Nietzsche in the 1870s and early
1880s and wrote to Freud concerning their opinions of Nietzsche. And of
course there was Freud's intimate twenty-six-year relationship with Lou
Salome who, as I shall discuss shortly, had previously been intimate with
 382 THE YALO~l READER

Nietzsche. We know, too, that Otto Rank gave Freud a complete set of
Nietzsche's writings bound in white leather. Freud prized these books.
When the gestapo forced him to abandon most of his library and exit
Vienna hastily, he took care to keep his Nietzsche collection with him.
The detailed minutes of the Psychoanalytic Society in Vienna inform
us that two entire meetings in 1908 were devoted to Nietzsche. In these
minutes Freud acknowledged that Nietzsche's intuitional method had
reached insights amazingly similar to those reached through the labori-
ously systematic scientific efforts of psychoanalysis. The Psychoanalytic
Society explicitly credited Nietzsche as being the first to discover the sig-
nificance of abreaction, of repression, of forgetting, of flight into illness,
of illness as an excessive sensitivity to the vicissitudes of life, and of the
instincts in mental life-both the sexual and sadistic instincts. Freud, in
fact, went so far as to point out the two or three ways in which he
thought Nietzsche had not anticipated psychoanalysis. Obviously, in or-
der to do that, Freud must have known the many ways in which Nietz-
sche did anticipate the discipline.
Although Freud said at times that he had not read Nietzsche, he did
say at other times that he had tried to read Nietzsche but was too lazy-
an odd statement, considering Freud's legendary diligence and energy.
(A perusal of his daily schedule, often consisting of ten to twelve clinical
hours before he sat down to write, always leaves me gasping for breath.)
On still other occasions (and here, I believe, we move closer to the truth)
Freud said he tried to read Nietzsche but got dizzy because Nietzsche's
pages were so crammed with insights uncomfortably dose to his own.
Thus to read Nietzsche was to deprive himself of the satisfaction of mak-
ing an original discovery: in other words, Freud had to remain ignorant
of Nietzsche's work lest he, as he put it, be forced to view himself as a
"verifying drudge."
Elsewhere he explicitly acknowledged that Schopenhauer and Nietz-
sche so precisely described and anticipated the theory of repression that
it was only because he (Freud) was not well read that he had the chance
to make a great discovery. And making a great discovery was extraordi-
narily important to Freud, who realized early in life that a university ca-
reer would be closed to him because of the anti-Semitism rampant in
iin-de-siecle Vienna. Private practice was the only venue available to
 The Teaching Novel 383

him, and the great independent discovery was the only route to the fame
he so craved. The idea of himself as an original thinker making indepen-
dent discoveries was thus crucially important to Freud, whose creative
energy depended on this romantic image of himself. "Even Einstein,"
Freud said, "had the advantage of a long line of predecessors from Isaac
Newton forward, whereas I had to hack every step of my own way alone
through a tangled jungle."
Grounded in classical philosophy, especially the earliest Western
philosophers, the pre-Socratic Greeks, Nietzsche had a very different at-
titude toward priority. "Am I cal led upon," Nietzsche asked, "to discover
new truths? There are far too many old ones as it is." He believed that the
past was always embodied in the great man and sought only "to put his-
tory in balance again." Never a modest man, Nietzsche predicted that "a
thousand secrets of the past will crawl out of their hiding places into my
sunshine."14
Thus there is evidence that Freud knew and admired Nietzsche's
work. According to his biographer Ernest Jones, Freud placed several
great men in a pantheon and said he could never achieve their rank."
In this group were Goethe, Kant, Voltaire, Darwin, Schopenhauer-and
Nietzsche. Perhaps some of Freud's confused feelings toward Nietzsche
issued from his ambivalence toward the entire discipline of philosophy.
At times Freud derided philosophy for its lack of a scientific methodol-
ogy. Yet at other times he yearned to settle into pure philosophic and his-
torical speculation, and considered his entire medical career as a detour,
a false turn from his true calling as a Lebens-philosopher, an unraveler of
the mystery of how man came to be what he is.
Hence there is unfinished business between Nietzsche and the field
of psychotherapy: although Nietzsche was prescient about the field of
psychotherapy and although he exercised considerable influence upon
Freud, Freud never acknowledged that debt. The entire field of psy-
chotherapy has followed Freud's lead and ignored Nietzsche's contribu-
tions. One of my intentions in When Nietzsche Wept is to address this
oversight and to begin to harvest, more explicitly, Nietzsche's psycholog-
ical insights.
There is still another reason to write about Nietzsche-the extraordi-
nary drama of his life makes him an intriguing novelistic subject. He was
 38.f THE Y ALO.\l READER

born in 1844 into a family o( modest means. His father, a Lutheran min-
ister, died when Nietzsche was five. His genius noted at an early age,
Nietzsche was awarded a scholarship to one of the best schools in Ger-
many. At the age of twenty-four, before he matriculated from a graduate
university program in philology, he was offered, and he accepted, the
chair in classical philology at the University of Basel. While there, he
was tormented by an illness that first appeared in his adolescence and
was destined to plague him all his life. The illness was not the syphilis
that ultimately was 10 kill him, but almost certainly a severe migraine
condition.
His migraine so incapacitated him-according to Stefan Zweig, some-
times he was ill more than two hundred days in a given year-that at the
age of thirty, Nietzsche had to resign his professorship. As he put it, he
kicked the dust of the German-speaking world from his shoes and de-
parted to Italy, where he spent the rest of his life traveling mostly in South-
ern Italy and Switzerland, going from one modest hotel to another, in
search of the climate and atmospheric conditions that would grant him
health enough to think and to write for two or three consecutive days.
Where, then, the drama? From the perspective of external events,
Nietzsche's life might seem unusually uneventful. Yet from the internal
perspective there is great drama in the lonely life of this man, one of the
great courageous spirits of history, wandering from one unassuming inn
to another in Italy and Switzerland and, all the while, unflinchingly con-
fronting the harshest facts of human existence. And Nietzsche always
pursued his task starkly, without material comfort (he lived on a small
university pension), without a home (he referred to himself as a tor-
toise-the steamer trunk he lugged from hotel to hotel contained all his
possessions), without a family (save for a distant mother and the prob-
lematic Elisabeth). He lived without the touch of a loving friend, without
a professional community (he never again held a university position),
without a country (because of his anti-German sentiments he gave up his
German passport and never stayed in one place long enough lo obtain
another). He had little public recognition (his publishers, he said, should
have worked at political intrigue-they were skilled at keeping secrets
and his books were their greatest secret) and no professional acclaim or
students.
 The Teaching Novel 385

Perhaps the lack of acclaim troubled Nietzsche so little because he

had an unswerving belief in his ultimate place in history. In his preface to
one of his later books (The Antichrist) he says, "This book belongs to the
very few. Perhaps none of them is even living today. Only the day after
tomorrow belongs to me. Some are born posthumously." (I liked the
phrase "born posthumously" so well that for a time I considered using it
for my book's title.)
During these years Nietzsche suffered a great deal from the effects of
the debilitating migraine, as well as from isolation and the sheer task of
living a life devoid of illusion. He often said that despair is the price one
pays for self-awareness, and wondered how much truth a man could
stand. Perhaps, also, the despair issued from some kind of presentiment
of his percolating disease-the ticking bomb that would burst his brain at
the seams when he was forty-five.

Let us return now to the basic thought experiment that constitutes the
spine of my novel: Suppose that Nietzsche were placed in a historical sit-
uation where he would have been enabled to invent a psychotherapy,
derived from his own published writings, that could have been used to
heal Nietzsche himself.
In which way could a psychotherapeutic experience have helped
Nietzsche? Through insight? Unlikely. Recall that Freud said Nietzsche
was a man who had more insight about himself than any man who ever
lived. More than insight would have been needed. What Nietzsche
needed was a therapeutic encounter, a meaningful relationship. Nietz-
sche experienced himself as desperately isolated. His letters bulge with
references to his loneliness: "Neither among the living nor the dead is
there anyone with whom I feel kinship''; "No one who had any sort of
God to keep him company ever reached my level of loneliness.":'
But Nietzsche in psychotherapy? Is it conceivable that Nietzsche
would have made himself so vulnerable to another? And would Nietz-
sche's grandiose, arrogant self have permitted the self-disclosure re-
quired for successful therapy? Obviously the plot called for some device
that would have permitted Nietzsche to be in therapy and yet, at the
same time, in control of his therapy procedure.
And when should the story be set? Nietzsche was in despair much of
 386 TH E Y A LO M R EA DER

his life. Would there have been a particularly propitious time for a thera-
peutic encounter? Ultimately, I settled on the autumn of 1882: Nietzsche
was thirty-eight and, after the breakup of a brief, passionate (but chaste)
love affair, had slumped into such a state of despair that his letters were
full of suicidal ideation. The woman, Lou Salome, a young and remark-
able Russian, would go down in history as a writer, critic, disciple of
Freud, practicing psychoanalyst, and friend and lover to several eminent
men of the late nineteenth century, including the poet Rainer Maria
Rilke.
One of the most striking aspects of Nietzsche's depression in 1882
was his rapid recovery: though he was suicidal in the autumn of 1882, it
was only a few months later, in the spring of 1883, that he began ener-
getically writing Thus Spake Zarathustra. He completed the first three
parts in only ten days, writing in a frenzy, writing as no philosopher had
ever before written, as though he were in a trance, as though he were a
medium through whom Thus Spake Zarathustra was released.
Furthermore, Thus Spake Zarathustra is a life-affirming, life-celebrat-
ing work. How was Nietzsche able to transport himself from such de-
spair to such life affirmation in only a few months? Wouldn't it have been
reasonable, and wonderful, for Nietzsche to have had a successful ther-
apy encounter at the end of 1882?
But who would be Nietzsche's therapist? That was a vexing problem.
In 1882 there were no professional psychotherapists. There was no such
thing as dynamic psychotherapy: Freud was twenty-seven years old and
had yet to enter the field of psychiatry. If Nietzsche had seen a contem-
porary physician for his despair, he might have been told there was no
medical treatment for his condition, or he might have been sent to
Baden-Baden, Marienbad, or one of the other central European spas for a
water cure, or perhaps he might have been referred to the church for reli-
gious counseling. There were no practicing secular therapists. Although
A. A. Liebault and Hippolyte Bernheim had a school of hypnotherapy in
Nancy, France, they offered no psychotherapy per se, only hypnotic
symptom-removal.
If only I could have set the novel a decade later; by then Freud would
have been developing psychoanalytk methods and a Freud-Nietzsche
encounter would have made an interesting story. This, however, was not
possible: by 1892 Nietzsche had already lapsed into irreversible demen-
 The Teaching Novel 387

tia. No, all things pointed toward 1882 as the most propitious historical
moment.
Unable to identify a psychotherapist in 1882, I decided to invent one.
I began sketching a fictional Jesuit priest-therapist (a lapsed priest, be-
cause of Nietzsche's anticlerical sentiments). Then it suddenly dawned
on me that there was, after all, right under my nose, one therapist alive in
1882-Josef Breuer, Freud's friend and mentor, who was the first person
to employ dynamic theory and methods in the psychotherapy of a pa-
tient. (I knew Breuer's work particularly wel I because, for a decade, I had
taught a Freud appreciation course in which I discussed the contribu-
tions of Breuer.) Although the full case history of the patient, Bertha Pap-
penheim (whom Breuer gave the pseudonym Anna 0.), was not
published until 1893, in a psychiatric journal, and would reappear in
1895 in Freud's and Breuer's Studies in Hysteria, Breuer had actually
treated Bertha Pappenheim many years earlier, in 1881.
Once I had selected Breuer as Nietzsche's therapist, the rest of the
plot quickly fell into place. In the early 1880s Nietzsche had consulted a
great many central European physicians because of his deteriorating
health. Breuer was not a psychiatrist but was a superb medical diagnosti-
cian and the personal physician to many of the eminent figures of his era.
It would have been historically plausible for Nietzsche to have sought
consultation with Breuer.
I chose Lou Salome as the instrument to bring Nietzsche and Breuer
together. Feeling guilty about her role in Nietzsche's depression, she asks
Breuer to meet with Nietzsche. In this regard Lou Salome's behavior is
indeed fictional, since the historical evidence paints her as a free spirit
unlikely to be burdened by a heavy conscience.
But she was undoubtedly a woman of considerable beauty, charm,
and persuasiveness. Although Breuer first takes the position that there is
no medical treatment for lovesick despair, Lou Salome urges him to im-
provise and reminds him that, until he invented it, there was also no
treatment for Anna O.'s hysteria. (Although the case had not yet been
published in 1882, I suggest that Lou Salome might have heard about it
from her brother, Jenia, who, by the sheerest chance and good fortune
for the historical consistency of my plot, happened to be a medical stu-
dent in Vienna in 1882 and might have studied with Breuer.)
Breuer reluctantly agrees and fashions a plan (in consultation with the
 388 THE Y AL0.\1 READER

young Freud, who, in 1882, was a medical intern and a frequent visitor
to the Breuer household) to consult with Nietzsche about his physical
health and then, slowly and subtly, to redirect attention to his psycholog-
ical distress. Nietzsche, however, whose personal definition of hell might
have been a situation where he disclosed his vulnerability to a stranger,
powerfully resists all Breuer's attempts to engage him in therapy and, af-
ter two medical consultations, sharply breaks off contact.
Before he can leave Vienna, however, Nietzsche is stricken with a
cardiac arrhythmia and a severe migraine requiring Breuer's treatment.
For a short period, while desperately ill, Nietzsche appears more vulner-
able and amenable to a psychological investigation, but twenty-four
hours later, when he recovers, he reverts to his distant, concealed per-
sona. Late at night Breuer, while trudging home from his consultation
with Nietzsche, ponders his options and suddenly has an inspired idea:

Breuer gave up. He stopped thinking. His legs took over and
he continued walking toward a warm, well-lit home, toward
his children, and his loving, unloved Mathilde. He concen-
trated only on breathing in the cold, cold sit. warming it in
the cradle of his lungs, and releasing it in steamy clouds. He
listened to the wind, to his steps, to the bursting of the fragile
icy crust of snow underfoot. And suddenly he knew a way-
the only way!
His pace quickened. All the way home, he crunched the
snow and, with every step, chanted to himself, "! know a
way! I know a way!"

In the following excerpt, one of the pivotal chapters, Breuer launches his
scheme to ensnare Nietzsche in a therapeutic contract.

When Nietzsche Wept: Chapter 12

On Monday morning, Nietzsche came to Breuers office for the final

stages of their business together. After carefully studying Breuer's item-
ized hill to be sure nothing had been omitted, Nietzsche filled out a
 The Teaching ~o\·el 389

bank draft and handed it to Breuer. Then Breuer ga\'e Nietzsche his
clinical consultation report and suggested he read it while still in the of-
fice in case he had any questions.
After scrutinizing it, ~ietzsche opened his briefcase and placed it in
his folder of medical reports.
"An excellent report, Doctor Breuer, comprehensive and c01npre-
hensible. And unlike n1any of my other reports, it contains no profes-
sional jargon, which, though offering the illusion of knowledge, is in
reality the language of ignorance. And now, back to Basel. I have taken
too much of your tirne."
Nietzsche closed and locked his briefcase. "I leave you. Doctor, feeling
more indebted to you than to any man ever before. Ordinarily, leavetak-
ing is accompanied by denials of the pennanence of the event: people say,
'Auf Wiedersehen'-until we meet again. They are quick to plan for re-
unions and then, even more quickly, forget their resolutions. Iam not one
of those. I prefer the truth-which is that we shall almost certainly not
meet again. I shall probably never return to Vienna, and I doubt you will
ever be in such want of a patient like me as to track me down in Italy."
Nietzsche tightened his grip on his briefcase and started to get up.
It was a moment for which Breuer had prepared carefully. "Profes-
sor Nietzsche, please, not just yet! There is another matter I wish to dis-
cuss with you."
Nietzsche tensed. Ko doubt, Breuer thought, he has been expecting
another plea to enter the Lauzon Clinic. And dreading it.
"No, Professor Nietzsche, it's not what .,vou think, not at all. Please
relax. It is quite another matter. I've been procrastinating in raising this
issue for reasons that will soon be apparent."
Breuer paused and took a deep breath.
"I have a proposition to make you-a rare proposition, perhaps one
never before made by a doctor to a patient. I see myself delaying. This
is hard to say. I'm not usually at a loss for words. But it's best sirnplv to
say rt.
"I propose a professional exchange. That is, I propose that for the
next month I act as physician to your body. I will concentrate only on
your physical symptoms and medications. And you, in return, will act as
physician to n1y mind, 1ny spirit."
 390 THE YALOM Rt-:ADF.R

Nietzsche, still gripping his briefcase, seemed puzzled, then wary.

"What do you mean-your mind, your spirit? How can I act as physi-
cian? Is this not hut another variation of our discussion last week-that
you doctor me and I teach you philosophy?"
"No, this request is entirely different. I do not ask you to teach me,
but to heal me."
"Of what, may I ask I"
"A difficult question. And yet r pose it to my patients all rhe time. J
asked it of you, and now it is my turn to answer it. I ask you to heal me
of despair."
"Despair?" Nietzsche relaxed his hold on his hriefcase and leaned
forward. "What kind of despair? I see no despair."
"Not on the surface. There I seem to be living a satisfying life. But,
underneath the surface, despair reigns. You ask what kind of despair?
Let us say rhat my mind is not my own, that I am invaded and assaulted
by alien and sordid thoughts. As a result, J feel self-contempt, and J
doubt my integrity. Though I care for my wife and children, I don't love
them! fn fact, I resent being imprisoned by them. I lack courage: the
courage' either to change my life or to continue living it. I have lost sight
of why I live-the point of it all. I am preoccupied with aging. Though
every day I grow closer to death, I am terrified of it. Even so, suicide
sometimes enters my mind."
On Sunday, Breuer had rehearsed this answer often. But today it
had been-in a strange way, considering the underlying duplicity of the
plan---:Jincerc. Breuer knew he was a poor liar. Though he had to con-
ceal the big lie-that his proposal was a ploy to engage Nietzsche in
treatment-he had resolved to tell the truth about everything else.
Hence, in his speech, he presented the truth about himself in slightly ex-
aggerated form. He also tried to select concerns that might in some way
interlace with some of Nietzsche's own, unspoken concerns.
For once, Nietzsche appeared truly astounded. He shook his head
slightly, obviously wanting no part of this proposal. Yet he was having
difficulty formulating a rational objection.
"No, no, Doctor Breuer, this is impossible. I cannot do this, I've no
training. Consider the risks-everything might be made worse."
"But, Professor, there is no such thing as training. Who is trained?
 The Teaching Novel 39r

To whom can I turn? To a physician? Such healing is not part of the

medical discipline. To a religious leader? Shall I take the leap into reli-
gious fairy tales? I, like you, have lost the knack for such leaping. You, a
Lebens-philosopher, spend your life contemplating the very issues that
confound my life. To whom can I turn if not to you?"
"Doubts about yourself, wife, children? What do I know about
these?"
Breuer responded at once. "And aging, death, freedom, suicide, the
search for purpose-you know as much as anyone alive! Aren't these
the precise concerns of your philosophy? Aren't your books entire trea-
tises on despair?"
"I can't cure despair, Doctor Breuer. I study it. Despair is the price
one pays for self-awareness. Look deeply into life, and you will always
find despair."
"I know that, Professor Nietzsche, and I don't expect cure, merely
relief. I want you to advise me. I want you to show me how to tolerate a
life of despair."
"But I don't know how to show such things. And I have no advice
for the singular man. I write for the race, for humankind."
"But, Professor Nietzsche, you believe in scientific method. If a race,
or a village, or a flock has an ailment, the scientist proceeds by isolating
and studying a single prototypic specimen and then generalizing to the
whole. I spent ten years dissecting a tiny structure in the inner ear of the
pigeon to discover how pigeons maintain their equilibrium! I could not
work with pigeonkind. I had to work with· individual pigeons. Only
later was I able to generalize my findings to all pigeons, and then to
birds and mammals, and humans as well. That's the way it has to be
done. You can't conduct an experiment on the whole human race."
Breuer paused, awaiting Nietzsche's rebuttal. None came. He was
rapt in thought.
Breuer continued. "The other day you described your belief that the
specter of nihilism was stalking Europe. You argued that Darwin has
made God obsolete, that just as we once created God, we have all now
killed him. And that we no longer know how to live without our reli-
gious mythologies. Now I know you didn't say this directly-correct
me if I'm mistaken-hut I believe you consider it your mission to
 392 THE YALOM READER

demonstrate that out of disbelief one can create a code of behavior for
man, a new morality, a new enlightenment, to replace one born out of
superstition and the lust for the supernatural." He paused.
Nietzsche nodded for him to continue.
"I believe, though you may disagree with my choice of terms, that
your mission is to save humankind from both nihilism and illusion?"
Another slight nod from Nietzsche.
"Well, save me! Conduct the experiment with me! I'm the perfect sub-
ject. I have killed God. I have no supernatural beliefs, and am drowning
in nihilism. I don't know why to live! I don't know how to live!"
Still no response from Nietzsche
"If you hope to develop a plan for all mankind, or even a select few,
try it on me. Practice on me. See what works and what doesn't-it
should sharpen your thinking."
"You offer yourself as an experimental lamb?" Nietzsche replied.
"That would be how I repay my debt to you?"
"I'm not concerned about risk. I believe in the healing value of talk-
ing. Simply to review my life with an informed mind like yours-that's
what I want. That cannot fail to help me."
Nietzsche shook his head in bewilderment. "Do you have a specific
procedure in mind?"
"Only this. As I proposed before, you enter the clinic under an as-
sumed name, and I observe and treat your migraine attacks. When I
make my daily visits, I shall first attend to you. I shall monitor your
physical condition and prescribe any medication that may be indicated.
For the rest of our visit, you become the physician and help me talk
about my life concerns. I ask only that you listen to me and interject any
comments you wish. That is all. Beyond that, I don't know. We'll have
to invent our procedure along the way."
"No." Nietzsche shook his head firmly. "It is impossible, Doctor
Breuer. I admit your plan is intriguing, but it is doomed from the onset.
I am a writer, not a talker. And I write for the few, not the many."
"But your books are not for the few," Breuer quickly responded. "In
fact, you express scorn for philosophers who write only for one another,
whose work is removed from life, who do not live their philosophy."
"I don't write for other philosophers. But I do write for the few who
 The Teaching Novel 393

represent the future. I am not meant to mingle, to live among. My skills

for social intercourse, my trust, my caring for others-these have long
atrophied. If, indeed, such skills were ever present. I have always been
alone. I shall always remain alone. I accept that destiny."
"But, Professor Nietzsche, you want more. I saw sadness in your eyes
when you said that others might not read your books until the year two
thousand. You want to be read. I believe there is some part of you that
still craves to be with others."
Nietzsche sat still, rigid in his chair.
"Remember that story you told me about Hegel on his deathbed?"
Breuer continued. "About the onlv, one student who understood him
being one who misunderstood him-and ended by saying that, on your
own deathbed, you couldn't claim even one student. Well, why wait for
the year two thousand? Here I am! You have your student right here,
right now. And I'm a student who will listen to you, because my life de-
pends on understanding you!"
Breuer paused for breath. He was very pleased. In his preparation
the day before, he had correctly anticipated each of Nietzsche's objec-
tions and countered each of them. The trap was elegant. He could
hardly wait to tell Sig.
He knew he should stop at this juncture-the first object being, after
all, to ensure that Nietzsche did not take the train to Basel today-but
could not resist adding one further point. "And, Professor Nietzsche, I
remember how you said the other day that nothing disturbed you more
than to be in debt to another with no possibility of equivalent repay-
ment. "
Nietzsche's response was quick and sharp. "You mean that you do
this for me?"
"No, that's just the point. Even though my plan might in some way
serve you, that is not my intention! My motivation is entirely self-
serving. I need help! Are you strong enough to help me?"
Nietzsche stood up from his chair.
Breuer held his breath.
Nietzsche took a step toward Breuer and extended his hand. "I agree
to your plan," he said.
Friedrich Nietzsche and Josef Breuer had struck a bargain.
 394 THE Y ALOM READER

Letter from FriedrichNietzsche to Peter Gast

4 December 1882
My dear Peter,
A change of plans. Again. I shall be in Vienna for an entire
month and, hence, must, with regret, postpone our Rapallo visit.
I will write when I know my plans more precisely. A great deal
has happened, most of it interesting. I am having a slight attack
(which would have been a two-week monster were it not for the
intervention of your Dr. Breuer) and am too weak now to do
more than give you a precis of what has transpired. More to
fol1ow.
Thank you for finding me the name of this Dr. Breuer-he is
a great curiosity-a thinking, scientific physician. Is that not
remarkable? He is willing to tell me what he knows about my
illness and-even more remarkable-what he does not know!
He is a man who greatly wishes to dare and I believe is
attracted to my daring to dare greatly. He has dared to offer me a
most unusual proposition, and I have accepted it. For the next
month he proposes to hospitalize me at the Lauzon Clinic, where
he will study and treat rny medical illness. (And all this to be at
his expense! This means, dear friend, that you need not concern
yourself about my subsistence this winter.)
And I? What must I offer in return? I, who none believed
would ever again be gainfully employed, I am asked to be Dr.
Breuer's personal philosopher for one month to provide personal
philosophic counsel. His life is a torment, he contemplates
suicide, he has asked me to guide him out of the thicket of
despair.
How ironic, you must think, that your friend is called upon to
rnuffle death's siren call, the same friend who is so enticed by
that rhapsody, the very friend who wrote you last saying that the
barrel of a gun seemed not an unfriendly sight!
Dear friend, I tell you this about my arrangement with Dr.
Breuer in total confidence. This is for no one else's ear, not even
 The Teaching Novel 395

Overbeck. You are the only one I entrust with this. I owe the
good doctor total confidentiality.
Our bizarre arrangement evolved to its present form in a
complex manner. First he offered to counsel me as part of my
medical treatment! What a clumsy subterfuge! He pretended
that he was interested only in my welfare, his only wish, his only
reward, to make me healthy and whole! But we know about
those priestly healers who project their weakness into others and
then minister to others only as a \.vay of increasing their own
strength. \Ve know about "Christian charity"!
Naturally, I saw through it and called it by its true name. He
choked on the truth for a while-called me blind and base. He
swore to elevated motives, mouthed fake sympathy and comical
altruisms, but finally, to his credit, he found the strength to seek
strength openly and honestly from me.
Your friend, Nietzsche, in the marketplace! Are you not
appalled by the thought? Imagine my Human, All Too Human,
or my The Gay Science, caged, tamed, housebroken! Imagine my
aphorisms alphabetized into a practicum of homilies for daily life
and work! At first, I, too, was appalled! But no longer. The
project intrigues me-a forum for my ideas, a vessel to fill when
I am ripe and overflowing, an opportunity-indeed, a
laboratory, to test ideas on an individual specimen before
positing them for the species (that was Dr. Breuer's notion).
Your Dr. Breuer, incidentally, seems a superior specimen,
with the perceptiveness and the desire to stretch upward. Yes, he
has the desire. And he has the head. But does he have the eyes-
and the heart-to see? \Ve shall see!
So today I convalesce and think quietly about application-a
new venture. Perhaps I was in error to think that my sole
mission was truth finding. For the next month, I shall see if my
wisdom will enable another to live through despair. Why does he
come to me? He says that after tasting my conversation and
nibbling a bit of Human, All Too Human, he has developed an
appetite for my philosophy. Perhaps, given the burden of my
physical disease, he thought that I must be an expert on survival.
 396 THE YALOM READER

Of course he doesn't know the half of my burden. My friend,

the Russian bitch-demon, that monkey with false breasts,
continues her course of betrayal. Elisabeth, who says Lou is
living with Ree, is campaigning to have her deported for
immorality.
Elisabeth also writes that friend Lou has moved her hate-and-
lie campaign to Basel, where she intends to imperil my pension.
Cursed be that day in Rome when I first saw her. I have often
said to you that every adversity--even encounters with pure
evil-makes me stronger. But if [ can turn this shit into gold, I
shall ... I shall ... -we shall see.
I have not the energy to make a copy of this letter, dear
friend. Please return it to me.
Yours,
F.N.

This section, elaborating upon the fluid, shifting relationship between

therapist and patient, was a great delight to write. I have lost sight of the
precise moment of inspiration, but I do know that several relevant stories
about the basic nature of the patient-therapist relationship have rattled
about in my mind for many years. In one way or another, the echoes of
these tales ring throughout the pages of When Nietzsche Wept.

The Story of the Two Healers

Herman Hesse, in his novel Magister Ludi, tells a tale about two hermits
who were powerful healers. The two worked in different ways, one
through offering sagacious advice, and the other through quiet and in-
spired listening. They never met but worked as rivals for many years until
the younger healer grew spiritually ill and fell into despair. He was un-
able to heal himself with his own therapeutic methods and ultimately, in
desperation, set out on a long journey to seek help from Dion, his rival
healer.
While on his pilgrimage he fell into a conversation with an older trav-
 The Teaching Novel 39i

eler to whom he described the purpose and goal of his journey. Imagine
his astonishment when the older man informed him that he was Dion,
the very man he sought.
Without hesitation the older healer invited his younger rival into his
cave, where they lived and worked together for many years, first as stu-
dent and teacher, then as full colleagues. Years later the older man fell ill
and on his deathbed called his young colleague to him. "I have a great
secret to tell you," he said, "a secret that I have long kept. Do you re-
member that night we met when you told me you were on your way to
see me?"
The younger man replied that he could never forget that night, the
turning point of his entire life.
The dying man took the hand of his younger colleague and revealed
the secret: that he, too, had been in despair and on the night of their
meeting was journeying to seek help from him.

Hesse's moving tale strikes deep into the very heart of the therapy re-
lationship. It is an illuminating statement about giving and receiving
help, about honesty and duplicity, and about the relationship between
the healer and patient. For years after reading it I found it so compelling
that I never wanted to tamper with it. Yet recently I have been drawn to
the idea of composing variations on its basic theme. Consider, for exam-
ple, how each man received help. The younger healer was nurtured,
nursed, taught, mentored, and parented. The older healer, on the other
hand, received help in a different manner-through serving another,
through obtaining a disciple from whom he received filial love, respect,
and salve for his isolation.
But often I have wondered whether these two wounded healers took
advantage of the best therapy available to them. Perhaps they missed the
opportunity for something deeper, something more powerfully mutative.
Perhaps the real therapy occurred at the deathbed scene when they
moved into honesty with the admission that both were burdened with
simple human frailty. Although it may have been helpful to keep a secret
for twenty years, it may also have prevented a more profound kind of
help. What would have happened, what manner of growth might have
taken place, if their revelation had occurred twenty years earlier?
 398 THEY ALOM READER

A Wounded Healer: Emergency

Thirty-five years ago I read a fragment of a play, Emergency, by Helmuth
Kaiser, published in a psychiatric journal (and later in Effective Psy-
chotherapy, a volume of Kaiser's collected papers)." Although I've never
seen a reference to it or, until recently, reread it, Kaiser's delicious plot
has stayed in my mind all these years. It begins with a woman visiting a
therapist to plead with him to help her husband, also a therapist, who
was deeply depressed and likely to kill himself.
The therapist replied that he, of course, would be glad to help and ad-
vised her to tell her husband to call for an appointment. The woman re-
sponded that therein lay the problem: her husband denied that he was
troubled and rejected all suggestions that he obtain help. The therapist
wondered how he could be of service. How could he help anyone un-
willing to see him?
"I have a plan," the woman said. She suggested that he should pre-
tend to be a patient, enter into treatment with her husband, and through
a gradual role reversal, smuggle help for her husband into their meetings.
The rest of the play fragment is poorly executed and fails to fulfill its
promise. But the central conceit-the patient becoming the therapist-
seemed a gorgeous idea, and I yearned to finish that play someday.

Turning the Tables-Another Version

When I first came to Stanford in 1962, Don Jackson, a highly gifted ther-
I
apist, offered a weekly teaching seminar in which he demonstrated inter- I

view techniques. He had an innovative, intuitive interviewing style and

never failed to use some unexpected, quirky (and effective) approach.
In one conference he interviewed a highly delusional, three-hundred-
fifty-pound Hawaiian chronic patient who believed he was the celestial
emperor of the ward and dressedaccordingly, in magenta trousers and a
long flowing purple cape. Every day, perched imperiously on his velvet-
draped chair, regarding patients and staff alike as supplicants and vas-
sals, he held court on the ward. After a few minutes of exposure to the
patient's regal demeanor, Jackson suddenly fell to his knees, bowed his
head to the ground, took his keys out of his pocket, and, arms out-
 398 THEY Al.OM READER

A Wounded Healer: Emergency

Thirty-five years ago I read a fragment of a play, Emergency, by Helmuth
Kaiser, published in a psychiatric journal (and later in Effective Psy-
chotherapy, a volume of Kaiser's collected papers).17 Although I've never
seen a reference to it or, until recently, reread it, Kaiser's delicious plot
has stayed in my mind all these years. It begins with a woman visiting a
therapist to plead with him to help her husband, also a therapist, who
was deeply depressed and likely to kill himself.
The therapist replied that he, of course, would be glad to help and ad-
vised her to tell her husband to call for an appointment. The woman re-
sponded that therein lay the problem: her husband denied that he was
troubled and rejected all suggestions that he obtain help. The therapist
wondered hew he could be of service. How could he help anyone un-
willing to see him?
"I have a plan," the woman said. She suggested that he should pre-
tend to be a patient, enter into treatment with her husband, and through
a gradual role reversal, smuggle help for her husband into their meetings.
The rest of the play fragment is poorly executed and fails to fulfill its
promise. But the central conceit-the patient becoming the therapist-
seemed a gorgeous idea, and 1 yearned to finish that play someday.

Turning the Tables-Another Version

When I first came to Stanford in 1962, Don Jackson, a highly gifted ther-
apist, offered a weekly teaching seminar in which he demonstrated inter-
view techniques. He had an innovative, intuitive interviewing style and
never failed to use some unexpected, quirky (and effective) approach.
In one conference he interviewed a highly delusional, three-hundred-
fifty-pound Hawaiian chronic patient who believed he was the celestial
emperor of the ward and dressed accordingly, in magenta trousers and a
long flowing purple cape. Every day, perched imperiously on his velvet-
draped chair, regarding patients and staff alike as supplicants and vas-
sals, he held court on the ward. After a few minutes of exposure to the
patient's regal demeanor, Jackson suddenly fell to his knees, bowed his
head to the ground, took his keys out of his pocket, and, arms out-
 400 TH E Y :\ LO )..f R EA DER

I have found this to be particularly true in my group therapy practice.

Many times I have started a therapy group session feeling troubled about
some personal issue and finished the meeting feeling considerably re-
lieved. The intimate healing ambiance of a good therapy group is almost
tangible. Scott Rutan, an eminent group therapist, once compared the
therapy group to a bridge built during a battle. Although there may be
some casualties sustained during the building (that is, group therapy
dropouts), the bridge, once in place, can transport a great many people
to a better place.

Most of these themes are played out, in one way or another, in the
Nietzsche-Breuer relationship. At first Breuer improvised a therapeutic
approach that seemed to be the only possible way to engage Nietzsche
in therapy. Yet this therapeutic relationship, much like that between the
healers in Magister Ludi, was conceived in duplicity. From this point for-
ward the focus of the novel is upon the gradual transformation of this dis-
honest relationship into an authentic one ultimately redemptive to both.
Both characters are at once patient and therapist. Sometimes giving and
receiving help takes place explicitly; at other times it must be smuggled
into the relationship. Their relationship goes through many stages-from
manipulation to care, from distrust to love, from subject and object to I
and thou.
The first major sign of the relationship's evolution is Breuer's percep-
tion that therapy is more powerful than he had expected; soon he is un-
able to resist becoming a genuine patient. What kind of patient? I have
posited a midlife crisis for Breuer manifested by a powerful obsessive
countertransferential love entanglement with his former patient Bertha
Pappenheim. Although Breuer's professional work is well known, little is
known of the personal Breuer. ls my fictionalization of Breuer's inner life
plausible? There is some historical basis for my suppositions: generations
of analysts have speculated about the mysterious and explosive ending
to Breuer's treatment of Bertha Pappenheim, and many, including Freud,
have posited that Breuer had fallen in love with his beautiful and tal-
ented patient.
In this phase of their relationship Nietzsche applies himself diligently
to the task of inventing a therapy to help Breuer examine his life in gen-
 The Teaching Novel 401

eral and free himself from his obsession with Bertha in particular. Several
chapters follow a similar structure: Nietzsche and Breuer spend an hour
in which Nietzsche invents a number of methods to lay bare the existen-
tial roots of Breuer's despair. At times he accedes to Breuer's request for
more direct help and experiments with behavioral methods. Following
each session the reader sees the private therapy notes that both Nietz-
sche and Breuer have written-a format suggested by my earlier book,
Every Day Gets a Little Closer.
Nietzsche continues to invent, employ, and discard a number of exis-
tential therapy approaches until finally, in the following excerpt, he of-
fers Breuer his mightiest thought, eternal recurrence-the great and
terrible idea that was percolating in Nietzsche's mind in 1882 and which
he was to develop in his next book, Thus Spake Zarathustra.
The scene is set in a cemetery where Nietzsche has accompanied
Breuer on a visit to his parents' grave. They have been conversing conge-
nially about their dead fathers.
For both men, the cemetery visit opens old childhood wounds; as
they stroll, they reminisce. Nietzsche recounts a dream (an actual, non-
fictional dream) he remembers from when he was six, a year after his fa-
ther had died.

When Nietzsche Wept: Chapter 20

"It's as vivid today as ifl'd dreamed it last night. A gra\'e opens and my
father, dressed in a shroud, arises, enters a church, and soon returns ca r-
rying a small child in his arms. He climbs back into his grave with the
child. The earth closes on top of them, and the gravestone slides over
the opening.
"The truly horrible thing was that shortly after I had that dream, my
younger brother was taken ill and died of convulsions."
"How ghastly!" Breuer said. "HO\v eerie to have had such a pre-
vision 1 How do you explain it?"
"I can't. For a long time, the supernatural terrified me, and I said my
prayers with great earnestness. Over the last few years, however, I've
begun to suspect that the dream was unrelated to my brother, that it
 402 TH E Y A LO M RE A DER

was me 1ny father had come for, and that the dream was expressing my
fear of death."
At ease with one another in a way they had not been before, both
men continued to reminisce. Breuer recalled a dream of some calamity
occurring in his old home: his father standing helplessly, praying and
rocking, wrapped in his blue-and-white prayer shawl. And Nietzsche
described a nightmare in which, entering his bedroom, he saw, lying in
his bed, an old man dying, a death rattle in his throat.
"We both encountered death very early," said Breuer thoughtfully,
"and we both suffered a terrible early loss. I believe, speaking for my-
self, I've never recovered. But you, what about your loss? What about
having had no father to protect you?"
"To protect me-or to oppress me? Was it a loss? I'm not so sure. Or
it may have been a loss for the child, but not for the man."
"Meaning?" Breuer asked.
"Meaning that I was never weighed down by carrying my father on
my back, never suffocated by the burden of his judgment, never taught
that the object of life was to fulfill his thwarted ambitions. His death
may well have been a blessing, a liberation. His whims never became
my law. I was left alone to discover 1ny own path, one not trodden be-
fore. Think about it! Could I, the Antichrist, have exorcised false beliefs
and sought new truths with a parson-father wincing with pain at my
every achievement, a father who would have regarded 1ny campaigns
against illusion as a personal attack against him?"
"But," Breuer rejoined, "if you had had his protection when you
needed it, would you have had to be the Antichrist?"
Nietzsche did not respond, and Breuer pressed no further. He was
learning to accommodate to Nietzsche's rhythm: any truth-seeking in-
quiries were permissible, even welcomed; but added force would be re-
sisted. Breuer took out his watch, the one given him by his father. It was
time to turn back to the fiacre, where Fischmann awaited. With the
wind at their backs, the walking was easier.
"You may be more honest than I," speculated Breuer. "Perhaps my
father's judgments weighed me down more than I realized. But most of
the time I miss him a great deal."
"What do you miss?"
Breuer thought about his father and sampled the memories passing
 The Teaching Novel 403

before his eyes. The old man, yarmulke on head, chanting a blessing be-
fore he tasted his supper of boiled potatoes and herring. His smile as he
sat in the synagogue and watched his son wrapping his fingers in the
tassels of his prayer shawl. His refusal to let his son take back a move in
chess: "Josef, I cannot permit myself to teach you bad habits." His deep
baritone voice, which filled the house as he sang passages for the young
students he was preparing for their bar rnitzvah,
"Most of all, I think I miss his attention. He was always. mv, chief au-
dience, even at the very end of his life, when he suffered considerable
confusion and memory loss. I made sure to tell him of my successes, 1ny
diagnostic triumphs, my research discoveries, even my charitable dona-
tions. And even after he died, he was still mv, audience. For vears , I
imagined him peering over my shoulder, observing and approving my
achievements. The more his image fades, the more I struggle with the
feeling that my activities and successes are all evanescent, that they have
no real meaning."
"Are you saying, Josef, that if your successes could be recorded in the
ephemeral mind of your father, then they would possess meaning?"
"I know it's irrational. It's much like the question of the sound of a
tree falling in an empty forest. Does unobserved activity have mean-
.
1ng.
~ ..
"The difference is, of course, that the tree has no ears, whereas it is
you, yourself, who bestows meaning."
"Friedrich, you're more self-sufficient than 1-inore than anyone
I've known! I remember marveling, in our very first meeting, at your
ability to thrive with no recognition whatsoever from your colleagues."
"Long ago, Josef, I learned that it is easier to cope with a bad reputa-
tion than with a bad conscience. Besides, I'm not greedy; I don't write
for the crowd. And I know how to be patient. Perhaps my students are
not yet alive. Only the day after tomorrow belongs to me. Some philoso-
phers are born posthumously!"
"But, Friedrich, believing you will be born posthumously-is that so
different from my longing for my father's attention? You can wait, even
until the day after tomorrow, but you, too, yearn for an audience."
A long pause. Nietzsche nodded finally and then said softly, "Per-
haps. Perhaps I have within me pockets of vanity yet to be purged."
Breuer merely nodded. It did not escape his notice that this was the
 404 THE YA LOM REA DER

first time one of his observations had been acknowledged by Nietzsche.

Was this to be a turning point in their relationship?
No, not yet! After a moment, Nietzsche added, "Still, there is a dif-
ference between coveting a parent's approval and striving to elevate
those who will follow in the future."
Breuer did not respond, though it was obvious to him that Nietz-
sche's motives were not purely self-transcendent; he had his own back-
alley ways of courting remembrance. Today it seemed to Breuer as if all
motives, his and Nietzsche's, sprang from a single source-the drive to
escape death's oblivion. Was he growing too morbid? Maybe it was the
effect of the cemetery. Maybe even one visit a month was too frequent.
But not even morbidity could spoil the mood of this walk. He
thought of Nietzsche's definition of friendship: two who join together
in a search for some higher truth. Was that not precisely what he and
Nietzsche were doing that day? Y cs, they were friends.
That was a consoling thought, even though Breuer knew that their
deepening relationship and their engrossing discussion brought him no
closer to relief from his pain. For the sake of friendship, he tried to ig-
nore his disturbing idea.
Yet, as a friend, Nietzsche must have read his mind. "I like this walk
we take together, Josef, but we must not forget the raison d'etre of our
meetings-your psychological state."
Breuer slipped and grabbed a sapling for support as they descended a
hill. "Careful, Friedrich, this shale is slick." Nietzsche gave Breuer his
hand, and they continued their descent.
"I've been thinking," Nietzsche continued, "that, though our discus-
sions appear to be diffuse, we, nonetheless, steadily grow closer to a so-
I ution. It's true that our direct attacks on your Bertha obsession have
been futile. Yet in the last couple of days we have found out why: be-
cause the obsession involves not Bertha, or not only her, but a series of
meanings folded into Bertha. We agree on this?"
Breuer nodded, wanting to suggest politely that help was not going
to come by way of such intellectual formulations. But Nietzsche hurried
on. "It's dear now that our primary error has been in considering
Bertha the target. We have not chosen the right enemy."
"And that is-?''
 The Teaching Novel 405

.. You know, Josef! Why make me say it? The right enemy is the un-
derlying meaning of your obsession. Think of our talk today-again
and again, we've returned to your fears of the void, of oblivion, of death.
It's there in your nightmare, in the ground liquefying, in your plunge
downward to the marble slab. It's there in vour, cemetery' dread, in your
,
concerns about meaninglessness, in your wish to be observed and re-
membered. The paradox, your paradox, is that you dedicate yourself to
the search for truth but cannot bear the sight of what you discover."
"But you, too, Friedrich, must be frightened by death and by god-
lessness. From the very beginning, I have asked, 'How do you bear it?
How have you come to terms with such horrors?'"
"It may be time to tell you," Nietzsche replied, his manner becoming
portentous. "Before, I did not think that you were ready to hear me."
Breuer, curious about Nietzsche's message, chose, for once, not to
object to his prophet voice.
"I do not teach, Josef, that one should 'bear' death, or 'come to terms'
with it. That way lies life-betrayal! Here is n1y lesson to you: Die at the
right time!"
"Die at the right time!" The phrase jolted Breuer. The pleasant af-
ternoon stroll had turned deadly serious. "Die at the right time? What
do you mean? Please, Friedrich, I can't stand it, as I tell you again and
again, when you say something important in such an enigmatic way.
Why do you do that?"
"You pose two questions. Which shall I answer?"
"Today, tell me about dying at the right time."
"Live when you live! Death loses its terror if one dies when one has
consummated one's life! If one does not live in the right time, then one
can never die at the right time."
"What does that mean?" Breuer asked again, feeling ever more frus-
trated.
"Ask yourself, Josef: Have you consummated your life?"
"You answer questions with questions, Friedrich!"
"You ask questions to which you know the answer," Nietzsche
countered.
"If I knew the answer, why would I ask?"
"To avoid knowing your own answer ! "
 406 TH E Y A LO M RE A DER

Breuer paused. He knew Nietzsche was right. He stopped resisting

and turned his attention within. "Have I consummated my life? I have
achieved a great deal, more than anyone could have expected of me.
Material success, scientific achievement, family, children-but we've
gone over all that before."
"Still, Josef, you avoid n1y question. Have you lived your life? Or
been lived by it? Chosen it? Or did it choose you? Loved it? Or regret-
ted it? That is what I mean when I ask whether you have consummated
your life. Have you used it up? Remember that dream in which your fa-
ther stood by helplessly praying while something calamitous was hap-
pening to his family? Are you not like him? Do you not stand by
hel plessly, grieving for the life you never lived?"
Breuer felt the pressure mounting. Nietzsche's questions bore down
on him; he had no defense against them. He could hardly breathe. His
chest seemed about to burst. He stopped walking for a moment and
took three deep breaths before answering.
"These questions-you know the answer! No, I've not chosen! No,
I've not lived the life I've wanted! I've lived the life assigned me. I-the
real I-have been encased in my life."
"And that, Josef, is, I am convinced, the primary source of your
Angst. That precordial pressure-it's because your chest is bursting with
unlived life. And your heart ticks away the time. And time's covetous-
ness is forever. Time devours and devours-and gives back nothing.
How terrible to hear you say that you lived the life assigned to you! And
how terrible to face death without ever having claimed freedom, even
in all its danger!"
Nietzsche was firmly in his pulpit, his prophet's voice ringing. A
wave of disappointment swept over Breuer; he knew now that there
was no help for him.
"Fr icdrich," he said, "these are grand-sounding phrases. I admire
them. They stir my soul. But they are far, far a,vay from my life. What
does claiming freedom mean to my everyday situation? How can I be
free? It's not the same as you, a young single man giving up a suffocat-
ing university career. It's too late for me! I have a family, employees, pa-
tients, students. It's for too late! We can talk forever, but I cannot
change my life-it is woven too tight with the thread of other lives."
 The Teaching Novel 407

There was a long silence, which Breuer broke, his voice weary. "But
I cannot sleep, and now I cannot stand the pain of this pressure in my
chest." The icy wind pierced his greatcoat; he shivered and wrapped his
scarf more tightly around his neck.
Nietzsche, in a rare gesture, took his arm, "My friend," he whis-
pered, "I cannot tell you how to live differently because, if I did, you
would still be living another's design. But, Josef, there is something I can
do. I can give you a gift, the gift of tny mightiest thought, my thought of
thoughts. Perhaps it may already be somewhat familiar to you, since I
sketched it briefly in Human, All Too Human. This thought will be the
guiding force of 1ny next book, perhaps of all 1ny future books."
His voice had lowered, assuming a solemn, stately tone, as if to sig-
nify the culmination of everything that had gone before. The two men
walked arm in arm, Breuer looked straight ahead as he awaited Nietz-
sche's words.
"Josef, try to clear your mind. Imagine this thought experiment!
What if some demon were to say to you that this life-as you now live it
and have lived it in the past-you will have to live once more, and innu-
merable times more: and there will be nothing new in it, but every pain
and every joy and everything unutterably small or great in your life will
return to you, all in the same succession and sequence-even this wind
and those trees and that slippery shale, even the graveyard and the
dread, even this gentle n10111entand you and I, arm in arm, murmuring
these words?"
As Breuer remained silent, Nietzsche continued, "I magine the eter-
nal hourglass of existence turned upside down again and again and
again. And each time, also turned upside down are you and I, mere
specks that we are."
Breuer made an effort to understand him. "How is this-this-this
ranrasv-c- "
['

"I t ' s more t h an a crantasy, " N.

ictzsc h e msistec
. . I . " more rea lly t lum a
thought experiment. Listen only to n1y words! Block out everything
else! Think about infinity. Look behind you-imagine looking infi-
nitely far into the past. Time stretches backward for all eternity. And. if
time infinitely stretches backward, must not everything that can happen
have already happened? Must not all that passes now have passed this
 408 THE YA LOM REA DER

\vay before? Whatever walks here, mustn't it have walked this path be-
fore? And if everything has passed before in time's infinity, then what
<lo you think, Josef, of this moment, of our whispering together under
this arch of trees? Must not this, too, have come before? And time that
stretches back infinitely, must it not also stretch ahead infinitely? Must
not we, in this moment, in every moment, recur eternally?"
Nietzsche fell silent, to give Breuer time to absorb his message. It
was midday, but the sky had darkened. A light snow began to fall. The
fiacre and Fischmann loomed into sight.
On the ride back to the clinic, the two men resumed their discussion.
Nietzsche claimed that, though he had termed it a thought experiment,
his assumption of eternal recurrence could be scientifically proven.
Breuer was skeptical about Nietzsche's proof, which was based on two
metaphysical principles: that time is infinite, and force (the basic stuff of
the universe) is finite. Given a finite number of potential states of the
world and an infinite amount of time that has passed, it follows, Niet-
zsche claimed, that all possible states must have already occurred; and
that the present state must be a repetition; and, likewise, the one that
gave birth to it and the one that arises out of it and so on, backward into
the past and forward into the future.
Breuers perplexity grew. "You mean that through sheer random oc-
currences this precise moment would have occurred previously?"
"Think of time that has always been, time stretching back forever. In
such infinite time, must not recombinations of all events constituting
the world have repeated themselves an infinite number of times?"
"Like a great dice game?',
"Precisely! The great dice game of existence!"
Breuer continued to question Nietzsche's cosmological proof of eter-
nal recurrence. Though Nietzsche responded to each question, he even-
tually grew impatient and fina1ly threw up his hands.
"Time and time again, Josef, you have asked for concrete help. How
many times have you asked me to be relevant, to offer something that
can change you? Nou/ I give you what you request, and you ignore it by
picking away at details. Listen to me, my friend, listen to my words-
this is rhe most important thing I will ever say to you: let this thought
take possession of you, and I promise you it will change you forever!"
 The Teaching Nevel 409

Breuer was unmoved. "But how can I believe without proof? I can-
not conjure up belief. Have I given up one religion simply ro embrace
another?"
"The proof is extremely complex. It is still unfinished and will re-
quire years of work. And now, as a result of our discussion, I'm not sure
I should even bother to devote rhe time to working our the cosmological
proof-perhaps others, too, will use it as a disrracrion. Perhaps they,
like you, will pick away at the intricacies uf the proof and ignore the im-
portant point-the psychological consequence~· of eternal recurrence."
Breuer said nothing. He looked our the window of the fiacre and
shook his head slighrlv.
"Let me put it another wav," Nietzsche continued. "Will you not
grant me that eternal recurrence is probable? No, wait, l don't need
even that! Let us say simply that it is possible, or mnely possible. Thnt is
enough. Certainly it is more possible and more provable than the fairy
tale of eternal damnation! \Vhat do you have to lose by considering it a
possibility? Can you not think of it. then, as 'Nietzsche's wager'?"
Breuer nodded
"I urge you, rhen, ro consider rhe implications of eternal recurrence
for your life-not abstractly, but now, today, in the most concrete
sense!"
"You suggest," said Breuer. "that every action I make, every pain I
experience, will be experienced through all infinity?"
"Yes, eternal recurrence means that every time you choose an action
you must be willing to choose it for all eternity. And it is the s:11111:: for
every action not made, enry stillborn thought, every choice avoided
And all unlived life will remain bulging inside you, unlived through all
eternity. And the unheeded voice of your conscience will cry out to you
forever."
Breuer felt dizzy; it was hard to listen. He tried ro concentrate on
Nietzsche's mammoth mustache pounding up and <lown at each word.
Since his mouth and lips were entirely obscured, there was no fore-
warning of the words to come. Occasionally his glance would catch
Nietzsche's eyes, but they were too sharp, and he shifted his attention
down to the fleshy bur powerful nose. or up to the heavy on:rhanging
eyebrows which resembled ocular mustaches
 410 THE Y ALOM READER

Breuer finally managed a question: "So, as I understand it, eternal

recurrence promises a form of immortality?"
HNo!" Nietzsche was vehement. "I teach that life should never be
modified, or squelched, because of the promise of some other kind of
life in the future. What is immortal is this life, this moment. There is no
afterlife, no goal toward which this life points, no apocalyptic tribunal
or judgment. This moment exists forever, and you, alone, are your only
audience."
Breuer shivered. As the chilling implications of Nietzsche's proposal
grew more clear, he stopped resisting and, instead, entered a state of un-
canny concentration.
"So, Josef, once again I say, let this thought take possession of you.
Now I have a question for you: Do you hate the idea? Or do you love it?"
"I hate it!" Breuer almost shouted. "To live forever with the sense that
I have not lived, have not tasted freedom-the idea fills me with horror."
"Then," Nietzsche exhorted, "live in such a way that you love the idea!"
"All that I love now, Friedrich, is the thought that I have fulfilled my
duty toward others."
"Duty? Can duty take precedence over your love for yourself and for
your own quest for unconditional freedom? If you have not attained
yourself, then 'duty' is merely a euphemism for using others for your
own en largement. "
Breuer summoned the energy for one further rebuttal. "There is
such a thing as a duty to others, and I have been faithful to that duty.
There, at least, I have the courage of my convictions."
"Better, Josef, far better, to have the courage to change your con-
victions. Duty and faithfulness are shams, curtains to hide behind. Self-
liberation means a sacred 110, even to duty."
F rightcned, Breuer stared at Nietzsche.
"You want to become yourself," Nietzsche continued. "How often
ha Ye I heard you say that? How often have you lamented that you have
never known your freedom? Your goodness, your duty, your faithful-
ness-these are the bars of your prison. You will perish from such small
virtues. You must learn to know your wickedness. You cannot be par-
tially free: your instincts, too, thirst for freedom; your wild dogs in the
cellar-they bark for freedom, Listen harder, can't you hear them?"
"Hut I cannot be free," Breuer implored. "I have made sacred mar-
 The Teaching Novel .p I

riage vows. I have a duty to rny children, n1y students, my patients."

"To build children you must first be built yourself. Otherwise, you'll
seek children out of animal needs, or loneliness, or to patch the holes in
yourself Your task as a parent is to produce not another self, another
Josef, but something higher. It's to produce a creator.
"And your wife?" Nietzsche went on inexorably. "Is she not as im-
prisoned in this marriage as you? Marr iage should be no prison, but a
garden in which something higher is cultivated. Perhaps the only way to
. . . . ,,
save your marnage ts to grve it up.
"I have made sacred \'OWS of wedlock."
"Marriage is something large. It is a large thing to always be two, to
remain in love. Yes, wedlock is sacred. And yet ... " Nietzsche's voice
trailed off.
"And yet?" Breuer asked.
"Wedlock is sacred. Yet"-Nietzsche's voice was harsh-"it is better
to break wedlock than to be broken by it!"
Breuer closed his eyes and sank into deep thought. Neither man
spoke for the remainder of their journey.

Friedrich Nietzsche's Notes on Dr. Breuer, 16 December 1882

A stroll that began in sunlight and ended darkly. Perhaps toe journeyed
too far into the graveyard. Should we have turned back earlier? Have I given
him too potoerful a thought? Eternal recurrence is a mighty hammer. ft will
break those who are not yet ready for it.
Nol A psychologist, an unriddler of souls, needs hardness more than any-
one. Else he will bloat with pity. And his student drown in shallow water.
Yet at the end of our wal~ Josef seemed sorely pressed, barely able to con-
verse. S01ne are not born hard. A true psychologist, like an artist, must loue
his palette. Perhaps more kindness, more patience was needed. Do I strip be-
fore teaching how to weave new clothing? Have I taught him "freedom
from" without teaching "freedom for"?
No, a guide must be a railing by the torrent, but he must not b« a crutch.
The guide must lay bare the trails that lie before the student. But ht' must not
choose the path.
"Become my teacher," he asks. "Help me overcome despair." Shall I con-
ceal my wisdom? And the student's responsibility? He must harden himself
 412 THEY ALOM READER

to the cold, hisfingers must grip the railing, he must lose himself many times
on wrongpaths beforefinding the right one.
In the mountains alone, I travel the shortest way-from peak to peak,
But students lose their way when I walk too far ahead. I must learn to
shorten my stride. Today, we may have traveled too fast. I unraveled a
dream, separated one Bertha from another, reburied the dead, and taught dy-
ing at the right time. And all of this was but the-overture to the mighty theme
of recurrence.
Have I pushed him too deep into misery? Often he seemed too upset to
hear me. Yet what did I challenge? What destroy? Only empty values and
tottering beliefs! That which is tottering, one should also push!
Today I understood that the best teacher is one who learnsfrom his stu-
dent. Perhaps he is right about my father. How different my life would be
had I not lost him! Can it be true that I hammer so hard because I hate him
for dying? And hammer so loud because I still crave an audience?
I worry about his silence at the end. His eyes were open, but he seemed
not to see. He scarcely breathed.
Yet I know the dew falls heaviest when the night is most silent.
 CHAPTER Io

The Psychological Novel

P. D. James, the fine British writer, begins her novels with a vision of
place from which her plot and characters emerge. Other novelists begin
with plot or with characters. I know a writer who was unable to finish
one novel but managed to lift the characters, still talking to one another,
and plunk them down into an entirely different book.
My novel Lying on the Couch like When Nietzsche Wept, is neither
place-driven, nor plot-driven, nor character-driven. Instead, it is idea-
driven. I intended When Nietzsche Wept to be an inquiry into the exis-
tential approach to psychotherapy. In Lying on the Couch I meant to
explore some fundamental ideas about the therapeutic relationship.
Every investigation of the nature of the therapeutic relationship
sooner or later leads to Carl Rogers's dictum: it is the relationship that
heals. That notion, perhaps psychotherapy's most fundamental axiom-
and "axiom" is not too strong a term-posits that the mutative force in
the process of personal change is the nature, the texture, of the relation-
ship between patient and therapist. Other considerations (for example,
the ideological school to which the therapist belongs, the actual content
of the therapy discussion, or the techniques employed, such as free as-
sociation, or reconstruction of childhood or psychodrama) are quite
secondary.
 ..p4 THEY ALOM READER

Not only did Carl Rogers demonstrate the centrality of the therapeutic
relationship, but he also identified the specific characteristics of the suc-
cessful relationship-namely, that the effective therapist relates to the pa-
tient in a genuine, unconditionally supportive, and accurately empathic
manner.
These findings, central to psychotherapy practice for decades, appear
beyond dispute--not only because they are supported by so much em-
pirical evidence, but because they seem so right, so self-evident. Yet let
us pluck the variables off the research rating scales and consider their ap-
pearance in vivo. Picture the psychotherapy hour. Heads bowed to-
gether, a therapist and patient converse about important matters. The
patient reveals intimate material. The therapist responds with empathy,
support, clarifications, interpretations. Is this a genuine relationship?
In the past it was easier to identify genuineness, or at least the ab-
sence of genuineness. The archaic blank screen analyst did not relate
genuinely. But most therapists today, fortunately, eschew such a role and
instead interact directly with their patients, revealing more of themselves.
Hence the determination of genuineness in contemporary practice be-
comes more complex and subtle. How do genuine, or "authentic." thera-
pists behave? Do they shuck the trappings of their professional role and
become "real" in the therapy situation? As real in the hour as out of the
hour? What about payment? Is therapy merely purchased friendship?
Should self-revealing and the attachment go both ways? Do therapists
feel deeply about their clients? Love their clients? Profit themselves, psy-
chologically, from the therapy they offer to others?

TRANSPARENCY
In an irreverent and playful manner Lying on the Couch explores these
vexing problems. It attempts to illuminate core aspects of the patient-
therapist relationship through a sustained focus on therapist trans-
parency. There is an ongoing debate in the field about therapists'
self-revelation. Should therapists share their feelings openly in therapy?
Feelings about themselves? Their own lives? Feelings toward their pa-
tients? The theme of transparency is introduced in one of the opening
 The Psychological Novel .p5

paragraphs of Lying on the Couch. Here Ernest Lash, the protagonist,

pays homage to his psychotherapy ancestors.

"Thank you, thank you," Ernest would chant. He thanked

them all-all the healers who had ministered to despair. First,
the ur-ancestors, their empyreal outlines barely visible: Jesus,
Buddha, Socrates. Below them, somewhat more distinct-
the great progenitors: Nietzsche, Kierkegaard, Freud, Jung.
Nearer yet, the grandparent therapists: Adler, Horney, Sulli-
van, Fromm, and the sweet smiling face of Sandor Ferenczi.

Note the last phrase. Why the extra tip of the hat to Sandor Ferenczi?
Precisely because of Ernest's fascination with therapist transparency. San-
dor Ferenczi (1873-1933), a Hungarian psychoanalyst, was a member of
Freud's inner circle and probably Freud's closest professional and per-
sonal confidant. Basically pessimistic about therapy, Freud was not heav-
ily committed to experimentation with therapy technique. By nature he
was more drawn to speculative questions about the application of psy-
choanalysis to understanding the origins of culture. Of all the analysts in
the inner circle, it was Sandor Ferenczi who was most relentless and
bold in the search for improved therapist technique.
Never was he more bold than in a radical 1932 transparency experi-
ment where he pushed therapist self-disclosure to the limit. This experi-
ment, which he referred to as "mutual analysis," consisted of his
analyzing a patient one hour and the patient analyzing him the next.'
Ferenczi's experiment failed, shipwrecked on some treacherous reefs of
early analysis. There were, for example, complications around the issue
of free association and confidentiality: Ferenczi found that he could not
free-associate to one patient without having to share thoughts about his
other analysands. And Ferenczi fretted .about billing: who should pay
whom? Ultimately he grew discouraged and abandoned the experiment.
His disappointed patient believed Ferenczi was unwilling to continue
because he feared having to acknowledge that he was in love with her.
Ferenczi held a contrary opinion: that he was unwilling to express the
fact that he hated her.
For a while I considered using Ferenczi as a character in the novel
 .p6 THE YALOM READER

and alternating the action between the present and 1932. In preparation,
I read all the fiction I could locate that was set in two time periods, but I
eventually abandoned the idea because ( never found a satisfactory nov-
elistic device to bind the two eras together. (Such standard devices as an
old manuscript discovered and read in another era or characters from a
different era inhabiting the same house seemed too frail to support a
novel on psychotherapy.) Finally I built Ferenczi's idea, not his person,
into the plot by having my protagonist reenact Ferenczi's experiment in
contemporary times.
Lying on the Couch opens with a therapy session in which Ernest Lash
faces a dilemma about his degree of transparency. For five long years he
has treated Justin, who originally came in requesting help in leaving a
horrendous marriage. For months Ernest dispassionately investigated the
dynamics of the marriage: Justin's passive aggressiveness, his role in the
marital discord, his instigation of his wife's irrational behavior, his origi-
nal choice of a mate, and his unwillingness to leave the marriage. After
an exhaustive exploration Ernest eventually came to agree with Justin-
this was, indeed, a marriage from hell. Thereafter, for a period of two
years, Ernest did everything a person could do to persuade another to
take action: he advised Justin, encouraged, exhorted, analyzed resis-
tance. But nothing worked, and the discouraged Ernest gave up. "This
man is immobile," he declared, 11he is passive, hopelessly stuck, a dead-
I
weight, rooted to the ground; he will never leave this marriage." And so
Ernest lowered his goals and resigned himself to more supportive "con-
taining" therapy.
'
l
l
Later in the opening chapter, Justin saunters in for a therapy hour and
almost en passant tells Ernest, "Oh, yes, I left my wife last night." Natu-
rally Ernest has mixed feelings: on the one hand, he is pleased his patient
has taken the long-delayed step of liberation; on the other hand, he is
t
vexed to be informed of it so casually. And even more vexed a few min- ~·

utes later when Justin tells him that the day before the young woman
with whom he has been having an affair said to him, "It's time, Justin, to
j
leave your wife." And so he did, that very evening.
Despite himself, Ernest thinks, "Here l, one of the premier therapists
of San Francisco, have been breaking my ass for five years to persuade
him to leave his marriage and this little teenage twit merely says, 'It's
time,' and Justin jumps to it." And Ernest is jangled even more when
 The Psychological Novel ..p 7

Justin goes on to muse about how much more convenient life would be if
he could afford to buy a condo-if only he still had the eighty thousand
dollars he has spent for therapy over the last few years.
Justin senses Ernest's mood quite accurately and confronts him about
not being pleased with the positive steps his patient has taken. In an at-
tempt to protect himself and to preserve the therapeutic alliance, Ernest
self-righteously denies Justin's observation. Later that evening, as he re-
views the therapy hour, he realizes that he had just disconfirmed his
patient's accurate perception of an event. lf a goal of therapy is to im-
prove a patient's reality-testing, Ernest muses, then it is difficult to escape
the conclusion that he had just been engaged, not in therapy, but in
countertherapy.
After further brooding upon his duplicitous behavior, Ernest resolves
to be more honest in his relationships with his patients. He decides on a
course of full, even radical, self-disclosure: he will run Ferenczi's 1932
transparency experiment with the next new patient who enters his office.
But he will set more sensible, less heroic, conditions: rather than alter-
nate hours of free association with the patient, he will be consistently
honest in every transaction during each therapy hour. Ernest's trial-and-
error experiment proceeds throughout the novel and teaches him a great
deal about the consequences-both positive and negative-of greater
therapist transparency.
Despite the burlesque sequences in many sections of Lying on the
Couch, my attitude toward transparency is entirely serious and the rules
of therapist self-disclosure that Ernest stumbles upon are meant to be use-
ful guidelines to the practicing clinician. I have always felt that openness
in therapy enhances the efficacy of treatment. Too often therapists delib-
erately embrace an opaque posture in their work-either to conform to
Freud's blank-screen mandate (a rule that Freud did not follow in his own
analytic work) or to protect themselves from too much self-exposure, in-
volvement, or fatigue. Other therapists remain opaque because they take
seriously the words of Dostoevsky's Grand Inquisitor, who insisted that
human beings really want magic, mystery, and authority. Accordingly,
these therapists attempt to heal through authority and employ age-old au-
thoritarian techniques: placebos; Latin prescriptions; the robes, incanta-
tions, and rituals of medical cure.
I have always believed that psychotherapy is an intrinsically robust
 418 THE Y ALOM READER

process that need not rest upon the accoutrements of authority. In fact,
insofar as therapy is conceptualized as a process of personal growth and
enlightenment, I consider the appeal to authority counterproductive.
Often therapists are alarmed at the idea of transparency and reject it
out of hand because they assume it demands that they reveal a great deal
about their personal life--both past and present. As Ernest discovers,
however, there are other levels of self-disclosure that are far more crucial
to therapeutic success. In the novel I focus particularly upon two: (1)
transparency concerning the therapy procedure itself and (2) trans-
parency concerning the therapist's here-and-now experience.
The process of being transparent about the therapy procedure begins
even before the first hour with the preparation for therapy. Some of my
early research demonstrated that a systematic preparation for group ther-
apy (which includes a lucid discussion of the rationale and mechanics of
therapy) significantly influences the efficacy of group therapy. Others
have demonstrated that preparation has the same beneficial effect in the
individual therapy setting.
Therapists who are transparent about their here-and-now experience
reveal their immediate feelings to the patient in the moment. They may
say that they feel distant or close to the patient; or moved, shut out, criti-
cized at every turn; or elevated, idealized, or avoided by the patient.
There are examples of this on almost every page of Lying on the Couch. I
take therapist transparency very seriously and have, throughout my ca-
reer, experimented with a series of techniques designed to encourage
and enhance transparency. I shall describe a few of these.
One transparency technique I've used is "multiple therapy." In an ar-
ticle discussing this teaching format, I described how a colleague and I
and several trainees met with a single patient and worked together as
a group, focusing at times upon the patient and at other times upon the
group process (that is, upon the nature of the relationship between the
group members). Our openness demonstrated to both students and pa-
tients that obfuscation and mystification were unnecessary.2
Another transparency exercise I've employed is the open group re-
hash. In most group therapy training programs students observe therapy
groups through two-way mirrors or TV and discuss the meeting after its
completion. Group therapy members permit the observation but gener-
ally resent it, since it raises their discomfort and self-consciousness.
 The Psychological NoH·l 419

Yet, by being willing to increase their transparency, therapists can

transform observation from a limited teaching device into an integral part
of therapy. I have long made a practice of inviting the group members to
observe the student rehash of the group meeting-sometimes students
and group members simply switch rooms for the postsession. In my ex-
perience such a format invariably energizes both the therapy and the
teaching.'
In my model of inpatient therapy groups I use a similar approach: to-
ward the end of the meeting we adopt a "fishbowl" format-the student
observers and the group leaders form an inner circle and review the
group session in the presence of the group members for ten minutes.4
Then, in the final ten minutes, the group members discuss their feelings
about this review. Very frequently the rehash raises so many issues and
so much affect that the members consider the final ten minutes of the
session to be the most profitable part of the meeting.
Another benefit of such teaching formats is that patients gain respect
for the therapeutic enterprise if they observe the therapist and student
therapists personally engaging in the same honest discourse they encour-
age in their therapy.
Earlier in this volume, in a paper on alcoholics in group therapy, I de-
scribed my practice of mailing summaries of each outpatient group
meeting to the members before the next session. Among other purposes,
the summaries serve to provide a vehicle for therapist transparency: I in-
clude comments about my personal feelings and observations of the
meeting. I review the interventions I made-those that I considered im-
portant, those I wished J had made in the session but did not, and those I
regretted making.
Generally in therapy groups there is a particularly clear mandate for
therapists to be more interactive and transparent. This is necessary for
two reasons: first, because group leaders are lightning rods for so many
powerful feelings that they must work through their relationships with
many of the group members; second, because the leaders' behavior-
through the mechanism of modeling-is instrumental in shaping the
norms of the group.
Although much of my writing has centered on group therapy, I be-
lieve that transparency is no Jess important in the individual therapy set-
ting, where therapists must be willing to be open about the mechanisms
 420 THE YALOM READER

of therapy and about their own here-and-now feelings. Nothing the ther-
apist does takes precedence, in my vie~ over building a trusting rela-
tionship with the patient. I have long believed that other activities in
therapy-for example, exploration of the past and the construction of a
unified life narrative-are valuable only insofar as they keep therapist
and patient bound together in some mutually valued, interesting en-
deavor while the real healing force, the therapeutic relationship, germi-
nates and takes root.
My own self-disclosure, especially about here-and-now feelings, al-
most invariably has deepened the therapeutic relationship; to the best of
my knowledge the opposite has never occurred-therapy has never been
impaired by my revealing too much. Very frequently in my practice I see
patients who have had some prior unsatisfactory therapy. Over and over
again I hear them voice the same complaint: their therapist was too im-
personal, too uninvolved, too wooden. I have almost never heard a pa-
tient criticize a therapist for being too open, honest, or interactive.
The salubrious effect of therapist transparency is the very core of
Lying on the Couch, as Ernest doggedly pursues the experiment that, un-
known to him, is played out in the most unfavorable possible circum-
stance-in the therapy of a patient committed to duplicity.

THERAPEUTIC BOUNDARIES
Another major therapist-patient theme I explore in Lying on the Couch is
the question of appropriate boundaries. Can a relationship be genuine
and yet at the same time be sharply and formally limited? Do the strict
time limits, the formality, and the exchange of money corrode the gen-
uineness of the relationship? ls the therapist a friend? Is there love be-
tween therapist and patient? Should caring therapists ever touch or hold
their patients? What are the appropriate sexual, social, business, finan-
cial boundaries of a therapeutic relationship?
These contemporary concerns are not only crucial and complex: they
are also highly inflammatory. With so many lawsuits, so many cases of
reported abuse by therapists (and priests, teachers, physicians, police of-
ficers, employers, supervisors, gurus-by anyone involved in a power
 The Psychological No\'el 421

imbalance), it seemed distinctly risky to discuss boundaries in an irrever-

ently comic novel. I attempted to maintain a balanced perspective-on
the one hand, to address the alarming incidence of abuse suffered by pa-
tients, and on the other hand, to confront the equally alarming legalistic
backlash that threatens the very fabric of the therapy relationship.
What is one to think, for example, of articles in professional journals
that seriously propose that all therapy hours be videotaped with a conti n-
uously running security patrol camera to protect the patient from sexual
abuse by the therapist and the therapist from false charges by the patient?
How is one to respond to the sanctimonious, patronizing official guide-
lines prescribing appropriate behavior that so many professional organi-
zations mail to therapists? These publications warn that attorneys assume
that smoke means fire and, accordingly, instruct practitioners to err on
the far side of formality: one must wear neckties; avoid sweaters, first
names, or social chitchat; not offer coffee or tea; end sessions very punc-
tually; and (for male therapists) not schedule a female patient for the last
hour of the day. (Soon one becomes wary of scheduling anyone for the
last hour of the day.)
All these factors have resulted in a new defensive psychotherapy. The
legal profession has so invaded the intimacy of the therapy hour that ad-
ministrators don't stop to consider the extent to which a security TV cam-
era would destroy the heart of the therapy enterprise. Practitioners
conduct therapy hours with the perceived presence of a tort attorney oc-
cupying a third chair in the office. Students are taught to write progress
notes in charts as though a hostile attorney were reading them. Thera-
pists who have been wrongfully sued-an ever-growing cohort-become
less open, less trusting.
I know a competent, dedicated psychiatrist-let us call her Dr.
Robertson-who treated a depressed man successfully with antidepres-
sants for a year. The patient refused to engage in psychotherapy or to
come for appointments more than once monthly. The patient's depres-
sion broke through after a year and Dr. Robertson unsuccessfully tried
other medications. She repeatedly urged the patient to come in more fre-
quently and to enter psychotherapy, but the patient refused to see her or
anyone else in therapy. More than once, Dr. Robertson sought consulta-
tion from colleagues. Over a period of months the patient collected a
 422 TH E YA LO M RE A DER

cache of sleeping pills and eventually took a fatal overdose; he left a sui-
cide note for his wife with detailed instructions about the family financial
affairs. The last line of the note: "Sue Robertson!"
The family sued and was ultimately offered a small settlement by the
malpractice insurance company, which wished to expedite the process
and save legal fees. Even though Dr. Robertson was cleared of any
wrongdoing, the two-year legal process left her depleted and disillu-
sioned; she even considered changing professions. She tells me that,
when interviewing prospective new clients, a question now invariably
comes to mind: "Will this person sue me?"
In Lying on the Couch I wanted to explore therapist-patient boundary
issues in all their complexity: the risks and temptations, the desires of the
therapist, the modes of avoiding pitfalls, the dangers to the exploited pa-
tient. Most of all, I strove for a fulf understanding of each two-person
drama: I wanted to explore the deep subjective experience of each par-
ticipant without rushing to blame or to lynch. If psychotherapists will not
attempt to understand behavior and motivation in the therapy situation,
who will?
Hence Lying on the Couch examines many controversial questions,
even, for example, the delicate one of whether, if the relationship is a
genuine one, there may be a legitimate role for sexual energy (not sexual
behavior) in successful therapy. A dream a patient describes to her thera-
pist in the novel is illustrative:

Idreamt you and I were attending a conference together at a

hotel. At some point you suggested I get a room adjoining
yours so we could sleep together. So I went to the desk and
arranged for my room to be moved. Then a little later you
change your mind and say it's not a good idea. So then .I go
back to the desk to cancel the transfer. Too late. All of my
things had been moved to the new room. But it turns out that
the new room is a much nicer room-larger, higher, better I
view. And better, too, numerologically: the room number, 1
929, was a far more propitious number for me.

This dream (an actual dream of one of my clients) suggests that, for some
 The Psychological Novel 423

clients, sexual energy may play an important role in the therapeutic

process. The dream suggests that the intense intimacy of the relationship
(catalyzed by the illusion of ultimate sexual union) results in consider-
able personal growth for the client (her new room is larger, nicer, with a
better view, and is numerologically more advantageous). By the time she
understands the illusory nature of her hopes for union, it is too late to re-
vert: the positive changes have been set in place.
Although [ am persuaded there is a role for great intimacy, even love,
in the therapeutic relationship, and though I am candid and graphic in
my discussion of the risks and temptations from the therapist's perspec-
tive, I do not mean to minimize or excuse sexual exploitation and viola-
tions on the part of the therapist. A careless reading of Lying on the
Couch may Jead the reader to conclude that I am offering an apologia for
the offending therapist. Absolutely not. I am convinced that, almost in-
variably, a sexual relationship between patient and therapist is highly de-
structive for the patient and equally destructive for the therapist at the
level of conscience, self-worth, and integrity.

DREAMS

Another therapy theme explored in Lying on the Couch is the relevance

and use of dreams. Too many contemporary psychotherapists neglect
dreams in their work. Many of my students avoid even asking their pa-
tients to relate dreams (as wel I as fantasies). To some extent, they may be
responding to the emphasis health maintenance organizations give to
brief therapy, but many new therapists who have less formal training
than the past generation of therapists are, I believe, awed and intimi-
dated by the voluminous, arcane literature on dream interpretation.
Accordingly, I have made a deliberate attempt to demonstrate a prag-
matic approach to dream work in Lying on the Couch. I try to show that
dreams are useful not because of astonishing deep insights that emerge
from exhaustive dream analysis but simply because the patients' associa-
tions to dreams lead them to unexpected memories, reflections, and dis-
closures.
I have never been able to invent convincing dreams in my fiction.
 424 THE YALOM READER

Every attempt lacks the requisite mysterious, uncanny, well ... dreamy
quality. Consequently, all the dreams in Lying on the Couch are real.
Some of them are my own dreams, like this one (which I give to the pro-
tagonist, Ernest):

I was walking with my parents and my brother in a mall and

then we decided to go upstairs. I found myself on an elevator
alone. It was a long, long ride. When I got off, I was by the
seashore. But I couldn't find my family. I looked and looked
for them. Though it was a lovely setting . . the seashore is
always paradise for me ... I began to feel pervasive dread.
Then I started to put on a nightshirt which had a cute, smiling
face of Smokey the Bear. That face then became brighter,
then brilliant . . . soon the face became the entire focus of
the dream-as though all the energy of the dream was trans-
ferred onto that cute grinning little Smokey the Bear face.

There was no mystery for me about the source of this dream. I dreamt it
immediately after spending most of the night sitting with a dying friend.
His death hurled me into a confrontation with my own death (repre-
sented in the dream by pervasive dread, by my separation from my fam-
ily, and by my long elevator ascent to a heavenly seashore).
J put my sentiments into Ernest's words:

How annoying, Ernest thought, that his own dream-maker

had bought into the fairy tale of an ascent to paradise! But
what could he do? The dream-maker was its own master,
formed in the dawn of consciousness, and was obviously
shapedmore by popular culture than by volition.

The power of the dream resided in the nightshirt adorned by the gleam-
ing Smokey the Bear emblem. I could see through that symbol: after my
friend's death and before calling the funeral parlor, his widow and I had
discussed how to dress him-how does one clothe a corpse for a crema-
tion? Smokey the Bear represented cremation! I was certain of it. Eerie,
 The Psychological Novel ..p5

but instructive. Recall Freud's insight that a primary function of dreams is

to preserve sleep. In this instance, frightening thoughts-death and cre-
mation-are transformed into something more benign and pleasing: the
cunning figure of Smokey the Bear. But the dream mechanism was only
partially successful: it enabled me to continue sleeping, but it could not
prevent death anxiety from seeping out into the dream.
Most of the dreams in my fiction are my patients' dreams. Obtaining
their permission was instructive in a number of ways. One powerful
dream in Lying on the Couch came from a patient who dreamt of walk-
ing along the Big Sur coast and coming upon a river which, remarkably,
flowed backward, away from the sea. He followed the river inland and
discovered his father and then his grandfather standing in front of
caves.
The river flowing backward was a poignant image of the wish to
break time, to reverse its inexorable flow, to resuscitate his dead father
and grandfather. Originally, eighteen months previously when we had
worked on the dream, it had led us to deep and dark realms-his fears of
aging and death; his belief that he, like the other men in his family,
would have to face the end of life alone; his deep regret at having turned
his back on his family of origin.
When I requested his permission to cite the dream in my novel, he
appeared baffled and denied that he had ever dreamt such a dream. I
asked him to read my notes of that therapy session, but still the dream
appeared entirely alien to him. Such an amnesiac response to a potent
dream is a good demonstration of the power of repression. Not only do
we find it difficult to recall dreams in the first place, but even after having
recalled them, we often repress them once again.
Incidentally, the notes of that session eighteen months before con-
tained not only the dream but several other important observations about
his relationship to ambition and to authority. When the patient read
those notes, his therapy was immediately catalyzed-he realized how
much he had changed in his attitudes toward authority, and realized, as
well, how much work still remained. The process of psychotherapy may
be thought of as "cyclotherapy": we return again and again to rework, at
deeper and deeper levels, the same themes.
I have often been asked whether clients object to my writing about
them. Almost always it is the clients not written about who have ex-
 426 THE YALOM READER

pressed concern, wondering whether they are not interesting or special

enough to warrant inclusion in my work. Without exception, clients have
gladly permitted me to cite their dreams. I always give them the opportu-
nity to approve the final document before publication, but none have
ever asked to change any part of the dream.
Consider this curious incident involving a dream in Love's Execu-
tioner. A patient whom I had not seen for many years called me for an
appointment after the publication of the book. She entered my office, sat
down, and with a somber voice told me that she knew she was not
Thelma, the protagonist of the first story, yet one of Thelma's dreams
strangely resembled a dream she had once described to me.
I was immediately alarmed at being confronted by an unhappy pa-
tient who was apparently accusing me of taking something from her
without permission. The dream in question involved a woman dancing
with a man and then lying on the dance floor with him and having sex.
Just before orgasm she whispered in his ear, "Kill me."
I knew that this dream did not belong to Thelma. I had heard the
dream long ago from someone else, though I had forgotten whom, and,
in the service of making it a better story, had stitched it onto Thelma. As I
spoke to the patient I recalled that it was indeed her dream, and apolo-
gized profusely for having forgotten and, consequently, for not having
obtained her permission.
She brushed that off. I had misunderstood her, she said. Ownership of
the dream was not her concern; what troubled her was the thought that
her imagination could be so banal that another client would dream the
same dream. She left my office much reassured about her creativity and
the uniqueness of her dreams.
Thus far, we have been discussing the use of clients' dreams in therapy.
In Lying on the Couch I describe a variation: Ernest dreams about Car-
olyn, his client, and takes the radical step of sharing his dream with her:

I am rushing through an airport. I spot you amidst a throng of

passengers. I am glad to see you and I run up and try to give
you a big hug but you keep your purse in the way, making it
a bulky and unsatisfactory hug.

The ensuing discussion of the dream proves fruitful in therapy. Several

 The Psychological Novel 427

possible meanings are aired. Ernest suggests that the dream depicts his
attempt to develop a close therapeutic relationship with her, an attempt
that is foiled by her interjecting into the therapy her demands for sexual-
ity (represented by the symbol of the purse, which so often signifies the
vagina) and thus preventing true intimacy from evolving. His patient,
Carolyn, counters with a simpler, more parsimonious interpretation,
namely, that the purse simply represents the exchange of money and that
his desire to have a real relationship (that is, a man-woman sexual en-
counter) is frustrated by their professional contract. Ernest suggests yet
another meaning:

"Another thought I had, Carolyn, was about the contents of

the purse. Of course, as you suggest, money immediately
comes to mind. But what else could be stuffed in there that
gets in the way of our intimacy?"
"I'm not sure what you mean, Ernest."
11/
mean that perhaps you may not be seeing me as I really
am because of some preconceived ideas or biases getting in
the way. Maybe you're toting some old baggage that's block-
ing our relationship-for example, wounds from your past
relationships with other men, your father, your brother, your
husband. Or perhaps expectations from another era: think,
for example, of your former therapist, Ralph Cooke, and of
how often you've said to me: 'Be like Ralph Cooke ... be my
lover-therapist.' In a sense, Carolyn, you're saying to me:
Don't be you, Ernest, be something or someone else."

Which interpretation is true? The patient's sexualization of the relation-

ship? The therapist's regret that he could not have a romantic, nonpro-
fessional relationship with his client? The client's transference-based
distortion of the real relationship? In the pragmatic spirit of William
James, the truth is what works. And what works in the novel and the real-
life situation in which this dream (my own dream) occurred is the ac-
knowledgment by both therapist and client that there is truth in each of
these interpretations: taken together they are instrumental in deepening
the authenticity of the relationship and the therapeutic work.
 428 TH E Y A LO M R EA DE R

THE HERE .. AND .. Now

Earlier in this volume I have emphasized the key role that the here-and-
now plays in group psychotherapy. One of my goals in Lying on the
Couch is to demonstrate that it is no less important in individual therapy.
There is a long tradition in individual therapy of focusing on transfer-
ence, that is, examining distortions in the patient-therapist relationship in
order to shed light on other relationships, particularly parental relation-
ships. Generations of analysts have used the information gleaned from
the study of transference to inform their interpretations. Their aim has
been to use here-and-now material to facilitate the patient's recall and
understanding of earlier formative relationships. In recent years new pro-
gressive analytic schools have broadened the transference focus and
have reversed the emphasis: that is, they now explore the past in order to
understand present relationships. But often the goal remains insight, and
the therapy relationship is used primarily as an investigative tool.
I attempt to demonstrate in Lying on the Couch that a focus on the
here-and-now has implications beyond transference clarification-
namely, that the relationship to the patient is important in its own right
and that forces more powerful than insight are at play in therapy, forces
that can be enhanced by focusing on and enriching the "in-betweenness"
of therapist and patient. The therapeutic act of establishing a deeply inti-
mate and authentic relationship, in itself, is healing. Such a relationship
can become an antidote to loneliness and offer an internal reference point
for patients, who learn that such intimacy is rewarding and that they are
capable of attaining it. Furthermore the work of creating and sustaining an
authentic relationship with the therapist is often excellent modeling for
the formation of future relationships in a patient's life.
A therapy group generates so much data about interpersonal relation-
ships that it is not difficult to maintain the entire focus of the group in the
here-and-now. Many individual therapists neglect the here-and-now fo-
cus because they mistakenly believe that the insularity of the individual
therapy precludes the development of rich here-and-now data. Lying on
the Couch demonstrates how the therapist can focus on the here-and-
now in the individual therapy hour. Ernest, my protagonist, makes a con-
scious effort to focus on process (that is, the nature of the relationship
between therapist and patient) several times each session.
 The Psychological Novel ·+29

Sometimes the here-and-now inquiry may be a simple process check

for example, such questions as "How are you and I doing today?" or
"What about the space in between us today? Far? Near?" or "The hour is
almost over: are there feelings about the way we are relating that we
should examine before we stop?"
Every aspect of the hour provides data-patients' arrival and depar-
ture, their punctuality, their payment of bills. One patient, for example,
enters my office tentatively and apologizes when my faulty latch pre-
vents the door from closing satisfactorily. She apologizes again when,
taking a piece of tissue to clean her glasses, she moves the Kleenex box a
few inches. And then she begins the hour by apologizing for not having
made more progress in therapy.
My office is a cottage in the midst of a large garden. Some patients ig-
nore the garden; others never fail to comment upon it, especially during
the spring bloom. Another patient characteristically chooses to comment
on the mud on the path or the construction noise in the neighborhood.
This same patient elected to read Lying on the Couch but not to pay for
it: he read it in snatches standing in the back of various bookstores. His
reason: "I gave at the office." An exploration of this here-and-now data
proved invaluable in helping this patient explore his fear of exploitation
and his deep anger at me and any other authority figure. A mild, gentle
man externally, he has deeply ingrained passive-aggressive trends, which
take the form of severe procrastination and have persistently gotten him
into serious difficulty with supervisors.
Another patient never tells me the end of stories. He may be on the
brink of some bold act-sending his novel to an agent, confronting his
boss to protest a salary cut, or demanding that a former girlfriend tell him
why she broke off their relationship-and then he never lets me know
the outcome. Why not? Does he think I am not curious, that ! have no
concern for him? Is he ashamed of the outcome? Does he consider him-
self so uninteresting that I would have little curiosity about him? Or does
he simply never think about the wishes or needs of the other? Does he
treat other people this way too? Perhaps this here-and-now behavior
contains a clue about his inability, in general, to maintain intimate rela-
tionships.
The process of therapy is an alternating sequence of affect evocation
and affect integration. Strong affects are experienced in the session-irri-
 430 THE Y ALOJ\1 READER

tation, fear, arousal, hatred-and then examined by the patient and ther-
apist. Even if the affect has little to do with the therapist-for example,
grief over a past loss-it is still profitable for the therapist to ask how the
patient feels about expressing strong emotions in the presence of an-
other. One may inquire, simply, "How did it feel to cry in front of me, to
let me see your sadness?"

THE LEAP INTO PURE FICTION

When Nietzsche Wept and Lying on the Couch are both novels of ideas
that address fundamental questions about the nature of psychotherapy.
There are, however, significant differences between the two books. Since
my first publications in the 1960s, my writing has been gradually moving
away from a home base of academic psychiatry to the domain of pure
fiction. When Nietzsche Wept was a move in that direction; Lying on the
Couch was a more radical step.
When Nietzsche Wept is fiction, yes, but a safe and structured fiction.
It is, I believe, a complex book from the perspective of the philosophic
themes explored, but from the standpoint of novelistic technique it is not
a giant step away from my previous writing. In some ways it is fiction-
writing with training wheels.
For one thing, there was much in When Nietzsche Wept that I did not
have to fictionalize. Many of the characters are historical figures:
Friedrich Nietzsche, Josef Breuer, Sigmund Freud, Bertha Pappenheim
(Anna 0.), and Lou Salome. Of course, we know little about their psy-
chological concerns (with the exception of Freud's), and I had to fiction-
alize each interior life. But in general, I stayed as close as possible to the
actual recorded events of the lives of my characters in 1882 and then
proceeded to insert a fictional thirteenth month into the winter of that
year.
Once I had selected the year and the place (Vienna and Venice), I set
about creating many of my visual details with the help of old photographs
and an 1885 Baedeker guide of Vienna. I could also draw upon my visual
memory, since I had once spent several months at the Vienna campus of
Stanford University (teaching Freud to undergraduates). And, of course,
 The Psychological Novel 43 r

much of the intellectual content of the novel is not fictional but is drawn
from the body of Nietzsche's pre-1882 philosophical writings.
Lying on the Couch was a far riskier project, not only because it
would discuss vexing and controversial issues but also because it was to
be pure fiction. Ever since my adolescence I had wanted to write a novel.
I had suppressed that desire, sublimated it, dreamt of it, viewed it from
afar, paced around it, and now, finally, I took the plunge.
Earlier I referred to When Nietzsche Wept as a teaching novel. Did I
also intend Lying on the Couch to be a teaching novel? I was ambivalent
about that. On the one hand, the psychotherapy practitioner and trainee
constituted my secret audience during the writing, and nothing would
please me more than for Lying on the Couch to be assigned in therapy
training programs. On the other hand, I longed to be a real novelist, and
whenever I faced a decision point in writing Lying on the Couch l opted
each time for literary considerations-for the book to be entertaining
rather than didactic. Over and over I sacrificed juicy opportunities to in-
sert a pedagogical aside.
Nonetheless, I did not, and do not, experience the freedom of most
novelists. For one thing, I am restrained by knowing that the patients in
my practice read my novels. Moreover, I have much visibility in the field
as a professor of psychiatry at Stanford and as an author of textbooks
used in many psychotherapy training programs. It is important for me
that my students not confuse my professional writing with my psy-
chotherapy fiction. Whenever possible, I emphasize that my fiction is fic-
tional, that I do not endorse al I the behavior of the therapists I write
about, and that the plot of each book and inner I ife of each character are
pure invention. Still, there are questions raised as to whether my novels
are indeed fiction. In my defense, I have noted that Robert Ludlum's nov-
els reek of murder and mayhem, yet no one accuses him of being a serial
killer; nor is Philip Roth, who writes incessantly of diverse and bizarre
sexual practices, dismissed as a pervert.
My fears were realized in the first review of the book, which ques-
tioned whether the novel was truly fiction or whether, like Love's Execu-
tioner, it represented a personal confessional. Another reviewer posited
that the novel questioned the relevance of psychotherapy. My intentions,
however, were quite different. I have never doubted the relevance nor
 432 THE Y ALOM READER

the power of psychotherapy, and although I satirize some aspects of con-

temporary therapeutic practice, my protagonist, Ernest Lash, is meant to
be a man of integrity. Despite his lust, his bumbling, his struggles with his
primitive appetites, he remains totally committed to his patients and to
his vision of the continuing possibility of human growth.

Is FICTION FICTIONAL? TRUTH TRUE?

Writing Lying on the Couch felt like a radical departure from my previous
professional writing, an adventurous plunge into the realm of "pure fic-
tion." But what is "pure fiction"? Recent years have witnessed consider-
able readjustment of the boundary between fiction and nonfiction.
Consider the development in psychotherapy of the view that an accurate
reconstruction of an individual's life is, to a great extent, illusory. The
psychotherapeutic goal has become a construction and not a reconstruc-
tion; we search to provide some plausible satisfying life narrative--even
a fiction-that can provide coherence and understanding. Or consider
the new research on implanted memories, which indicates that false
memories may be implanted easily and that individuals are often unable
to differentiate them from ''real" memories of actual events. The old sure
distinctions between truth and fiction grow increasingly blurred.
Nietzsche, perhaps more than any other thinker, has contributed to
the blurring. He compared truth to discarded snakeskins shed as their
owners grew larger and older. His perspectivistic view of truth posits that
there is no truth, there is only interpretation: truth is a convenience,
"truth is the kind of error without which a certain species of life could
not survive."!
Truth blends with fiction in the writing of Lying on the Couch; a great
many scenes have some kind of relationship to reality: they are drawn
from, based on, or inspired by actual events. For example, chapter 7 1,
takes place in a psychoanalytic institute meeting in which a revered but l
maverick psychoanalyst is expelled from the institute. Although the
scene is meant to be comic and fantastical, it is inspired by an actual
event-the expulsion, twenty-five years ago, of Masud Khan from the
British Psychoanalytic Institute (as related to me by Dr. Charles Rycroft
and described in Judy Cooper's biography of Masud Khan).6
 The Psychological Novel 433

In the prologue to Lying on the Couch, Seymour Trotter, a patriarch of

the profession and a past president of the American Psychiatric Associa-
tion, is a composite of at least three figures: a therapist who, years before,
had sexually abused one of my patients; an eminent figure in Boston
psychoanalytic circles; and Jules Masserman, a past president of the
American Psychiatric Association and the American Psychoanalytic As-
sociation, who was indicted for sexually abusing patients after drugging
them with sodium pentothal.
The plot of the prologue was partially inspired by a story that floated
around when I was a resident in psychiatry. In one of the first major mal-
practice settlements, a prominent New York analyst was found guilty of
sexual abuse, and a huge insurance settlement was awarded to his young
female patient. Months later, so the story went, they were seen strolling
arm in arm on a beach near Rio de Janeiro. Is this tale true or apoc-
ryphal? I don't know. I only know that it remained dormant in my mind
for almost forty years and then found expression in the novel.
Thus fiction is not wholly fictional in that real incidents and individu-
als are often incorporated into the narrative. The following incident de-
picts how fiction and memory may meld in less obvious ways.
In When Nietzsche Wept Nietzsche, while wandering in the ceme-
tery and reflecting upon the gravestones, composes a little ditty:

till stone is laid on stone

and though none can hear
and none can see
each sobs softly: remember me, remember me.

These lines of doggerel (preceded by several others which did not make
the final cut in the novel) came to me quickly, and I wrote them with a
flush of pleasure-my first published verse. About a year later, when I
was changing offices, my secretary found a large sealed manila enve-
lope, yellowed with age, which had fallen behind the file cabinet. It con-
tained a large packet of poetry I had written in my late adolescence and
had not seen for decades. Among the verses were the identical lines,
word for word, which I thought I had freshly composed in the novel. I
had written them in 1954, forty years before, at the time of my fiancee's
father's death. I had plagiarized myself.
 434 THE Y ALOM READER

A somewhat similar incident involves one of the Beatles, George Har-

rison, who w~s sued by a musician claiming that Harrison's song "My
Sweet Lord" had plagiarized the musician's earlier song, "He's So Fine."
Expert musicologists agreed that the scores were remarkably similar and
the court ordered Harrison to pay damages. Harrison hardly needed to
plagiarize another musician's work; instead, what probably occurred
was that he had heard the song, repressed it, and then reinvented it.
These incidents are testimony to the existence of the unconscious. I
think of such stories whenever I hear neuropsychologists proclaim that
no research evidence documents the existence of the unconscious. At
such times the neurophysiologist Sherrington's comment comes to mind:
"If you teach an Airedale to play the violin, you don't need a string quar-
tet to prove it."
When Nietzsche Wept blurred boundaries between fiction and truth
by placing real historical characters in a fictional setting. This postmod-
ern blurring of literary boundaries-between biography, autobiography,
and fiction-has been slowly evolving for the past twenty years. Recall,
for example, the playwright Tom Stoppard's 1966 Rosencrantz and
Guildenstern Are Dead, in which minor characters from Hamlet become
protagonists of their own play, or his 1974 Travesties, which describes a
fictional meeting between Joyce, Lenin, and Tristan Tzara. In my book
Love's Executioner, I had already experimented with blurring the bound-
aries between case history and fiction.
In psychotherapy the boundary between fiction and personal history
has always been unclear. It is only recently, perhaps because of Donald
Spence's landmark book, Narrative Truth and Historical Truth, that thera-
pists have become appreciative of their own narrative-constructive (as
opposed to reconstructive) efforts in psychotherapy. Therapists and ana-
lysts no longer consider themselves, as Freud did, psychological archae-
ologists striving to excavate the real historical truth of a life: we have all
become Nietzschean perspectivists. We understand that the truth
changes according to the perspective of the observer and, in the case of
therapy, truth's form is vastly influenced by the nature of the therapeutic
relationship.
Leslie Farber provides an illustrative vignette of psychotherapy per-
spectivism in an essay entitled "Lying on the Couch" which appeared in
 The Psychological Novel 435

his 1976 book, Lying, Despair, Jealousy, Envy, Sex, Suicide, Drugs, and
the Good Life. Early in his career, while being analyzed in an office in his
analyst's home, he had been frequently disturbed by the discordant
sounds of her son practicing on the violin elsewhere in the house. When
he finally complained, his analyst immediately accommodated him by
leaving the office and silencing her son.
Soon afterward his analytic hours were flooded with memories of
playing the violin during his own childhood. Since he had been a pre-
cocious musician, his father had harbored great hopes of seeing him
become a concert violinist. When he "outgrew" the violin in his adoles-
cence, his father was wounded and disappointed: the rift between them
required months, years, to heal.
Only much later did Farber realize that he had "lied on the couch"
and succumbed to a romanticization of his youth. Although he had in-
deed played the violin when young, he was a mediocre musician and no
one had ever raised the question of a musical career. Certainly the violin
had never caused a rift with his father, with whom he had always re-
mained on good terms. Yet during his analysis the narrative had been
wonderfully satisfying to him and ultimately prompted him to explore
more deeply his transference to his analyst.
Incidentally, the title of Farber's essay, "Lying on the Couch," provides
an illustration of the difficulty of ascertaining attribution: I have no doubt
I took the name of my novel from this essay, yet I have no memory of
"deciding" to use it. I had not reread or even laid eyes on Farber's book
since 1976, but as I was plotting my novel, the title simply appeared in
my mind and I knew instantaneously that it was the right one.
So, too, for the story fragments I described in my essay on When Nietz-
sche Wept (Herman Hesse's story of the two healers, and Helmuth
Kaiser's play fragment, Emergency). Did I methodically use these tales in
my plot construction? Was it really true, as I have suggested elsewhere,
that these tafes had "rattled about in my mind for many years" and that
"their echoes ring throughout the pages"? Or is that a fiction, a romanti-
cized version of the sense-providing narrative we so often construct in
therapy and in life?
Alas, I simply do not remember! The computer has made original jot-
tings and first drafts obsolete. As far as I can recall, it was months after
 436 THE Y ALOM READER

the completion of When Nietzsche Wept1 while preparing a lecture on

the process of writing a psychotherapy novel, that the possible influence
of these tales first occurred to me. Whether the stories consciously or un-
consciously influenced the novel, or whether I simply recalled them later
for the purpose of inventing a coherent linear narrative suitable for a lec-
ture, is something I shall never know.
Farber's fiction of the violin virtuoso reminds us that memory may be
too often conceptualized as trauma-based-that is, the experience of
trauma is instrumental in what we choose to remember and to forget.
Memory may also be influenced by an aesthetic drive-by the desire to
make an artistic product of one's I ife.
The satisfying life narrative the patient constructs during therapy often
changes as new data emerge. Sometimes one may develop alternating
narratives that are brought into play to meet the demands of a particular
situation. I can personally attest to two guiding life narratives that be-
came evident to me during my personal analysis. j
I described one of these narratives earlier-that of myself as a young
storyteller, a novelist rnanque, who knew that the most marvelous thing
one could do in life was to write a fine novel, but who, because of cul-
tural pressures, chose a medical career and only decades later was able
to return to his true calling.
This romantic narrative has served me well. It was always there in the
background, available when needed, comforting me when I was over-
come with doubts about my professional research or my therapy prac-
tice. Now, as I distance myself from a remedicalized field of psychiatry, it
has moved more into the foreground. Whenever I open an issue of the
American Journal of Psychiatry and flip through page after page of re·
ports on psychopharmacological or brain imaging research hoping, in
vain, to find even one article I can understand, one article dealing with
the human concerns of patients, I draw this narrative more closely
around me, saying, "I don't belong in medicine or even psychiatry; I'm a
writer-that's where I really live."
A second, alternate core narrative that unfolded in my analysis had its
inception when I was thirteen. On a cold November night, at about three
in the morning, my father suffered a serious coronary, and we (my
mother, father, and I) awaited the arrival of our family physician, Dr.
 The Psychological Novel 437

Manchester. My mother was distraught and, as she habitually did in

times of stress, looked around for someone to blame. As usual, her gaze
fell upon me.
"It's your fault," she shouted, "you did th is-al I the aggravation, al I
the grief you gave him-you did this to him. You. You." We waited for
the doctor's arrival, my mother weeping, my father groaning with pain,
and I shivering abjectly by his bed, holding his hand, hating my mother
and pondering whether there was truth in her accusation. Finally Dr.
Manchester arrived. Never before in my life had I heard a more beauti-
ful, more terror-allaying sound than the tires of his big Buick crunching
the autumn leaves piled by the curb.
He was wonderful. Miraculous. He eased my father's pain with an
injection. He calmed my mother with reassurances. He affectionately
tousled my hair and let me hold his stethoscope. He waited with us till
the ambulance arrived and followed it to the hospital. So grateful was I
that, then and there (as I remember it), r resolved to be a physician and to
pass on to others what Dr. Manchester had given me.
This narrative has carried me through most of my life. My primary
identity has been that of a physician or healer, and I have never allowed
anything to take precedence over my commitment to patients. Even in
recent years, as I have become a more dedicated writer, it is difficult to
release my grip upon the "doctor" life narrative. I know that I resist cut-
ting down my therapy practice; once I hear the particulars of an individ-
ual's despair I have great difficulty refusing to take the patient into
treatment.
And, of course, whenever I am bruised by negative book reviews, I
run back into the arms of my identity as a physician and soothe myself
by saying: "I'm not a writer; I'm a physician. Always have been."

LYING AND PSYCHOTHERAPY

The double entendre of the title Lying on the Couch raises yet another as-
pect of the boundary between fiction and nonfiction. When do patients
lie and when do they tell the truth? Many years ago, during my military
 43 8 TH E Y :\ LO i\1 R EADER

service, a sergeant was admitted to my ward exhibiting a strange set of

symptoms. He was only a few weeks short of completing thirty years of
service (which would have provided him with a handsome lifelong pen-
sion) when he was arrested for sexually abusing a young boy. He imme-
diately fell into an amnesiac, confused state in which he answered ali
questions incorrectly but in such a manner as to indicate that he knew
the correct answers: for example, five times four is nineteen, six times
three is seventeen, a horse has three legs.
His officers suspected malingering. How convenient for the sergeant,
they said, to develop a psychosis just in time to avoid responsibility for a
criminal act that would incur a dishonorable discharge and loss of his
military pension. Even the near-miss way he answered questions sug-
gested lying. But a lie has intention and a birth: there must have been a
time when he invented the lie, and a place in his mind where he knew
he was lying. Where was that place, that time? I could never find it. No
matter how deep I went with prolonged interviews, hypnosis, or sodium
pentothal, I never found the seam of the lie.
Eventually he prevailed and got what everyone thought he wanted: a
medical discharge with his pension intact. I lost touch with him after
that; I was far too busy in the army to follow up discharged patients.
(Later in my life I would never miss out on the end of such a story.) Most
likely, however, his was a Pyrrhic victory: usually individuals exhibiting
his symptoms (the formal diagnosis used to be Ganser syndrome, also
known as the syndrome of approximate answers) wind up, to everyone's
surprise, living out much of their life in psychosis.
Overt lying is part of everyday business in forensic psychiatry or any
situation where some third party-the law, an employer, an insurance
company, a spouse-intrudes into the therapy situation. But in the tradi-
tional therapy relationship, where patients pursue greater personal com-
fort, self-understanding, and personal growth, lying takes the far more
subtle forms of concealment, exaggeration, omission, and distortion.
Even though we depth psychotherapists appreciate that there is a ba-
sic unknowability to the other, we never stop struggling to bridge the gap
separating us from the client. In retrospect, I now understand that many
of my experiments with therapy technique have been motivated by this
desire. I reveal more and more of myself in an effort to encourage pa-
 The Psychological ~o,·el 439

tients to reciprocate. I tap into dreams and fantasies. I encourage patients

to hold nothing back. I have (far too rarely, incidentally) visited their
homes in order to learn more about them. I ask them to bring in pictures
of their past and present families. I asked Ginny (of Every Day Gets a Lit-
tle Closer) to reveal in her written reports what she had concealed in our
meetings. Even in my fiction I asked Nietzsche and Breuer to write re-
ports of their secret unexpressed feelings about their meetings.
I often lead therapy groups of my own individual patients and marvel
at how much everyone conceals. Clients commonly withhold from the
group much that they have revealed in the individual hours. Sometimes I
look around the group and think, "Everyone is lying"-concealing both
vital parts of themselves and their feelings toward the other members. I
have known patients who have refused to reveal their enormous wealth,
abused backgrounds, criminal convictions, sexual paraphilias, or extra-
marital affairs. Recently I had two psychotherapists in therapy groups
who, despite my urgings, refused to reveal their profession to the group
(one for fear that his words wou Id be given undue weight, the other for
fear of being judged as an unfit therapist because of her personal psy-
chological problems). Almost everyone conceals some of their stronger
feelings toward other members-envy, attraction, lust, fear, repulsion.
Often I feel like a Magus, knowing so much more than is overt in the
group. Indeed, one of the vexing problems for therapists doing com-
bined therapy (individual and group) is to know how to handle their
privileged knowledge.
Consider Leslie Farber's tale of having been a young violin prodigy.
Was he explicitly lying? Or unconsciously romanticizing his life by re-
shaping his memory according to the demands of the two-person situa-
tion? Was he so desirous of winning approval from his analyst that his
memory was reforged? Perhaps he was competing with his analyst's son
and hoped to win her admiration by alluding to his superior musical
skill. Or he may have been grateful to her for silencing her son and re-
warded her with a flood of derepressed delectable memories.
Memory's unreliability is incontestable. Nietzsche was fully apprecia-
tive of its malleability when he wrote, '"I have done that,' says my mem-
ory. 'I cannot have done that,' says my pride, and remains inexorable.
Eventually-memory yields." Over and again memory yields, and there
 440 THE Y ALOM READER

is no objective perch from which one may view the yielding. As he grew
older, Mark Twain said, his memory of events that never happened grew
more vivid.
Case histories in the nonfiction textbook are far less true than is gen-
erally known. Publishers are so threatened by the current litigation
epidemic that most published case histories in the contemporary psy-
chotherapy literature are almost entirely fictionalized. But is that a le-
gitimate pedagogical concern? Is "realness" equivalent to historical
accuracy? I've often found fictional characters to be more "real" than his-
torical characters. Because novelists know their characters fully, they
have a distinct advantage over psychotherapists who collude with their
subjects to keep their secrets. Thus my fictional characters-Ernest Lash,
Josef Breuer, or Friedrich Nietzsche-may be more real, that is, fully
known, than some of the real-I ife characters described in my nonfiction
work, such as the vignettes in my textbooks and the case histories in
Love's Executioner.
Much the same may be said for another practitioner of nonfiction, the
professional biographer, who, like the psychotherapist, attempts to re-
create a life. But is biographical nonfiction real? Consider how greatly bi-
ographers are limited by their sources. If psychotherapists, who spend
countless hours listening to intimate details of lives, marvel at how little
they really know their patients, imagine how far biographers are from the
mark. Consider how much of your own essence would be captured in a
biography based only on your papers or E-mail, or on published reminis-
cences of acquaintances. Even if biographers write about a contempo-
rary figure, still they are greatly limited by what they-or the subject-
choose to make public.
A biographer of Samuel Beckett once commented that Beckett began
their interviews with a characteristic greeting: "Here is the person who is
going to show the world what an empty fraud I am." What a delicious
quote, I thought. If I were writing the biography, I would have made it a
centerpiece. Yet when I asked the biographer about how she used this
material in her writing, she responded that she could never write about
that: it was confidential-a private joke between the two of them.
This quirky perspective of biography as fiction and fiction as life is
wonderfully summed up in Thornton Wilder's comment: "If historical
characters-Queen Elizabeth, Frederick the Great, or Ernest Hemingway,
 The Psychological Novel -l-l 1

for example-were to read their biographies, they would exclaim, 'Ah-

my secret is still safe.' But if Natasha Rostov were to read War and Peace,
she would cry out, as she covered her face with her hands, 'How did he
know? How did he know?'"

The prologue of Lying on the Couch, reproduced in the following pages,

takes place several years before the rest of the novel and may be read as
a freestanding story. Seymour Trotter, who is being questioned about sex-
ual misconduct with a young female patient, is a wounded healer, part
sham, part wizard; he is a falling giant who, in his descent, offers a gift to
Ernest. Seymour's story is meant as a cautionary tale, a dark backdrop
against which the rest of the novel will be played out.

Lying on the Couch: The Prologue

Ernest loved being a psychotherapist. Day after day his patients invited
him into the most intimate chambers of their lives. Day after day he
comforted them, cared for them, eased their despair. And in return, he
was admired and cherished. And paid as well, though, Ernest often
thought, if he didn't need the money, he would do psychotherapy for
nothing.
Lucky is he who loves his work. Ernest felt lucky, all right. More
than lucky. Blessed. He was a man who had found his calling-a man
who could say, I am precisely where I belong, at the vortex of my tal-
ents, my interests, my passions.
Ernest was not a religious man. But when he opened his appoint-
ment book every morning and saw the names of the eight or nine dear
people with whom he would spend his day, he was overcome with a
feeling that he could only describe as religious. At these times he had
the deepest desire to give thanks-to someone, to something-for hav-
ing led him to his ca1ling.
There were mornings when he looked up, through the skylight of
his Sacramento Street Victorian, through the morning fog, and i1nag-
ined his psychotherapy ancestors suspended in the dawn.
"Thank you, thank you," he would chant. He thanked them all-all
 442 THE YALOM READER

the healers who had ministered to despair. First, the ur-ancestors, their
empyreal outlines barely visible: Jesus, Buddha, Socrates. Below them,
somewhat more distinct-the great progenitors: Nietzsche, Kierke-
gaard, Freud, Jung. Nearer yet, the grandparent therapists: Adler, Hor-
ney, Sullivan, Fromm, and the sweet smiling face of Sandor Ferenczi.
A few years ago, they answered his cry of distress when, after his res-
idency training, he fell into lockstep with every ambitious young neu-
ropsychiatrist and applied himself to neurochcmistry research-the face
of the future, the golden arena of personal opportunity. The ancestors
knew he had lost his way. He belonged in no science laboratory. Nor in
a medication-dispensing psychopharrnacological practice.
They sent a messenger-a droll n1essenger of power-to ferry him
to his destiny. To this day Ernest did not know how he decided to be-
come a therapist. Rut he remembered when. He remembered the day
with astonishing clarity. And he remembered the messenger, too: Sey-
mour Trotter, a man he saw only once, who changed his life forever.
Six years ago Ernest's department chairman had appointed him to
serve a term on the Stanford Hospital Medical Ethics Committee, and
Ernest's first disciplinary action was the case of Dr. Trotter. Seymour
Trotter was a seventy-one-year-old patriarch of the psychiatric commu-
nity and a former president of the American Psychiatric Association.
He had been charged with sexual misconduct with a thirty-two-year-
old female patient.
At that time Ernest was an assistant professor of psychiatry just four
years out of residency. A full-time neurochemistry researcher, he was
completely naive about the world of psychotherapy-far too naive to
know he had been assigned this case because no one else would touch it:
every older psychiatrist in Northern California greatly venerated and
feared Seymour Trotter.
Ernest chose an austere hospital administrative office for the inter-
view and tried to look official, watching the clock while waiting for Dr.
Trotter, the complaint file on the desk in front of him, unopened. To
remain unbiased, Ernest had decided to interview the accused with no
previous knowledge and thus hear his story with no preconceptions. He
would read the file later and schedule a second meeting, if necessary.
Presently he heard a tapping noise echoing down the hallway. Could
 The Psychological Novel +B

Dr. Trotter be blind? No one had prepared him for that. The tapping,
followed hy shuffling, grew closer. Ernest rose and stepped into the
hallway.
No, not blind. Lame. Dr. Trotter lurched down the hall, balanced
uneasilv, between two canes. He was bent at the waist and held the canes
widely apart, almost at arm's length. His good, strong cheekbones and
chin still held their own, but all softer ground had been colonized by
wrinkles and senile plaques. Deep folds of skin hung from his neck, and
puffs of white hairy moss protruded from his ears. Yet age had not van-
quished this man-something young, even boyish, survived. What was
it? Perhaps his hair, gray and thick, worn in a crew cut, or his dress, a
blue denim jacket covering a white turtleneck sweater.
They introduced themselves in the doorway. Dr. Trotter staggered a
couple of steps into the room, suddenly raised his canes, twisted vigor-
ously, and, as though by the sheerest chance, pirouetted into his seat.
"Bull's-eye! Surprised you, eh?"
Ernest was not to be distracted. "You understand the purpose of this
interview, Dr. Trotter-and you understand why I'm tape-recording
. ?"
It.
"I've heard that the hospital administration is considering me for the
Worker of the Month award."
Ernest, staring unblinking through his large goggle spectacles, said
nothing.
"Sorry, I know you've got your job to do, but when you've passed
seventy, you'll smile at good cracks like that. Yeah, seventy-one last
week. And you're how old, Dr. ... ? I've forgotten your name. Every
minute," he said as he tapped his temple, "a dozen cortical neurons
buzz out like dying flies. The irony is, I've published four papers on
Alzheimer's-naturally I forget where, hut good journals. Did you
know that?"
Ernest shook his head.
"So you never knew and I've forgotten. That makes us about even,
Do you know the two good things about Alzheimer's? Your old friends
become your new friends, and you can hide your own Easter eggs."
Despite his irritation Ernest couldn't help smiling.
"Your name, age, and school of conviction?"
 +H THE YALO:\l READER

'Tm Dr. Ernest Lash, and perhaps the rest isn't germane just now,
Dr. Trotter. We've got a lot of ground to cover today."
"~dy son's forty. You can't he more than that. I know you're a gradu-
ate of the Stanford residency. I heard you speak :H grand rounds last
year. You did well. Very clear presentation. It's all psychopharm now,
isn't it? \Vhat kind of psychotherapy training you guys getting now?
Any at all?"
Ernest took off his watch and put it on the desk. "Some other time
I'll be glad to forward you a copy of the Stanford residency curriculum,
but for now, please, let's get into the matter at hand, Dr. Trotter. Per-
haps it would he best if you tell me about Mrs. Fdini in your own way."
"Okay, okay, okay. You want me to be serious. You want me to tell
you my story. Sit back, boychik, and I'll tell you a story. We'll start at the
beginning. It was about four years ago---at least four years ago .. I've
misplaced :1!1 of my records on this patient.. what was the date accord-
ing to your charge sheet? What? You haven't read it. Lazy? Or trying
to avoid unscientific hias '"
"Please. Dr. Trotter. continue."
"The first principle of interviewing is to forge a warm, rrusring envi-
ronment. Now that you've accomplished that so artfully, I feel a great
deal freer to talk about painful and embarrassing material. Oh-that
got to you. Gotta be careful of me, Dr. Lash, I've had forty years reading
faces. I'm ,·cry good at it. But if you've finished the interruptions, I'll
start. Ready?
''Years ago-let's say about four years-a woman, Belle, walks into,
or I should say drags herself into, my office---or bedraggles herself
in-bedraggles, that's better. Is bedraggle a verb? About mid-thirties,
from a wealthy background-Swiss-Italian--depressed, wearing a
long-slce,·ed blouse in the summertime. A cutter, obviously-c-wrists
scarred up. If you see long sleeves in the summertime, perplexing pa-
tient, always think of wrist cutting and drug injections, Dr. Lash.
Good-looking, great skin, seductive eyes, elegantly dressed. Real class,
hut on the \'erge of going to seed
"Long self-destructive history. You name it: drugs, tried everything,
didn't miss one. \Vhen I first saw her she was back to alcohol and doing
a lirr!c heroin chipping. Yet not truly addicted. Somehow she didn't
 The Psychological Novel 445

have the knack for it-some people are like that-but she was working
on it. Eating disorder, too. Anorexia mainly, but occasional bulimic
purging. I've already mentioned the cutting, lots of it up and down both
arms and wrists-liked the pain and blood; that was the only time she
felt alive. You hear patients say that all the time. A half-dozen hospital-
izations-brief. She always signed out in a day or two. The staff would
cheer when she left. She was good-a true prodigy-at the game of Up-
roar. You remember Eric Berne's Games People Play?
"No? Guess it's before your time. Christ, I feel old. Good stuff-
Berne wasn't stupid. Read it-shouldn't be forgotten.
"Married, no kids. She refused to have them-said the world was
too ghastly a place to inflict on children. Nice husband, rotten relation-
ship. He wanted kids badly, and there was lots of fighting about that.
He was an investment banker like her father, always traveling. A few
years into the marriage, his libido shut off or maybe got channeled into
making money-he made good money but never really hit the big time
like her father. Busy busy busy, slept with the computer. Maybe he
fucked it, who knows? He certainly didn't fuck Belle. According to her,
he had avoided her for years, probably because of his anger about not
having children. Hard to say what kept them married. He was raised in
a Christian Science home and consistently refused couples therapy, or
any other form of psychotherapy. But she admits she has never pushed
very hard. Let's see. What else? Cue me, Dr. Lash.
"Her previous therapy? Good. Important question. I always ask that
in the first thirty minutes. Nonstop therapy-s-or attempts at therapy-
since her teens. Went through all the therapists in Geneva and for a
while commuted to Zurich for analysis. Came to college in the U.S.-
Pomona-and saw one therapist after another, often only for a single
session. Stuck it out with three or four of them for as long as a few
months, but never really took with anyone. Belle was-and is-very
dismissive. No one good enough, or at least no one right for her. Some-
thing wrong with every therapist: too formal, too pon1pous, too judg-
mental, too condescending, too business-oriented, too cold, too busy
with diagnosis, too formula-driven. Psych meds? Psvchological testing?
Behavioral protocols? Forget it-anyone suggest those and they were
scratched immediately. What else?
 446 T H E Y A LO ~I R EA D E R

"How'd she choose me? Excellent question, Dr. Lash-focuses us

and quickens our pace. We'll make a psychotherapist of you yet. I had
that feeling about you when I heard your grand rounds. Good, incisive
mind. It showed as you presented your data. But what I liked was your
case presentation, especially the ·way you let patients affect you. I saw
you had all the right instincts. Carl Rogers used to say, 'Don't waste
your time training therapists-e-time is better spent in selecting them.' I
always thought there was a lot to that.
"Let's see, where was I? Oh, how she got to me: her gynecologist,
whom she adored, was a former patient of mine. Told her l was a regu-
lar guy, no bullshit, and willing to get my hands dirty. She looked me
up at the library and liked an article I wrote fifteen years ago discussing
Jung's notion of inventing a new therapy language for each patient. You
know that work? No? journal of Orthopsychiatry. I'll send you a reprint.
I took it even forther than Jung. I suggested we invent a new therapy
for each patient, that we take seriously the notion of the uniqueness of
each patient and develop a unique psychotherapy for each one.
"Coffee? Yeah, I'll have some. Black. Thanks. So that's how she got
to me. And the next question you should ask, Dr. Lash? Why then? Pre-
cisely. That's the one. Always a high-yield question to ask a new pa-
tient. The answer: dangerous sexual acting out. Even she could see it.
She had always done some of this stuff, but it was getting very heavy. ,
I
I

Imagine, driving next to vans or trucks on the highway-high enough

for the driver to see in-and then pu1ling up her skirt and masturbat- I
ing-at eighty miles an hour. Crazy. Then she'd take the next exit and !
if the driver followed her off, she'd stop, climb into his cabin, and give
him a blow job. Lethal stuff. And lots of it. She was so out of control
that when she was bored, she'd go into some seedy San Jose bar, sorne-
l
times Chicano, sometimes black, and pick someone up. She got off on
heing in dangerous situations surrounded by unknown, potentially vio-
lent men. And there was danger not only [rom the men but from the
prostitutes who resented her taking their business. They threatened her
lift: and she had to keep moving from one place to another. And AIDS,
herpes, safe sex, condoms? Like she never heard of them.
"So that, more or less, was Belle when we started. You get the pic-
ture? You got any questions or shall I just go on? Okay. So, somehow,
in our first session I passed all her tests. She came back a second time
 The Psychological :\'o\Tl -H 7

and a third and we began treatment, twice, sometimes three times a

week. I spent a whole hour taking a detailed history of her work with
all her previous therapists. That's always a good strategy when you're
seeing a difficult patient, Dr. Lash. Find out how they treated her and
then try to avoid their errors. Forget that crap about the patient not be-
ing ready for therapy! It's the therapy that's 1101 readv for the patient. But
you have to be bold and creative enough to fashion a new therapy for
each patient.
"Belle Felini was not a patient to be approached with traditional
technique. If I stay in rny normal professional role-taking a history,
reflecting, empathizing, interpreting-poof, she's gone. Trust me. Say-
onara. Auf Wiedersehen. That's what she did with every therapist she
ever saw-and many of them with good reputations. You know the old
story: the operation was a success, but the patient died.
"\Vhat techniques did I employ? Afraid you missed my point. Afy
technique is to abandon all technique! And J' m not just being smart-assed,
Dr. Lash-that's the first rule of good therapy .. --\nd that should be your
rule, too, if you become a therapist. I tried to be more human and less
mechanical. I don't make a systematic therapy plan-you won't either
after forty years of practice. I just trust 1ny intuition. But that's not fair
to you as a beginner. I guess, looking back, the most striking aspect of
Belle's pathology was her irnpulsiv ity. She gets a desire-bingo, she has
to act on it. I remember wanting to increase her tolerance for frustra-
tion. That was my starting point, my first, maybe my major, goal in
therapy. Let's see, how did we start? It's hard to remember the begin-
ning, so many years ago, without my notes.
"I told you I lost them. I see the doubt in your face. The notes are
gone. Disappeared when I moved offices about two years ago. You have
no choice but to believe me.
"The main recollections I have are that in the beginning things went
far better than I could have imagined. ~ot sure a,hy, but Helle took to
me immediately. Couldn't have been my good looks. I had just had
cataract surgery and my eye looked like hell. And n1y ataxia did not im-
prove my sex appeal ... this is familial cerebellar ataxia. if you're curi-
ous. Definitely progressive ... a walker in n1y future. another year or
two, and a wheelchair in three or four. C'est la vie.
"I think Belle liked me because I treated her like a person. I did ex-
 448 TH E YA LO l\I RE AD ER

actly what you're doing now-and I want to tell you, Dr. Lash, I appre-
ciate your doing it. I didn't read any of her charts. I went into it blind,
wanted to be entirely fresh. Belle was never a diagnosis to me, not a bor-
derline, not an eating disorder, not a compulsive or antisocial disorder.
That's the way I approach all n1y patients. And I hope I will never be-
come a diagnosis to you.
"What, do I think there's a place for diagnosis? Well, I know you
guys graduating now, and the whole psychopharrn industry, live by di-
agnosis. The psychiatric journals are littered with meaningless discus-
sions about nuances of diagnosis. Future flotsam. I know it's important
in some psychoses, but it plays little role-in fact, a negative role-in
everyday psychotherapy. Ever think about the fact that it's easier to
make a diagnosis the first time you see a patient and that it gets harder
the better you know a patient? Ask any experienced therapist in pri-
vate-they'll tell you the same thing! In other words, certainty is in-
versely proportional to knowledge. Some kind of science, huh?
"What I'1n saying to you, Dr. Lash, is not just that I didn't make a di-
agnosis on Belle; I didn't think diagnosis. I still don't. Despite what's
I
t
happened, despite what she's done to me, I still don't. And I think she
knew that. We were just two people making contact. And I liked Belle.
Always did. Liked her a lot! And she knew that, too. Maybe that's the
main thing.
"Now Belle was not a good talking-therapy patient-not by any-
one's standard. Impulsive, action-oriented, no curiosity about herself,
nonintr ospcctive, unable to free-associate. She always failed at the tradi-
tional tasks of thernpy-e-self-examination, insight-and then felt worse
about herself. That's why therapy had always bombed. And that's why I
knew I had to get her attention in other ways. That's why I had to in-
vent a new therapy for Belle.
"For example? Well, let me give you one from early therapy, maybe
the third or fourth month. I'd been focusing on her self-destructive sex-
ual behavior and asking her about what she really wanted from men,
including the first man in her life, her father. But I was getting
nowhere. She was real resistive to talking about the past-done too
much of that with other shrinks, she said. Also she had a notion that
poking in the ashes of the past was just an excuse to evade personal re-
 The Psychological Novel -H9

sponsibility for our actions. She had read 1ny book on psychotherapy
and cited me saying that very thing. I hate that. When patients resist hy
citing your own books, they got you by the halls.
"One session I asked her for some early daydreams or sexual fan-
tasies and finally, to humor me, she described a recurrent fantasy frorn
the time she was eight or nine: a storm outside, she comes into a room
cold and soaking wet, and an older man is waiting for her. He embraces
her, takes off her wet clothes, dries her with a large warm towel, gives
her hot chocolate. So I suggested we role-play: I told her to go out of the
office and enter again pretending to be wet and cold. I skipped the un-
dressing part, of course, got a good-sized towel from the washroom, and
dried her off vigorously-staying nonsexual, as I always did. I 'dried'
her back and her hair, then bundled her up in the towel, sat her down,
and made her a cup of instant hot chocolate.
"Don't ask me why or how I chose to do this at that time. When
you've practiced as long as I have, you learn to trust your intuition. And
the intervention changed everything. Belle was speechless for a while,
tears welled up in her eyes, and then she bawled like a baby. Belle had
never, never cried in therapy. The resistance just melted away.
"What do I mean hy her resistance melting? I mean that she trusted
me, that she believed we were on the same side. The technical term, Dr.
Lash, is 'therapeutic alliance.' After that she became a real patient. Im-
portant material just erupted out of her. She began to live for the next
session. Therapy became the center of her life. Over and over she told
me how important I was to her. And this was after only three months.
"Was I too important? No, Dr. Lash, the therapist can't he too irn-
portant early in therapy. Even Freud used the strategy of trying to re-
place a psychoneurosis with a transference neurosis-that's a powerful
way of gaining control over destructive sy1npto1ns.
"You look puzzled hy this. \Vell, what happens is that the patient be-
comes obsessed with the thernpisr-c-rurninates powerfully about each
session, has long fantasy conversations with the therapist between ses-
sions. Eventually the sy1nptoms are taken over by therapy. In other
words, the symptoms, rather than being driven by inner neurotic fac-
tors, begin to fluctuate according to the exigencies of the th era peutic re-
lationship.
 450 THE Y ALOM READER

"No, thanks, no more coffee, Ernest. But you have some. You mind
if I call you Ernest? Good. So to continue, I capitalized on this develop-
ment. I did all I could to become even more important to Belle. I an-
swered every question she asked me about my own life, I supported the
positive parts of her. I told her what an intelligent, good-looking
woman she was. I hated what she was doing to herself and told her so
very directly. None of this was hard: all I had to do was tell the truth.
"Earlier you asked what my technique was. Maybe my best answer is
simply: I told the truth. Gradually I began to play a larger role in her fan-
tasy life. She'd slip into long reveries about the two of us-just being to-
gether, holding each other, n1y playing baby games with her, my
feeding her. Once she brought a container of Jell-0 and a spoon into the
office and asked me to feed her-which I did, to her great delight.
"Sounds innocent, doesn't it? But I knew, even at the beginning, that
there was a shadow looming. I knew it then, I knew it when she talked
about how aroused she got when I fed her. I knew it when she talked
about going canoeing for long periods, two or three days a week, just so
she could be alone, float on the water, and enjoy her reveries about me. I
knew my approach was risky, but it was a calculated risk. I was going to
allow the positive transference to build so that I could use it to combat
her self-destructiveness.
"And after a few months I had become so important to her that I
could begin to lean on her pathology. First, I concentrated on the life-
or-death stuff: HIV, the bar scene, the highway-angel-of-mercy blow
jobs. She got an HIV test-negative, thank God. I remember waiting
the two weeks for the results of the HIV test. Let me tell you, I sweated
that one as much as she did.
"You ever work with patients when they're waiting for the results of
the HIV test? No? Well, Ernest, that waiting period is a window of op-
portunity. You can use it to do some real work. For a few days patients
come face-to-face with their own death, possibly for the first time. It's a
time when you can help them to examine and reshuffle their priorities,
to base their lives and their behavior on the things that really count. Ex-
I
istential shock therapy, I sometimes call it. But not Belle. Didn't faze her.

'
Just had too much denial. Like so many other self-destructive patients, \

Belle felt invulnerable at anyone's hand other than her own.

 The Psychological Novel 451

"I taught her about HIV and about herpes, which, miraculously, she
didn't have either, and about safe-sex procedures. I coached her on safer
places to pick up men if she absolutely had to: tennis clubs, PTA meet-
ings, bookstore readings. Belle was sornething-c-what an operator! She
could arrange an assignation with some handsome total stranger in five
or six minutes, sometimes with an unsuspecting wife only ten feet away.
I have to admit I envied her. Most women don't appreciate their good
fortune in this regard. Can you see rnen---especially a pillaged wreck
like me-doing that at will?
"One surprising thing about Belle, given what I've told you so far,
was her absolute honesty. In our first couple of sessions, when we were
deciding to work together, I laid out my basic condition of therapy: total
honesty. She had to commit herself to share every important event of her
life: drug use, impulsive sexual acting out, cutting, purging, fantasies-
everything. Otherwise, I told her, we were wasting her time. But if she
leveled with me about everything, she could absolutely count on me to
see this through with her. She promised and we solemnly shook hands
on our contract.
"And, as far as I know, she kept her promise. In fact, this was part of
my leverage because if there were important slips during the week-if,
for example, she scratched her wrists or went to a bar-I'd analyze it to
death. I'd insist on a deep and lengthy investigation of what happened
just before the slip. 'Please, Belle,' I'd say, 'I must hear everything that
preceded the event, everything that might help us understand it: the
earlier events of the day, your thoughts, your feelings, your fantasies.'
That drove Belle up the wall-she had other things she wanted to talk
about and hated using up big chunks of her therapy time on this. That
alone helped her control her impulsivity.
"Insight? Not a major player in Belle's therapy. Oh, she grew to rec-
ognize that more often than not her impulsive behavior was preceded
by a feeling state of great deadness or emptiness and that the risk tak-
ing, the cutting, the sex, the bingeing, were all attempts to fill herself up
or to bring herself back to life.
"But what Belle didn't grasp was that these attempts were futile.
Every single one backfired, since they resulted in eventual deep shame
and then more frantic-and more self-destructive-attempts to feel
 452 THE YALOM READER

alive. Belle was always strangely obtuse at apprehending the idea that
her behavior had consequences.
'1So insight wasn't helpful. I had to do something else-and I tried
every device in the book, and then some-to help her control her irn-
pulsivity. We compiled a list of her destructive impulsive behaviors, and
she agreed not to embark on any of these before phoning me and allow-
ing me a chance to talk her down. But she rarely phoned-she didn't
want to intrude on my time. Deep down she was convinced that my
commitment to her was tissue-thin and that I would soon tire of her and
dump her. I couldn't dissuade her of this. She asked for some concrete
memento of me to carry around with her. It would give her n1ore self-
control. Choose something in the office, I told her. She pulled my hand-
kerchief out of n1y jacket. I gave it to her, but first wrote some of her
important dynamics on it:
"'I feel dead and I hurt myself to know rm alive. I feel deadened and
must take dangerous risks to feel alive. I feel empty and try to fill myself
with drugs, food, semen. But these are brief fixes. I end up feeling
shame-and even more dead and empty.'
"I instructed Belle to meditate on the handkerchief and the messages
every time she felt impulsive.
"You look quizzical, Ernest. You disapprove? Why? Too gim- 1
!

micky? Not so. It seems gimmicky, I agree, but desperate remedies for
desperate conditions. For patients who seem never to have developed a
definitive sense of object constancy, I've found some possession, some
concrete reminder, very useful. One of my teachers, Lewis Hill, who
was a genius at treating severely ill schizophrenic patients, used to
breathe into a tiny bottle and give it to his patients to wear around their
necks when he left for vacation.
"You think that's gimmicky too, Ernest? Let me substitute another
word, the proper word: creative. Remember what I said earlier about
creating a new therapy for every patient? This is exactly what I meant.
Besides, you haven't asked the most important question.
"Did it work? Exactly, exactly. That's the proper question. The only
question. Forget the rules. Yes, it worked! It worked for Dr. Hill's pa-
tients and it worked for Belle, who carried around my handkerchief
and gradually gained more control over her impulsivity. Her 'slips' be-
 The Psychological Novel 453

came less frequent and soon we could begin to turn our attention else-
where in our therapy hours.
"What? Merely a transference cure? Something about this is really
getting to you, Ernest. That's good-it's good to question. You have a
sense for the real issues. Let me tell you, you' re in the wrong place in
your life-you're not meant to be a neurochernist. Well, Freud's deni-
gration of 'transference cure' is almost a century old. Some truth to it,
but basically it's wrong.
"Trust me: if vou, can break into a self-destructive cvcle
, of behav-
ior-no matter how you do it-you've accomplished something impor-
tant. The first step has got to be to interrupt the vicious circle of
self-hate, self-destruction, and then more self-hate from the shame at
one's behavior. Though she never expressed it, imagine the shame and
self-contempt Belle must have felt about her degraded behavior. It's the
therapist's task to help reverse that process. Karen Horney once said ....
Do vou, know Hornev's . work, Ernest?
"Pity, but that seems to be the fate of the leading theoreticians of our
field-their teachings survive for about one generation. Horney was
one of my favorites. I read all of her work during my training. Her best
book, Neuroses and Human Growth, is over fifty years old, but it's as
good a book about therapy as you'll ever read-and not one word of
jargon. I'm going to send you my copy. Somewhere, perhaps in that
book, she made the simple but powerful point: 'If you want to be proud
of yourself, then do things in which you can take pride.'
"I've lost my way in my story. Help me get started again, Ernest. ~vly
relationship with Belle? Of course, that's what we're really here for,
isn't it? There were many interesting developments on that front. But
I know that the development of most relevance for your committee is
physical touching. Belle made an issue of this almost from the start.
Now, I make a habit of physically touching all of my patients, male and
female, every session-generally a handshake upon leaving. or perhaps
a pat on the shoulder. Well, Belle didn't much care for that: she refused
to shake my hand and began making some mocking statement like, 'ls
that an APA-approved shake?' or 'Couldn't you try to be a little more
formal?'
"Sometimes she'd end the session by gi\'ing me a hug-always
 ..

454 THE Y ALO~l READER

friendly, not sexual. The next session she'd chide me about my behavior,
about rny formality, about the way I'd stiffen up when she hugged me.
And 'stiffen' refers to my body, not 1ny cock, Ernest-I saw that look.
You'd make a lousy poker player. We're not yet at the lascivious part.
I'll cue you when we arrive.
"She'd complain about rny age-typing. If she were old and wizened,
she said, I'd have no hesitation about hugging her. She's probably right
about that. Physical contact was extraordinarily important for Belle: she
insisted that we touch and she never stopped insisting. Push, push, push.
Nonstop. But I could understand it: Belle had grown up touch-
deprived. Her mother <lied when she was an infant, and she was raised
by a series of remote Swiss goyernesses. And her father! Imagine grow-
ing up with a father who had a gern1 phobia, never touched her, always
wore gloves in and out of the home. Had the servants wash and iron all
his paper currency.
"Gradually, after about a year, I had loosened up enough, or had
been softened up enough by Belle's relentless pressure, to begin ending
the sessions regularly with an avuncular hug. Avuncular? It means 'like
an uncle.' But whatever I gave, she always asked for more, always tried
to kiss me on the cheek when she hugged me. I always insisted on her
honoring the boundaries, and she always insisted on pressing against
them. I can't tell you how many little lectures I gave her about this, how
many books and articles on the topic I gave her to read.
"But she was like a child in a woman's body-a knockout woman's
body, incidentally-and her craving for contact was relentless. Couldn't
she move her chair closer? Couldn't I hold her hand for a few minutes?
Couldn't we sit next to each other on the sofa? Couldn't I just put my
arm around her and sit in silence, or take a walk, instead of talking?
"And she was ingeniously persuasive. 'Seymour,' she'd say, 'you talk
a good ga1ne about creating a new therapy for each patient, but what
you left out of your articles was "as long as it's in the official manual" or
"as long as it doesn't interfere with the therapist's middle-aged bour-
geois cornfort.?' She'd chide me about taking refuge in the APA's
guidelines about boundaries in therapy. She knew I had been responsi-
ble for writing those guidelines when I was president of the APA, and I
she accused me of being imprisoned by my own rules. She'd criticize me

l
 The Psychological No,·el 455

for not reading n1y own articles. 'You stress the honoring of each pa-
tient's uniqueness, and then you pretend that a single set of rules can fit
all patients in all situations. We all get lumped together: she'd say, 'as if
all patients were the same and should be treated the same.' And her
chorus was always, 'What's more important: Following the rules? Stay-
ing in your armchair cornfort zone? Or doing what's best for your pa-
tient?'
"Other times she'd rail about n1y 'defensive therapy': 'You're so ter-
rified about being sued. All you humanistic therapists cower before the
lawyers, while at the same time you urge your mentally ill patients to
grab hold of their freedom. Do you really think I would sue you? Don't
you know me yet, Seymour? You're saving my life. And I love you!'
"And, you know, Ernest, she was right. She had me on the run. I was
cowering. I was defending 1ny guidelines even in a situation where I
knew they were antitherapeutic, I was placing my timidity, my fears
about my little career, before her best interests. Really, when you look at
things from a disinterested position, there was nothing wrong with let-
ting her sit next to me and hold n1y hand. In fact, every time I did this,
without fail, it charged up our therapy: she became less defensive,
trusted me more, had more access to her inner life.
"What? Is there any place at all for firm boundaries in therapies? Of
course there is. Listen on, Ernest. ~'ly problem was that Belle railed at
all boundaries, like a bull and a red flag. \VhereYer-wherever-1 set
the boundaries she pushed and pushed against them. She took to wear-
ing skimpy clothes or see-through blouses with no brassiere. When I
commented on this, she ridiculed me for my Victorian attitudes toward
.
the bodv, I wanted to know every. intimate contour of her mind, she'd
say, yet her skin was a no-no. A couple of times she complained about a
breast lump and asked me to examine her-of course, I didn't. She'd
obsess about sex with me for hours on end, and beg me to have sex with
her just once. One of her arguments was that one-time sex with rne
would break her obsession. She'd learn that it was nothing special or
magical and then be freed to think about other things in Iife.
"How did her earn paign for sexual contact make me feel? Good
question, Ernest, but is it germane to this investigation?
"You're not sure? What seems to he gennane is what I did-that's
 456 THE YALOM READER

what I'm being judged for-not what I felt or thought. Nobody gives a
shit about that in a lynching[ But if you turn off the tape recorder for a
couple of minutes, J'll tell you. Consider it instruction. You've read
Rilke's Lettersto a YoungPoet, haven't you? Well, consider this my let-
ter to a young therapist.
"Good. Your pen, too, Ernest. Put it down, and just listen for a
while. You want to know how this affected me? A beautiful woman ob-
sessed with me, masturbating daily while thinking of me, begging me to
lay her, talking on and on about her fantasies about me, about rubbing
my sperm over her face or putting it into chocolate chip cookies-how
do you think it made me feel? Look at me! Two canes, getting worse,
ugly-my face being swallowed up in my own wrinkles, my body
flabby. falling apart.
"I admit it. l'm only human. 1t began to get to me. I thought of her
when I got dressed on the days we had a session. What kind of shirt to
wear? She hated broad stripes-made me look too self-satisfied, she
said. And which aftershave lotion? She liked Royall Lyme better than
Mennen, and I'd vacillate each time over which one to use. Generally
I'd splash on the Royall Lyme. One day at her tennis club, she met one
of my colleagues-a nerd, a real narcissist who's always been competi-
tive with me-and as soon as she heard he had some connection to me,
she got him to talk about me. His connection to me turned her on, and
she immediately went home with him. Imagine, this schnook gets laid
by this great-looking woman and doesn't know it's because of me. And
I can't tell him. Pissed me off.
"But having strong feelings about a patient is one thing. Acting on
them is another. And I fought against it-I analyzed myself continu-
ally, J consulted with a couple of friends on an ongoing basis, and I tried
to deal with it in the sessions. Time after time I told her there was no
way in hell I would ever have sex with her, that I wouldn't ever again be
able to feel good about myself if I did. I told her that she needed a good,
caring therapist much more than she needed an aging, crippled lover.
But I did acknowledge my attraction to her. I told her I didn't want her
sitting so close to me because the physical contact stimulated me and
rendered me less effective as a therapist. I took an authoritarian posture:
I insisted that my long-range vision was better than hers, that I knew
things about her therapy that she couldn't yet know.
 The Psychological Novel 457

"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 syrnptoms. 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 n~ry 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 I 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 my-
self, 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!'
"I started to say something placating, but she cut me off. Her desper-
ation had escalated and out of it came a desperate proposition. 'Sey-
mour, 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 in-
centive! 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 seri-
ous--<lead 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. Prepos-
terous! 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-hehaYior 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
 458 THE YA LOM REA DER

Belle's proposition. I couldn't help it. I toyed with it in my mind. A year

and a half-ezghteen 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 was 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 ex-
actly 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 in-
trinsically, radically changed, if she behaved in a fundamentally differ-
ent fashion for eighteen months?
"You won't commit yourself? I can't blame you-considering 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 111e 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?
i
"Come on, Ernest. Don't you? Don't you love the applause when you
finish giving grand rounds? Don't you love the people, especially the \
women, crowding around?
 The Psychological I\" ovel 459

"Good! I appreciate your honesty. Nothing to he 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 n1y job: to introduce
her to reality, to help her grow away from me. Even, God sa Ye us, to
forget me.
"Well, as the days and the weeks went on, I grew more and more in-
trigued with Belle's wager. Eighteen months of being dean, she offered.
And remember that was still an early offer. I'n1 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 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. Grear docs, every one
of them, but poker chumps. You know, Ernest, interns were paid al-
most nothing in those days, and at the end of the year all the other in-
terns were in deep debt. Me? I drove to my residency at Ann Arbor in a
new De Soto convertible, courtesv, of the Park A venue 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 n<:cding in-
centive, and I opened serious negotiation. I insisted on two yea rs. She
was so grateful to be taken seriously that she agreed to all my terms, and
 460 THE YA LOM READER

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 cut-
ting, no purging, no sex pickups in bars or highways or any other dan-
gerous 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 cou-
ples 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 first
time I began to see seeds of curiosity about herself; she signed up for
some university extension courses on abnormal psychology, and she be ..
gan 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 father's fanatical insistence on cleanliness and or-
der. 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 <lining antics: gloves, hand washing between courses, inspec-
tions 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 per- •
functory contact with her father, who soon remarried. His new wife
 The Psychological Novel 461

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 power-
ful affirmation' she'd ever gotten. She knew that the wager was a gift to
her: unlike 'gifts' she had received from other shrinks-words, inter-
pretations, promises, 'therapeutic caring'-this gift was real and palpa-
ble. 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 will-
ingness 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 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--exact1y! 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 rea-
son that you listen to my tale with such interest? More than interest! Do
 462 THE Y AL0.\1 READER

I go too far if I call u fascinationi Your eyes are like saucers. Ycs, Ernest,
you and me. You could have been me in my situation. My Faustian wa-
ger 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 1nay come when you open your-
self 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 ~nvay 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 rne course in your veins, let me teach you. Re-
member, 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 rep! ies.
"Okay, where were we? Well, the first year passed with Belle defi-
nitely 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 hus-
band refused couples therapy but agreed to meet with a Christian Sci-
ence practitioner for several sessions. Belle told me that their
communication had improved, and both of them seemed more content
with their relationship.
"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 movernenrs-c-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 ass-
 The Psychological ~o,·el 46 3

hole, she met at the tennis cluh. Hut at least it was safe sex, a for cry from
the bar and high way 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! Corn pare
her outcome with any drug therapy: Risperidone, Prozac, Paxil, Ef-
fexor, \Vellbutrin-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 anvone
. about it. Until now! You're mv. first real au-
dience.
"At about the eighteen-n1onth 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 eYery 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 rnarried, 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 onlv, an hour or two a week-she could live healthv, and
happy with that forever.
"Well, you can imagine that by this time I was growing a little un-
easy. 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 rny family die
young. At my age my father had been in his coffin for fifteen years. She
would outlive me at least twentv-five
. vear
. s, I even began exaggerating
my neurological impairment when I was with her. Once I staged an in-
tentional 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 vears
'
since I'd been a wake for the ten o'clock news. And mv.
failing vision, my shoulder bursitis, rny dyspepsia, rny prostate, rny
gassiness, my constipation. I even thought of getting a hearing aid. just
for the effect.
 464 THE Y Al.OM READER

"But all this was a terrihle blunder. One hundred eighty degrees
wrong! It just whetted her appetite even more. She had some perverse
infatuation with the idea of my being infirm or incapacitated. She had
fantasies of 1ny having a stroke, of n1y wife leaving me, of her moving in
to care for me. One of her favorite daydreams involved nursing me:
making 1ny 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 irnprovement 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 con-
trol and AIDS, and had been accepted in an MBA program at a local
. .
university.
"What's that, Ernest? How did I know she was telling 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 un-
seemly 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 mc-e-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 hut agreed to come in to help accel-
erate 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 1ny work-and who also corrobo-
rated Belle's story: working hard on her marriage, no cutting, no drugs, ~-,
community volunteer work. No, Belle was playing it straight.
"So what would you have done in this situation, Ernest? What?
 The Psychological Novel 465

Wouldn't have been there in the first place? Yeah, yeah, I know. Facile
answer. You disappoint me. Tell me, Ernest, if you wouldn't have been
there, where would you have been? Back in your lab? Or in the library?
You'd be safe. Proper and comfortable. But where would the patient
be? Long gone, that's where! Just like Belle's twenty therapists before
me-they all took the safe route, too. But I'n1 a different kind of thera-
pist. A saver of lost souls. I refuse to quit on a patient. I will break my
neck, I'll put my ass on the line, I'll try anything to save the patient.
That's been true n1y whole career. You know n1y reputation? Ask
around. Ask your chairman. He knows. He's sent me dozens of pa-
tients. I'm the therapist of last resort. Therapists send me the patients
they give up on. You're nodding? You've heard that about me? Good!
It's good you know I'm not just some senile schnook.
"So consider my position! \Vhat the hell could I do? I was getting
jumpy. I pulled out all the stops: I began to interpret like mad, in a
frenzy, as if my life depended on it. I interpreted everything that
moved.
"And I got impatient with her illusions. For example, take Belle's
loony fantasy of our being married and her putting her life on hold
waiting all week, in suspended animation, for an hour or two with me.
'What kind of life is that and what kind of relationship?' I asked her. It
was not a relationship-it was shamanism. Think of it from my point
of view, I'd say: What did she imagine I'd get out of such an arrange-
ment? To have her healed by an hour of my presence-it was unreal.
Was this a relationship? No! We weren't being real with each other; she
was using me as an icon. And her obsession with sucking me and swal-
lowing my sperm. Same thing. Unreal. She felt empty and wanted me
to fill her up with my essence. Couldn't she see what she was doing,
couldn't she see the error in treating the symbolic as if it were concrete
reality? How long did she think my thimbleful of sperm would fill her
up? In a few seconds her gastric hydrochloric acid would leaYe nothing
but fragmented DNA chains.
"Belle gravely nodded at my frenetic interpretations-and then re-
turned to her knitting. Her Narcotics Anonymous spon~nr had taught
her to knit, and during the last weeks she worked continuously on a
cable-stitched sweater for me to wear during our weekend. I found no
 466 THEY ALO:\! READ[R

way to rattle her. Yes, she agreed that she might be basing her life on
fantasy. Maybe she was searching for the wise old man archetype. But
was thar so bad) In addition to her MBA program, she was auditing a
course in anrhropology and reading The Golden Rough. She reminded
me that most of mankind lived according to such irrational concepts as
totems, reincarnation, heaven, and hell, even transferencecures of ther-
apy, and the deification of Freud. 'Whatever works works,' she said,
'and the thought of our being togcrher for the weekend works. This has
been the best time in my life; it feels just like being married to you. It's
like waiting and knowing you'll be coming home to me shortly; it keeps
me going, it keeps me content.' And with that she turned back to her
knitting. That goddamned sweater! I felt like ripping it out of her
hands.
"By the twenty-two-month mark, I hit the panic button. I lost all
composure and began wheedling, weaseling, begglng. I lectured her on
love. 'You say you love me, but love is a relationship, love is caring about
the other, caring about the growrh and the being ofrhe other. Do you
ever care about me? Howl feel? Do you ever think about my guilt, my
fear, the impact of this on my self-respect, knowing that I've done
somethlng unethical? And the impact on my reputation, the risk I'm
running-my profession, my marriage?'
"'How many times,' Belle responded, 'have you reminded me that
we are two people in a human encounter-nothing more, nothing less?
You asked me to trust you, and I trusted you-I trusted for the first
rime in my life. Now I ask you to trust me. This will be our secrer. I'll
take it to my grave. No matter what happens. Forever! And as for your
self-respect and your guilt and your professional concerns, well, what's
more important than the fact that you, a healer, are healing me? Will
you let rules and reputation and ethics take precedence over that?' You
got a good answer for that, Ernest? I didn't.
"Subtly, but ominously, she alluded to the potential effects of my
welshing on the wager. She had lived for two yean for this weekend
with me. Would she ever trust again? Any therapist? Or anyone, for
that matter? That, she let me know, would be something for me to feel
guilty about. She didn't have to say very much. I knew what my be-
trayal would mean to her. She had not been self-destructive for over
 The Psychological Novel 467

two years, but I had no doubt she had not lost the knack. To put it
bluntly, I was convinced that if I welshed, Belle would kill herself. I still
tried to escape from my trap, but n1y wing beats grew more feeble.
"'I'n1 seventy years old-you're thirty-four,' I told her. 'There's
something unnatural about us sleeping together.'
"'Chaplin, Kissinger, Picasso, Humbert Humbert and Lolita,' Belle
responded, not even bothering to look up from her knitting.
"You've built this up to grotesque levels,' I told her; 'it's all so in-
flated, so exaggerated, so removed from reality. This whole weekend
cannot fail to be a downer for vou.'
"'A downer is the best thing that could happen; she replied. 'You
know-to break down rnv obsession about you, n1y "erotic transfer-
ence," as you like to call it. This is a no-loser for our therapy.'
"I kept weaseling. 'Besides, at n1y age, potency wanes.'
"'Seymour,' she chided me, 'I'm surprised at you. You still haven't
gotten it, still haven't gotten that potency or intercourse is of no concern.
What I want is you to be with me and hold me-as a person, a woman.
Not as a patient. Besides, Seymour,' and here she held the half-knitted
sweater in front of her face, coyly peeked over, and said, 'I'm going to
give you the fuck of your life!'
"And then time was up. The twenty-fourth month arrived and I had
no choice but to pay the devil his due. If I welshed, I knew the conse-
quences would be catastrophic. If, on the other hand, I kept my word?
Then, who knows? Perhaps she was right, perhaps it would break the
obsession. Perhaps, without the erotic transference, her energies would
be freed to relate better to her husband. She'd maintain her faith in
therapy. I'd retire in a couple of years, and she'd go on to other thera-
pists. Maybe a weekend in San Francisco with Belle would be an act of
supreme therapeutic agape.
"What, Ernest? M y countertransference? Saine as yours would have
been: gyrating wildly. I tried to keep it out of 1ny decision. I didn't act
on my countertransference-1 was convinced I had no other rational
choice. And I'm convinced of that still, even in the light of what has
happened. But I'll cop to being more than a little enthralled. There I
was, an old man facing the end, with cerebellar cortical neurons croak-
ing daily, eyes failing, sexual life all hut over-rny wife, who's good at
 468 THE YA l. 0 ~1 RE ADER

g1v1ng things up, gave sex up long ago. And my attraction toward
Belle? I won't deny it: I adored her. And when she told me she was go-
ing to give me the fuck of tny life, I could hear n1y worn-out gonadal
engines cranking up and turning over again. But let me say to you-
and the tape recorder, let me say it as forcefully as I can-that's not why
I did it! That may not be important to you or the ethics board, but it's of
life-or-death importance to me. I never broke n1y covenant with Belle. I
never broke my covenant with any patient. I never put my needs ahead
of theirs.
"As for the rest of the story, I guess you know it. It's all in your chart
there. Belle and I met in San Francisco for breakfast at Mama's in
North Beach on Saturday morning and stayed together till Sunday
dusk. We decided to tell our spouses that I had scheduled a weekend
marathon group for 1ny patients. I do such groups for ten to twelve of
my patients about twice a year. In fact, Belle had attended such a week-
end during her first year of therapy.
"You ever run groups like that, Ernest? No? Well let me tell you
that they are powerful ... accelerate therapy like mad. You should
know about them. When we meet again-and I'm sure we will, under
different circumstances-e-I'Il tell you about these groups; I've been do-
j
ing them for thirty-five years.
"But back to the weekend. Not fair to bring you this for and not share
the climax. Let's see, what can I tell you? What do I want to tell you? I
tried to keep n1y dignity, to stay within my therapist persona, but that l
didn't last long-Belle saw to that. She called me on it as soon as we had
checked into the Fairmont, and very soon we were man and woman and
everything, everything that Belle had predicted came to pass.
"I won't lie to you, Ernest. I loved every minute of our weekend,
most of which we spent in bed. I was worried that all my pipes were
rusted shut after so 1nany years of disuse. But Belle was a master
plumber, and after some rattling and clanging everything began to
work again.
"For three years I had chided Belle for living in illusion and had im-
posed n1y reality on her. Now, for one weekend, I entered her world
and found out that life in the magic kingdom wasn't so bad. She was my
fountain of youth. Hour by hour I grew younger and stronger. I walked
 The Psychological ~o\'el 469

better, I sucked in mv, stomach. I looked taller. Ernest. I tell you, I felt
. ;

like bellowing. And Belle noticed it. 'This is what you needed, Sey-
mour. And this is all I ever wanted from vou-to be held, to hold, to
give my love. Do you understand that this is the first time in n1y life I
have given love? Is it so terrible?'
.. She cried a lot. Along with all other conduits, n1y lachrymal ducts,
too, had unplugged, and I cried too. She gaYe me so much that week-
end. I spent my whole career giving. and this was the first time it came
back, really came back, to me. It's like she g::iye for all the other patients
I'Ye ever seen.
"But then real life resumed. The weekend ended. Belle and I went
back to our twice-weekly sessions. I never anticipated losing that wager,
so I had no contingency plans for the postweekend therapy. I tried to go
back to business as usual, but after one or two sessions I saw I had a
problem. A big problem. It is almost impossible for intimates to return
to a formal relationship. Despite my efforts, a new tone of loving play-
fulness replaced the serious work of therapy. Sometimes Belle insisted
on sitting in my lap. She did a lot of hugging and stroking and groping.
I tried to fend her off, I tried to maintain J serious work ethic, but, let's
face it, it was no longer therapy.
"I called a halt and solemnly suggested we had two options: either
we try to go back to serious work, which meant returning to a nonphys-
ical and more traditional relationship, or we drop the pretense that
we're doing therapy and try to establish a purely social relationship.
And 'social' didn't mean sexual: I didn't want to compound the prob-
lem. I told you before, I helped write the guidelines condemning thera-
pists and patients having posttherapy sexual relationships. I also made it
clear to her that, since we were no longer doing therapy. I would accept
no more money from her.
"Neither of those options were acceptable to Belle. A return to for-
mality in therapy seemed a farce. Isn't the therapy relationship the one
place where you don't play gan1es? As for not paying, that was impossi-
ble. Her husband had set up an office at home and spent most of his
time around the house. How could she explain to him where she was
going for two regular hours a week if she was not regularly wr iting
checks for therapy?
 4 70 T H E Y A LO M R EA D ER

"Belle chided me for my narrow definition of therapy. 'Our meet-

ings together-intimate, playful, touching, sometimes making good
love, real love, on your couch-that is therapy. And good therapy, too.
Why can't you see that, Seymour?' she asked. 'Isn't effective therapy
good therapy? Have you forgotten your pronouncements about the
"one important question in therapy"-Does it work? And isn't my ther-
apy working? Aren't I continuing to do well? I've stayed clean. No
symptoms. Finishing grad school. I'm starting a new life. You've
changed me, Seymour, and all you have to do to maintain the change is
continue to spend two hours a week being close to me.'
"Belle was a smart cookie, all right. And growing smarter. I could
marshal no counterargument that such an arrangement was not good
therapy.
"Yet I knew it couldn't be. I enjoyed it too much. Gradually, much
too gradually, it dawned on me that I was in big trouble. Anyone look-
ing at the two of us together would conclude that I was exploiting the
transference and using this patient for my own pleasure. Or that I was a
high-priced geriatric gigolo!
"I didn't know what to do. Obviously I couldn't consult with any-
one-I knew what they would advise and I wasn't ready to bite the bul-
let. Nor could I refer her to another therapist-she wouldn't go. But to
be honest, I didn't push that option hard. I worry about that. Did I do
right by her? I lost a few nights' sleep thinking about her telling another
therapist all about me. You know how therapists gossip an1ong them-
sel ves about the antics of previous therapists-and they'd just love some
juicy Seymour Trotter gossip. Yet I couldn't ask her to protect me-
keeping that kind of secret would sabotage her next therapy. •
"So my small-craft warnings were up but, even so, I was absolutely
unprepared for the fury of the storm when it finally broke. One evening
I returned home to find the house dark, my wife gone, and four pictures
of me and Belle tacked to the front door: one showed us checking in at
the registration desk of the Fairmont Hotel; another showed us, suit-
cases in hand, entering our room together; the third was a close-up of
the hotel registration form-Belle had paid cash and registered us as
Dr. and Mrs. Seymour, The fourth showed us locked in an embrace at
the Golden Gate Bridge scenic overlook.
 The Psychological Novel 4 71

"Inside, on the kitchen table, I found two letters: one from Belle's
husband to my wife, stating that she might be interested in the four en-
closed pictures portraying the type of treatment her husband was offer-
ing his wife. He said he had sent a similar letter to the state board of
medical ethics and ended with a nasty threat suggesting that if I ever
saw Belle again, a lawsuit would be the least important thing the Trot-
ter family would have to worry about. The second letter was from my
wife-short and to the point, asking me not to bother to explain. I could
do my talking to her lawyer. She gave me twenty-four hours to pack up
and move out of the house.
"So, Ernest, that brings us up to now. What else can I tell you?
"How'd he get the pictures? Must've hired a private eye to tail us.
What irony-that her husband chose to leave only when Belle had im-
proved! But, who knows? Maybe he'd been looking for an escape for a
long time. Maybe Belle had burned him out.
"I never saw Belle again. All I know is hearsay from an old buddy of
mine at Pacific Redwood Hospital-and it ain't good hearsay. Her hus-
band divorced her and ultimately skipped the country with the family
assets. He had been suspicious of Belle for months, ever since he had
spotted some condoms in her purse. That, of course, is further irony: it
was only because therapy had curbed her lethal self-destructiveness that
she was willing to use condoms in her affairs.
"The last I heard, Belle's condition was terrible-back to ground
zero. All the old pathology was back: two admissions for suicidal at-
tempts--0ne cutting, one a serious overdose. She's going to kill herself.
I know it. Apparently she tried three new therapists, fired each in turn,
refuses further therapy, and is now doing hard drugs again.
"And you know what the worst thing is? I know I could help her,
even now. I'm sure of it, but I'm forbidden to see her or speak to her by
court order and under the threat of severe penalty. I got several phone
messages from her, but my attorney warned me that I was in great jeop-
ardy and ordered me, if I wanted to stay out of jail, not to respond. He
contacted Belle and informed her that by court injunction I was not per-
mitted to communicate with her. Finally she stopped calling.
"What am I going to do? About Belle, you mean? It's a tough call. It
kills me not to be able to answer her calls, but I don't like jails. I know I
 4 72 THE YA I. 0 M RE ADER

could do so much for her in a ten-minute conversation. Even now. Off

the record-shut off the recorder, Ernest. I'm not sure if I'm going to be
able to just let her sink.Not sure if I could live with myself.
"So, Ernest, that's it. The end of n1y tale. Finis. Let me tell you, it's
not the \vay I wanted to end my career. Belle is the major character in
this tragedy, but the situation is also catastrophic for me. Her lawyers
are urging her to ask for damages-to get all she can. They will have a
feeding frenzy-the malpractice suit is corning up in a couple of
months.
"Depressed! Of course I'm depressed. Who wouldn't be? I call it an
appropriate depression: I'm a miserable, sad old man. Discouraged,
lonely, full of self-doubts, ending my life in disgrace.
"No, Ernest, not a drug-treatable depression. Not that kind of de-
pression. No biological markers: psychomotor symptoms, insomnia,
l
weight loss-none of that. Thanks for offering.
"No, not suicidal, though I admit I'n1 drawn to darkness. But I'm a
survivor. I crawl into the cellar and lick my wounds.
"Yes, very much alone. My wife and I had been living together by
I
habit for many years. I've always lived for my work; my marriage has
always been on the periphery of my life. My wife always said I fulfill all
my desires for closeness with my patients. And she was right. But that's
not why she left. 11y ataxia's progressing fast, and I don't think she rel-
ished the idea of becoming my full-time nurse. My hunch is that she
welcomed the excuse to cut herself loose from that job. Can't blame her.
"No, I don't need to see anyone for therapy. I told you I'm not clini-
cally depressed. I appreciate your asking, Ernest, but I'd be a cantanker-
ous patient. So for, as I said, I'm licking my own wounds and I'm a
pretty good I icker.
"It's fine with me if you phone to check in. I'm touched by your of-
fer. But put your mind at ease, Ernest. I'm a tough son of a bitch. I'll be
all right."
And with that, Seymour Trotter collected his canes and lurched out
of the room. Ernest, still sitting, listened to the tapping grow fainter.

When Ernest phoned a couple of weeks later, Dr. Trotter once again re-
fused all offers of help. Within minutes he switched the conversation to
 The Psychological ~ovcl 4 73

Ernest's future and again expressed his strong conviction that, whatever
Ernest's strengths as a psychopharmacologist, he was still missing his
calling: he was a born therapist and owed it to himself to fulfill his des-
tiny. He invited Ernest to discuss the matter further over lunch, but
Ernest refused.
"Thoughtless of me," Dr. Trotter had responded without a trace of
irony. "Forgive me. Here I am advising you about a career shift and at the
same time asking you to jeopardize it by being seen in public with me."
"No, Seymour." For the first time Ernest called him by first name.
"That is absolutelv , not the reason. The truth is, and I am embarrassed
to say this to you, I'm committed already to serve as an expert witness at
your civil suit trial for malpractice."
"Embarrassment is not warranted, Ernest. It's your duty to testify. I
would do the same, precisely the same, in your position. Our profession
is vulnerable, threatened on all sides. It is our to duty to protect it and to
preserve standards. Even if you believe nothing else about me, believe
that I treasure this work. I've devoted my entire life to it. That's why I
told you my story in such detail-I wanted you to know it is not a story
of betrayal. I acted in good faith. I know it sounds absurd, yet even to
this moment I think I did the right thing. Sometimes destiny pitches us
into positions where the right thing is the wrong thing. I never betrayed
my field, nor a patient. Whatever the future brings, Ernest, believe me.
I believe in what I did: I would never betray a patient."
Ernest did testify at the civil trial. Seymour's attorney, citing his ad-
vanced age, diminished judgment, and infirmity, tried a novel, desper-
ate defense: he claimed that Seymour, not Belle, had been the victim.
But their case was hopeless, and Belle was awarded two million dol-
lars-the maximum of Seymour's malpractice coverage. Her lawyers
would have gone for more but there seemed little point to it since, after
his divorce and legal fees, Seymour's pockets were empty.
That was the end of the puhlic story of Seymour Trotter. Shortly af-
ter the trial he silently left town and was never heard fron1 again, aside
from a letter (with no return address) that Ernest received a year later.

Ernest had only a few minutes before his first patient. Hut he couldn't
resist inspecting, once again, the last trace of Seymour Trotter.
 4 74 THE YA LO ~1 RE AO ER

Dear Ernest,
You, alone, in those demonizing witch hunt days, expressed
concern for my welfare. Thank you-it was powerfully sustaining.
Am well. Lost, but don't want to be found. I owe you much--cer-
tainly this letter and this picture of Belle and me. That's her house
in the background, incidentally: Belle's come into a good bit of
money.
Seymour

Ernest, as he had so many times before, stared at the faded picture. On

a palm-studded lawn, Seymour sat in a wheelchair. Belle stood behind
him, forlorn and gaunt, fists clutching the handles of the wheelchair.
Her eyes were downcast. Behind her a graceful colonial home, and be-
yond that the gleaming milky-green water of a tropical sea. Seymour
was smiling-a big, goofy, crooked smile. He held on to the wheel-
chair with one hand; with the other, he pointed his cane jubilantly to-
ward the sky.
As always, when he studied the photograph, Ernest felt queasy. He
peered closer, trying to crawl into the picture, trying to discover some
clue, some definitive answer to the real fate of Seymour and Belle. The
key, he thought, was to be found in Belle's eyes. They seemed melan-
choly, even despondent. Why? She had gotten what she wanted, hadn't I
she? He moved closer to Belle and tried to catch her gaze. But she al-
vvays looked away.
I
r
 Notes
[Numbers in brackets refer to the note number of the original complete citation
of a reference in each chapter.]

CHAPTER I. THE THERAPEUTIC FACTORS

1. H. Feifel and J. Eells, "Patients and Therapists Assess the Same Psy-
chotherapy," Journal of Consulting and Clinical E,ychology 27 (1963): 310--18.
2. J. Schaffer and S. Dreyer, "Staff and Inpatient Perceptions of Change
Mechanisms in Group Therapy." American journal of Psychiatry I 39 (1982):
127-28; J. Flora-Tastado, "Patient and T'hernpist Agreement on Curative Fac-
tors in Psychotherapy," Dissertation Abstracts International 42 (1981): 371-B; S.
Bloch and J. Reibsrein, "Perceptions by Patients and Therapists of Therapeutic
Factors in Group Therapy," British Journal of Psychiatry 137 (1980): 274-78. R.
Cabral and A. Paton, "Evaluation of Group Therapy: Correlations Between
Clients' and Observers' Assessments," British Journal of Psychiatry 126 (1975):
475-77; and C. Glass and D. Arnkoff. "Common and Specific Factors in Client
Descriptions and Explanations for Change," journal of Integrative and Eclectic
Psychotherapy 7 (4 [ winter 1988]): 427-40.
3. T. Butler and A. Fuhriman, "Level of Functioning and Length of
Time in Treatment Variables Influencing Patients' Therapeutic Experience in
Group Psychotherapy." International Journal of Group Psychotherapy 33 (4 l Oc-
tober 19831): 489-504.
4. J. Maxmen, "Group Therapy as Viewed by Hospitalized Patients."
Archives of General Psychiatry 28 (March 1973): 404-8; T. Butler and A. Fuhri-
man, "Patient Perspective on the Curative Process: A Comparison of Day
Treatment and Outpatient Psychotherapy Groups," Small Group Behavior 11 (4
{November 1980]): 371-88; T. Butler and A. Fuhriman, "Curarivc Factors in
Group Therapy: A Review of the Recent Literature," Small Group Bchauior q
(2 [May 19831): 131-42; M. Leszcz, I. Yalorn, and ~L Norden. "The Value of In-
patient Group Psychotherapy: Patients' Perceptions." International Journal (f
Group Psychotherapy 35 (1985): 411-35; and E. Rynearson and S. :\klson,
"Short-term Group Psychotherapy for Patients with Functional Complaint."
Postgraduate Medical journal 76 ( 1984): 141-50.

475
 476 Notes

5. B. Corder, L. Whiteside, and T. Haizlip, "A Study of Curative Factors

in Group Psychotherapy with Adolescents," International journal of Group Psy-
chotherapy 31 (3 [July 1981]): 345-54; N. Macaskill, "Therapeutic Factors in
Group Therapy with Borderline Patients," International journal of Group Psy-
chotherapy 32 (1 [Ianuary 1982]): 61-73; and S. Colijn et al., "A Comparison of I
Curative Factors in Different Types of Group Psychotherapy," International I
journal of Group Psychotherapy 41 (3 I July 19911): 365-78.
6. M. Lieberman and L. Borman, Seif-Help Groupsfor Coping with Crisis
t
(San Francisco: [ossey-Bass, 1979); ;\,1. Lieberman, "Comparative Analyses of
Change Mechanisms in Group," in Advances in Group Therapy, edited by R.
Dies and K. R. ~facKenzie (New York: International Universities Press, 1983);
and S. Bloch and E. Crouch, Therapeutic Factors in Group Therapy (Oxford:
Oxford University Press, 1985), pp. 25-67.
7. F. Taylor, The Analysis of Therapeutic Groups (Oxford: Oxford Univer-
sity Press, 1961); and B. Berzon and R. Farson, "The Therapeutic Event in
Group Psychotherapy: A Study of Subjective Reports by Group Members,"
journal of Individual Psychology 19 (1963): 204-12.
8. T. Kaul and R. Bednar, "Experiential Group Research: Can the Can-
non Fire?" in Handbook of Psychotherap,, and Behavioral Change: An Empirical
Analysis, 4th ed., edited by S. Garfield and A. Bergin (New York: John Wiley,
1994), pp. 201-3; A. P. Goldstein, Therapist-Patient Expectancies in Psychother-
apy (New York: Pergamon Press, 1962); S. Bloch et al., "Patients' Expectations
of Therapeutic Improvement and Their Outcomes," American journal of Psy-
chiatry 133 (1976): q57-59; J. Frank and J. Frank, Persuasion and Healing: A
Comparative Study of Psychotherapy, 3d ed. (Baltimore: Johns Hopkins Univer-
sity Press, 1991), pp. 132-54; J. Connelly et al., "Premature Termination in
Group Psychotherapy: Pretherapy and Early Therapy Predictors," Interna-
tional Journal of Group Psychotherapy 36 (2 l 1986]): 145-52; A. Rabin et al., "Fac-
tors Influencing Continuation," Behavioral Therapy 23 ( 1992): 695-98; H.
Hoberman et al., "Group Treatment of Depression: Individual Predictors of
Outcome," Journal of Consulting and Clinical Psychology 56 (3 l 19881): 393-98;
~1. Pearson and A. Girling, "The Value of the Claybury Selection Battery in
Predicting Benefit from Group Therapy," British journal of Psychiatry 157
( 1990): 384-88; and \V. Piper, "Client Variables," in Handbook of Group Psy-
chotherapv, edited by A. Fuhriman and G. Burlingame (New York: John Wi-
ley, 1994).
9. Goldstein, Therapist-Patient Expectancies [81, pp. 35-53; Kaul and Bed-
nar, "Experiential Group Research" [8J, pp. 229-63; E. Uhlenhuth and D. Dun-
 Notes 477

can, "Some Determinants of Change in Psychoneurotic Patients," Archives of

General Psychiatry 18 (1968): 532-40; and J. Frank and J. Frank, Persuasion and
Healing l8], pp. 154-67.
10. Lieberman and Borman, Self-Help Groups 16]; and G. Goodman and
~1. Jacobs, "The Self-Help Mutual Support Group," in Handbook of Group Psy-
chotherapy [8].
J .. Moreno, "Group Treatment for Eating Disorders," in Handbook of
I 1.

Group Psychotherapy I 8 J.
12. S. Goldsteinberg and :\1. Buttenhcim, '"Telling One's Story' in an In-
cest Survivors' Group," International journal of Group Psychotherapy 43 (2 I April
1993]): Ij3-89; F. Mennen and D. Meadow, "Process to Recovery: In Support
of Long-Term Groups for Sexual Abuse Survivors," International journal of
Group Psychotherapy 43 (1 [January 19931): 29-+1: and ~1. Schadler, "Brief
Group Therapy with Adult Survivors of Incest, .. in Ponzi Group Therapy,
edited by Matthew Mc Kay and Kim Pa leg (Oakland, Calif.: :'\'ew Harbinger
Publications, 1992), pp. 292-322.
13. P. Tsui and G. Schultz, ''Ethnic Factors in Group Process." American
journal of Orthopsychiatry 58 ( 1988): 136-.p.
14. ~1. Galanter, "Zealous Self-Help Groups as Adjuncts to Psychiatric
Treatment: A Study of Recovery, Inc.," American journal of Psychiatry 143
(1988): 1248-53; M. Galanrer, "Cults and Zealous Self-Help Movemenrs,"
American journal of Psychiatry q5 (1990): 543-51; and C. Gartner, "A Self-Help
Organization for Nervous and Former Mental Parienrs-c-Recovery, Inc.,
Chicago," Hospitaland Community Psychiatry 42 (1991): 1055-56.
15. A. Low, Mental Health Through Wil! Training (Boston: Christopher
Publishing House, 1950).
16. Lieberman and Borman, Self-Help Groups [61, pp. 194-234: Goodman
and Jacobs, "The Self-Help Mutual Support Group," in Handbook of Group
Psychotherapy f 8]; and D. Salem, E. Seidman, and J. Rappaport, "Community
Treatment of the Mentally Ill: The Promise of Mutual Help Organizations."
Social Work 33 (1988): 403-408.
17. S. Tenzer, "Fat Acceptance Therapy: A Non-Dieting Group Approach
to Physical Wellness, Insight, and Self-Acceptance," JVomen and Therapy 8
(1989):
39-47·
18. Moreno, "Group Treatment for Eating Disorders." in Handbook of
Group Psychotherapy [S]: J. Mitchel et al., "A Comparison Study of Antidepres-
sants and Structured Intensive Group Therapy in the Treatment of Bulimia
Nervosa," Archives of General Psychiatry 47 ( 1990): t.p)--57; J. Laube, "Why
 478 Notes

Group for Bulimia?" International Journal of Group Psychotherapy 40 (2 (April

19901): 169-88; D. Franko, "The Use of a Group Meal in the Brief Group Ther-
apy of Bulimia Nervosa," International journal of Group Psychotherapy 43 (2
[April 1993]): 237-42; R. Bogdaniak and F. Piercy, "Model for the Group
Treatment of Eating Disorders," International Journal of Group Psychotherapy
37 (4 [October 19871): 589-602; and J.
Erisman and M. Siegel, "The Bulimia
Workshop: A Unique Integration of Group Treatment Approaches," Interna-
tional Journal of Group Psychotherapy 35 (4 [October 1985]): 585-602.
19. M. Kalb, "The Effects of Biography on the Divorce Adjustment
Process," Sexual and Marital Therapy 2 ( 1987): 53-64; and D. Grenvold and G.
Welch, "Structured Short-Term Group Treatment of Postdivorce Adjust-
ment," International Journal of Group Psychotherapy 29 (1979): 347-58.
20. L. Gallese and E. Treuting, "Help for Rape Victims Through Group
Therapy," Journal of Psychosocial Nursing and Mental Health Services 19 (1981):
20-21.
21. R. Kris and H. Kramer, "Efficacy of Group Therapy with Postmastec-
tomy Self-Perception, Body Image, and Sexuality," journal of Sex Research 23
(1986): 438-51.
22. E. Herman and S. Baptiste, "Pain Control: Mastery Through Group

Experience," Pain Io ( 1981 ): 79-86.

23. A. Beckett and }. Rutan, "Treating Persons with ARC and AIDS in
Group Psychotherapy," International Journal of Group Psychotherapy 40 (1 [Jan-
uary 1990J): 19-30.
24. F. Fromm-Reichman, Principles of Intensive Psychotherapy (Chicago:
University of Chicago Press, 1950).
25. Frank and Frank, Persuasion and Healing [81 p. 119; and }. Frank,
"Emotional Reactions of American Soldiers to an Unfamiliar Disease," Ameri-
can Journal of Psychiatry 102 (1946): 631-40.
26. J.
Frank et al., "Behavioral Patterns in Early Meetings of Therapy
Groups," American Journal of Psychiatry 108 (1952): 771-78; C. Peters and
H. Brunebaurn, "It Could Be Worse: Effective Group Therapy with the Help-
Rejecting Complainer," International Journal of Group Psychotherapy 27 (1977):
471-80; and E. Herne, Games People Play (New York: Grove Press, 1964).
27. J. Rubin and K. Locasio, "A Model for Communication Skills Group
Using Structured Exercises and Audiovisual Equipment/ International Journal
of Group Psychotherapy 35 (1985): 569-84.
28. J. Flowers, "The Differential Outcome Effects of Simple Advice, Al-
ternatives, and [ nsrructions in Group Psychotherapy," International Journal of
Group Psychotherapy 29 ( 1979): 305-1 S·
 Notes 479

29. Frank and Frank, Persuasion and Healing [8].

30. V. Frankl, The Will to Meaning (Cleveland: World Publishing, 1969).
3 I. S. Barlow, W. Hansen, et al., "Leader Communication Style: Effects on
Members of Small Groups," Small Group Behaoior 13 (c982): 5r3-81; E. Line-
ham and J. O'Toole, "Effects of Subliminal Stimulation of Symbiotic Fantasies
on College Student Self-Disclosure in Group Counseling," Journal of Counsel-
ing Psychology 29 (1982): 151-57; and S. Borgers, "uses and Effects of Modeling
by the Therapist in Group Therapy," journal for Specialists in Group iVork 8
( 198 3): I 33-39.
32. P. Van der Linden, "Individual Values in Therapeutic Communities,"
International Journal of Therapeutic Communities Ir ( 1990): 43-5 I; and D. Fram,
"Group Methods in the Treatment of Substance Abusers," Psychiatric Annals 20
(1990): 385-88.
33. A. Bandura, E. Blanchard, and B. Ritter, "The Relative Efficacy of De-
sensitization and Modeling Approaches for Inducing Behavioral, Affective,
and Attitudinal Changes,"Jow·nal of Personality and Social Psychology 13 (1969):
173-99; and A. Bandura, D. Ross, and S. Ross, "Vicarious Reinforcements and
Imitative Learning," Journal of Abnormal and Social Psychology 6j ( 1963): 60 r-7.
34. J. Moreno, "Psychodrarnatic Shock Therapy," Sociometry 2 ( 1939):

1-30.
35. S. Colijn et al., "A Comparison of Curative Factors."
36. J. Breuer and S. Freud, Studies on Hysteria, vol. 2 of The Standard Edi-
tion of the Complete Psvchologica! iVorks of Sigmund Freud, edited by James Stra-
chey (London: Hogarth Press, 1955).
37. M. Lieberman, I. Yalom, and M. Miles. Encounter Groups: First Facts
(New York: Basic Books, 1973).
38. S. Freedman and J. Hurley, "Perceptions of Helpfulness and Behavior
Groups," Group 4 (1980): 51-58.
39. 11. McCallum, \V. Piper, and H. Mor in, "Affect and Outcome in
Short-Term Group Therapy for Loss," International [ournal of Group Psv-
chotherapy 43 (1993): 303-19.
40. I. Yalom, J. Tinklenberg, and ~,1. Gilula, "Curative Factors in Group
Therapy," unpublished study, Department of Psychiatry, Stanford Univcrsitv.
1968.
4r. M. Smith, G. Glass, and T. Miller, The Benefits of Psychotherapy (Balti-
more: Johns Hopkins University Press, r980), p. 87.
42. Kaul and Bednar, "Experiential Group Research" !SJ; D. Orlinski and
K. Howard, "Process and Outcome in Psychotherapy." in Handbook of Psy-
chotherapy and Behavioral Change, 3d ed., edited by S. Garfield and A. Bergin
 480 Notes

(New York: John Wiley, I 986); R. Dies, "Practical, Theoretical, and Empirical
Foundations for Group Psychotherapy," in The American Psychiatric Association
Annual Review, vol. 5, edited by A. Frances and R. Hales (Washington, D.C.:
American Psychiatric Press, 1986); C. Tillitski, "A Meta-analysis of Estimated
Effect Sizes for Group vs. Individual Effect Sizes for Group versus Individual
vs. Control Treatments," International Journal of Group Psychotherapy 40 (1990):
215-24; and R. Toseland and M. Siporin, "When to Recommend Group Ther-
apy: A Review of the Clinical and Research Literature," International Journal of
Group Psychotherapy36 (1986): 171-201.
43. A. Bergin, "The Effects of Psychotherapy: Negative Results Revisited,"
Journal of Counseling Psychology 10 (1963): 244-50; H. Strupp, S. Hadley, and B.
Gomes-Schwartz, Psychotherapyfor Better or JVorse: The Problem ofNegativeEf-
fects (New York: Jason Aronson, 1977); and M. Lambert .md A. Hergin, "The
Effectiveness of Psychotherapy," in Handbook of P.;ychotherapy and Behavioral
Change, 4th ed. 18], pp. 176-80. Luhorsky et al. raise a dissenting voice: in their
study they found liccle evidence of negative psychotherapy effects: L. Luborsky,
P. Cries-Christoph, J. Mintz, and A. Auerbach, Who Will Benefit from Psy-
chotherapy? (New York: Basic Books, 1988).
4+ A. Horvath, L. Gascon, and L. Luborsky, "The Therapeutic Alliance
and Its Measures," in Dynamic Psychotherapy Research, edited by N. Miller, L.
Luborsky, and J. Docherty (New York: Basic Books, 1993); and L. Gaston,
.. The Concept of the Alliance and Its Role in Psychotherapy: Theoretical and
Empirical Considerations," Psychiatry 27 (1990): 143-53.
45. D. Orlinsky and K. Howard, "The Relation of Process to Outcome in
Psychotherapy," in Handbook of P.)·ychotherapy and Behavioral Change, 4th ed.
[81, pp. 308-76; H. Strupp, R. Fox, and K. Lessler, Patients View Their Psy-
chotherapy (Baltimore: Johns Hopkins University Press, 1969); P. Martin and A.
Sterne, "Post-hospital Adjustment as Related to Therapists' In-therapy Behav-
ior," Psychotherapy: Theory, Research, and Practice 13 ( 1976): 267-73; G. Barrett-
I
Lennard, "Dimensions of Therapist Response as Causal Factors in Therapeutic
Change," Psychological Monographs 76, 43 (whole, 562 [ 1962]); A. Gurman and
A. Razin, Effective Psychotherapy: A Handbook/or Research (New York: Perga-
mon Press, 1977); ~1. Parloff, I. Waskow, and B. Wolfe, "Research on Thera-
pist Variables in Relation to Process and Outcome," in Handbook of
Psychotherapyand Behavioral Change: An EmpiricalAnalysis, zd ed., edited by S.
Garfield and A. Bergin (New York: John Wiley, 1978), pp. 233-82; and P.
Buckley et al., "Psychodynamic Variables as Predictors of Psychotherapy Out-
come," American Journal of Psychiatry 14 I (6 Dune 1984]): 742-48.
46. A. Horvath and R. Symonds, "Relation Between Working Alliance
and Outcome in Psychotherapy: A Meta-analysis," Journal of Consulting Psy-
chology 38 (1991): 139--49; F. Fiedler, "Factor Analyses of Psychoanalytic, Non-
Directive, and Adlerian Therapeutic Relationships," Journal of Consulting
Psychology 15 (1951): _p-38; F. Fiedler, "A Comparison of Therapeutic Rela-
tionships in Psychoanalytic, Non-Directive and Adlerian Therapy." Journal of
Consulting Psychology q ( 1950): 436-45; and Lieberman, Yalom, and Miles, En-
counter Groups [37 J.
47. R. DeRubeis and M. Feeley, "Determinants of Change in Cognitive
Therapy for Depression," Cognitive Therapy and Research q ( 1990): 469-80; B.
Rounsaville et al., .. The Relation Berwcen Specific and General Dimension:
The Psychotherapy Process in Interpersonal Therapy of Depression," Journal
ofCon.mltingand Clinical Psrchology 55 (r987): 379-84; A. Bergin and .M. Lam-
bert, "The Evaluation of Thcrnpcutic Outcomes." in Handbook of Psychother-
apy and Behavioral Change, zd ed. [.JS], pp. 15<)-70; Gurrnan and Razin,
effective Psychotherapy l45I; and R. Sloane, F. R. Staples, A. H. Cristol, N. J.
Yorkston, and K. Whipple, Short-Term Analytically Oriented Psychotherapy vs.
Behavior Therapy (Cambridge: Harvard University Press, 1975).
48. Kaul and Bednar, "Experiential Group Research" [81.
49. Bloch and Crouch, Therapeutic Factors in Group Psychotherapy [6], pp.
99-103; and N. Evans and P. Jarvis, .. Group Cohesion: A Review and Reevalu-
ation," Small Group Behavior 2 ( 1980): 359-70.
50. For an in-depth discussion of research methodology and instrumenta-
tion, see: Kaul and Bednar, "Experiential Group Research" f8]; S. Drescher, G.
Burlingame, and A. Fuhriman, "Cohesion: An Odyssey in Empirical Under-
standing," Small Group Behavior 16 ( I 985): 3-30; and G. Burlingame, J.
Kircher, and S. Taylor, "Methodological Considerations in Group Therapy
Research: Past, Present, and Future Practices," in Handbook of Group Psy-
chotherapy f8J.
51. D. Cartwright and A. Zander, eds., Group Dynamics: Research and The-
ory (Evanston, Ill.: Row, Peterson, 1962), p. 7+
52. J. Frank, "Some Determinants, Manifestations, and Effects of Cohe-
sion in Therapy Groups," International [ournal of Group Psychotherapy 7 (19~7):
53-62.
53. Bloch and Crouch, Therapeutic Factorsin Group Psychotherapy I(> I.
54. Researchers either have had to depend on members' subjective ratings
of attraction to the group or critical incidents or, more recently. have striven for
greater precision by relying entirely on raters' evaluations of glohal climate or
such variables as fragmentation versus cohesiveness, withdrawal versus in-
volvement, mistrust versus trust, disruption versus cooperation, abusiveness
versus expressed caring, unfocused versus focused. See S. Budman et al., "Pre-
liminary Findings on a New Instrument to Measure Cohesion in Group Psy-
chotherapy," International Journal of Group Psychotherapy 37 ( 1987): 75-94.
55. D. Kivlighan and D. Mullison, "Participants' Perceptions of Therapeu-
tic Factors in Group Counseling," Small Group Behavior 19 ( 1988): 452-68; L.
Braaten, "The Different Patterns of Group Climate: Critical Incidents in High
and Low Cohesion Sessions of Group Psychotherapy," International journal of
Group Psychotherapy 40 ( J 990): 477-93; and S. Budge, "Group Cohesiveness Re-
examined," Group 5 (1981): 10-18.
56. R. MacKenzie and V. Tschuschke, "Relatedness, Group Work, and
Outcome in Long-Term Inpatient Psychotherapy Groups," journal of Psy-
chotherapy Practice and Research 2 (1993): 147-56.
57. Frank, "Some Determinants" [52 J.
58. H. Grunebaum and L. Solomon, "Peer Relationships, Self-Esteem, and
the Self," International journal of Group Psychotherapy 37 ( 1987): 475-513.
59. J. Frank, "Some Values of Conflict in Therapeutic Groups," Group
Psychotherapy 8 (1955): 142-51.
60. H. Sullivan, The Interpersonal Theory of Psychiatry (New York: W. W.
Norton, 1953); and H. Sullivan, Conceptions of Modem Psychiatry (New York:
Norton, 1940).
61. P. Mullahy, The Contributions of Harry Stack Sullivan (New York: Her-
mitage House, 1952), p. 10.
62. H. S. Sullivan, "Psychiatry: Introduction to the Study of Interpersonal
Relations," Psychiatry 1 (1938): 121-34-
63. Sullivan, Conceptions [6ol, p. 207.
64- Ibid., p. 237.

CHAPTER 2: THE THERAPIST WORKING IN THE HERE-AND-Now

r. Y. Agazarian,"Contemporary Theories of Group Psychotherapy: A

Systems Approach to the Group-as-a-Whole," International journal of Group
Psychotherapy 42 ( 1992): 1 77-204.
2 . M. Lieberman, I. Yalorn, and M. Miles, Encounter Groups: First Facts

(New York: Basic Books, 1973).

3. L. Ormont, "The Leader's Role in Resolving Resistances to Intimacy in
the Group Setting," International journal of Group Psychotherapy 38 (1988):
29-47.
4. M. Berger, "Nonverbal Communications in Group Psychotherapy,"
International Journal of Group Psychotherapy 8 (1958): 161-78.
 Notes 483

5. J. Flowers and C. Boor aern, "The Effects of Different Types of Inter-

pretation on Outcome in Group Therapy," Group 14 (1990): 81-88.
6. 0. Rank, Will Therapy and Truth and Reality (New York: Alfred A.
Knopf, 1950); R. May, Love and iVill (New York: \V. \V. Norton, 1969); S. Ari-
eti, The Will to Be Human (New York: Quadrangle Books, 1972); L. Farber,
The Ways of the Will (New York: Basic Books, 1966); A. Wheelis, "Will and
Psychoanalysis," Journal of the Psychoanalytic Association 4 (1956): 285-303; and
I. Yalom, Existential Psychotherapy (New York: Basic Books, 198 3).
7. Yalorn, Existential Psychotherapy f 6], pp. 286-350.
8. Farber, Ways of the Will [6J.
9. T. Aquinas, quoted in The Encyclopedia of Philosophy, edited by P. Ed-
wards, vol. 7 (New York: Free Press, 1967), p. 112.
10. J. Frank and J. Frank, Persuasion and Healing: A Comparative Study of
Psychotherapy, 3d ed. (Baltimore: Johns Hopkins University Press, 1991), pp.
21-5 I.
11. D. Spence, Narrative Truth and Historical Truth (New York: W.W.
Norton, 1982).

CHAPTER 3: GROUP THERAPY WITH SPEClALlZED GROUPS

1. M. Lieberman and I. D. Yalom, "Brief Group Therapy with the

Spousally Bereaved: A Controlled Study," International Journal of Group Psy-
chotherapy 42 (1992): 1-18.
2. I. D. Yalom and ~1. Lieberman, "Bereavement and Heightened Exis-

tential Awareness," Psychiatry 54 (1991): 334-45.

3. I. D. Yalorn, Existential Psychotherapy (New York: Basic Books, 1980),
P· i64.
4. M. A. Lieberman and L. Videka-Sherrnan, ..The Impact of Self-Help
Groups on the Mental Health of Widows and Widowers," American Journal of
Orthopsychiatry 56 (1986):435-49.
5. C. S. Lewis, "A Grief Observed," in The Oxford Book of Death, edited
by D. J. Enright (Oxford: Oxford University Press, 1983), p. I IO.
6. A. Tennyson, "In Memoriam A.H.H.," in The Oxford Book of Death, p.
105.

CHAPTER 4: THE FOUR ULTIMATE CONCERNS

1. J. Breuer and S. Freud, Studies on Hysteria, vol. 2 of The Standard Edi-

tion of the Complete Psychological ~VorksofSigmund Freud, edited by [arncs Stra-
chey (London: Hogarth Press, 1955; originally published 1895), pp. q5-83.
 2. Ibid., p. 158.
3. B. Spinoza, cited by M. de Unamuno, The Tragic Sense of Life, trans- j
lated by J.E. Flitch (New York: Dover, 1954), p. 6.
4. A. Malraux, cited in P. Lomas, True and False Experience (New York:
Taplinger, 1973), p. 8.
5. T. Hardy, "In Tenebris," Collected Poems of Thomas Hardy (New York:
Macmillan, 1926), p. 154.
6. The Encyclopedia of Philosophy, edited by P. Edwards, vol. 3 (New
York: Free Press, 1967), p. 14 7·
7. S. Kierkegaard, "How Johannes Clirnacus Became an Author," in A
Kierkegaard Anthology, edited by R. Bretall (Princeton, N.J.: Princeton Univer-
sity Press, 1946), p. 193.
8. Ibid.
9. W. Barrett, What Is existentialism? (New York: Grove Press, 1954), p.
2 I.

10. V. Frankl, oral communication, 1974.

I 1. R. May, E. Angel, and H. Ellenberger, Existence (New York: Basic
Books, 1 958), p. 1 1.

12. C. Rogers, cited in D. Malan, "The Outcome Problem in Psychother-

apy Research," Archives of General Psychiatry 29 (1973): 719-29.
r 3. Personal communication, 1978.

CHAPTER 5: DEATH, ANXIETY, AND PSYCHOTHERAPY

1. A. Meyer, cited by J. Frank,

oral communication, 1979.
2. Cicero, cited in M. Montaigne, The Complete Essays of Montaigne, trans-
lated by Donald Frame (Stanford: Stanford University Press, 1965), P: 56.
3. Seneca, cited ibid., p. 61.
4. Saint Augustine, cited ibid., p. 63.
5. Manilius, cited ibid., p. 65.
6. Ibid., P: 67.
7. M. Heidegger, Being and Time, translated by J. Macquarrie and E.
•
•
Robinson (New York: Harper & Row, 1962, pp.210-24.
8. Ibid., passim.
9. K. Jaspers, cited in J. Choron, Death and l,Vestern Thought (New York:
Collier Books, 1963), p. 226.
10. S. Freud, "Thoughts for the Times on War and Death," in vol. 14 of
The Standard Edition of the Complete Psychological Works of Sigmund Freud
(hereafter cited as Standard Edition), edited by James Strachey (London: Ho-
garth Press, 1957; originally published in I915), p. 29 t •
I I.Ibid., P· 290.
12. Montaigne, Complete Essays [21, P: 67.
13. L. Tolstoy, War and Peace (New York: Modern Library, 1931), p. 57.
14. L. Tolstoy, The Death of Ivan llych and Other Stories (New York: Signet
Classics, 1960).
15. D. Rosen, "Suicide Survivors," Western Journal of Medicine 122 (April
I 975): 289-94.

16. R. Noyes, "Attitude Changes Following Near-Death Experiences,"

Psychiatry 43 ( 1980): 234-242.
17. J. Diggory and D. Rothman, "Values Destroyed by Death," Journal of
Abnormal and Social Psychology 6 3 ( 1961 ): 205- 1 o.
18. S. Kierkegaard, The Concept of Dread (Princeton, N.J.: Princeton Uni-
versity Press, 1957), p. 55·
19. R. May, The Meaning of Anxiety, rev. ed. (New York: W.W. Norton,
1977), p. 207.
20. Kierkegaard, Concept of Dread f 18], p. 55.
21. May, Meaning of Anxiety I 191, p. 207.
22. Heidegger, Being and Time [ 71, p. 223.
23. A. Sharp, A Green Tree in Geddes (New York: Walker, 1968).
24. W. Bromberg and P. Schilder, "The Attitudes of Psychoneurotics To-
ward Death," Psychoanalytic Review 23 ( 1936): 1-28.
25. A. Witt, personal communication, September 1978.
26. Personal communication from a friend.
27. Freud, "Thoughts for the Times" [10], p. 298.
28. S. Kierkegaard, cited in E. Becker, The Denial of Death (New York:
Free Press, 1973), p. 70.
29. 0. Rank, Will Therapy and Truth and Reality (New York: Alfred A.
Knopf, 1945), p. 126.
30. P. Tillich, The Courage to Be (New Haven and London: Yale Univer-
sity Press, 1952), p. 66.
31. Becker, Denial of Death I 281, p. 66.
32. R. Lifton, "The Sense of Immortality: On Death and the Continuity of
Life," in Explorations of Psychohistory, edited by R. Lifton and E. Olson (Nc«:
York: Simon & Schuster, 1974), p. 282.
33. Rank, Will Therapy [291, p. 124.

34. E. Fromm, Escape from Freedom (New York: Holt, Rinehart & \Vin-
ston, 1941), p. 6.
 486 Notes

35. L. Tolstoy,Death oflvan llych [141, pp. 131-32.

36. R. Frost, In the Clearing (New York: Holt, Rinehart & Winston, 1962),
p. 39·
37. N. Kazantzakis, Report to Greco, translated by P. A. Bien (New York:
Simon & Schuster, 1965), p. 457.
38. N. Kazantzakis, The Odyssey: A Modern Sequel, translated by Kirnon
Friar (New York: Simon & Schuster, 1958).
39. C. Haker, Ernest Hemingway: A Life Story (New York: Charles Scrib-
ner, 1969), p. 5.
40. E. Hemingway, The Old Afan and the Sea (New York: Charles Scribner,
1961 ) .
..p. C. Wahl, "Suicide as a Magical Act," Bulletin of Menninger Clinic 21

(IVL:iy I 957 ): 91-98.

42. F. Kluckholm and F. Stroedbeck , Variations in Value Orientations (New
York: Harper & Row, 1961), p. 15.
43. J.
J'vL Keynes, cited in Norman Brown, Life Against Death (New York:
Vintage Books, 1959), p. rn7.
44. L. Tolstoy,Anna Karenina (New York: Modern Library. 1950), P: 168.
45. S. Freud, Some Character Types Met with in Psychoanalytic Work, vol. 14
of Standard Edition f 101, pp. 316-31.
46. Rank, Will Therapy [291. P· I 19.
4 7. A . Maslow, The Further Reaches of Human Nature (New York: Viking,
1 971), P· 35·
48. Becker.Denial of Death [28), pp. 35-39.
49. Fromm, Escape[rom Freedom [34l, pp. 174-79.
50. J. Masser man, The Practice of Dynamic Psychiatry (Lon<lon: W. B.
Saunders, 1955), pp. 4 76-81.
5 I. S. Kierkegaard, cited in May, }deaning of Anxiety\ 19], p. 38.
52. Heidegger, Reing and Time 171, p. 105.
53. S. Aricti, "Psychotherapy of Severe Depression," American Journal of
Psychiatry • .H ( 1977): 864-68.
5+ Rank, wut Therapy I 29 I, pp.
119-34.
55. S. Kierkegaard, cited in May, Afeaning of Anxiety [ 191, p. 37.
5(,. Heidegger, Being and Time [71, p. 294.
57. F. Nietzsche, The Gay Science, translated by Walter Kaufman (New
York: Vinragc Books, 1974), p. 37.
58. Cited in Montaigne, Complete Essays[2], P: 65.
59. G. Santayana, cited in K. Fisher, "Ultimate Goals in Psychotherapy,"
Journal of Existentialism 7 (winter 1966-67): 215-32.
 60. P. Landsburg, cited in Charon, Death and fVeitem Thought l9J, p. 16.
61. J. Donne, Complete Poetry and Selected Prose (New York: Modern Li-
brary, I 952), p. 332.
62. R. Gardner, "The Guilt Reaction of Parents of Children with Severe
Physical Disease," American journal of Aychiatry 12(> ( r 9(>9): 82----90.
63. Heidegger, Being and Time 171, p. 105.
64. S. Golburgh and C. Rotman, "The Terror of Life: A Latent Adolescent
Nightmare," Adolescence 8 ( 197 3): 5(>9-7+
65. E. Jaques, "Death and the Mid-Life Crisis," International journal of Psy-
choanalysis 46 (1965): 502-13.
66. C. Jung, cited in D. Levinson, The Seasons of a Afan'j· Life (~ew York:
Alfred A. Knopf, 1978), p. 4.
67. D. Krantz, Radical Career Change: Life Beyond H'ork (New York: Free
Press, 1 978).
68. Noyes, "Attitude Changes" f 1(>).
69. Montaigne, Complete Essays [2!, p. 62.
70. G. Zilboorg, "Fear of Death," Psychoanalvtic Quarterly 12 (1943):
465-75.
71. S. Freud, Three Essays on the Theory of Sexuality, vol. j of Standard Edi-
tion [10], pp. 125-231.

72. Dante Alighieri, La Divina Commedia (Florence, Italy: Casa Editrice

Nerbini, n.d.); translation by John Freccero, 1980.
73. Jaques, "Death and the :v1id-Life Crisis" [66).
74- .M. Eliade, Shamanism: Archaic Tcchniques of Ecstasy (Princeton, ~ .J .:
Princeton University Press, 1964), p. 43.
75. Ibid., p. 45.
76. J. Bugenral, The Search for Authenticity (New York: Holt, Rinehart &

Winston, 1965), p. 167.

77. J. Hinton, "The Influence of Previous Personality on Reactions to Hav-
ing Terminal Cancer," Omega 6 ( r 9j5): 95-1 1 1.
78. F. Nietzsche, cited in N. Brown, Life Against Death (Xew York: \'in-
tage Books, 1959), p. 107.
79. Montaigne, Complete Essays 121, p. 268.

CHAPTER 6: LITERATURE INFORMI~G PSYCHOLOGY:

LITERARY VIGNETTES

I. M. Heidegger, Reing and Time, translated by J. Macquarrie and E.

Robinson (New York: Harper & Row, 19(>2), p. 284-
 488 Notes

2. Everyman, in The Norton Anthology of English Literature, edited by M.

Abrams et al., vol. 1 (New York: W.W. Norton, 1962), pp. 281-303. R. Bollen-
<lorf, unpublished doctoral dissertation, Northern Illinois University, 1976.
3. L. Carroll, cited in J. Solomon, "Alice and the Red King," International
Journal of Psychoanalysis 44 (1963): 64-73.
4. A. Camus, The Fall (New York: Vintage Books, 1956), p. 58.
5. Ibid., p. 68.
6. Ibi<l., p. 63.
7. L. Tolstoy, ~Var and Peace (New York: Modern Library, 1931), p. 231.
8. Ibid., p. 245.
9. J. P. Sartre, cited in R. Hepburn, "Questions about the Meaning of
Life," Religious Studies 1 ( 1965): 125-40.
10. J. P. Sartre, 1Vo Exit and Three Other Plays (New York: Vintage Books,

r955).
11. Ibid., p. 91.
12. lbid., p. 92.
r 3. Ibid.
14. Ibid., p. 94.
15. Ibid.
16. Ibid., p. 105.
17. I bid., p. 108.
18. Ibid., pp. 121-22.
19. Ibid.,p.123.
20. I bid., r- 124.
21. G. Allport, cited in V. Frankl, The Will to Meaning (Cleveland: New
American Library, 1969), p. 66.
22. J. Gardner, Grendel (New York: Ballantine Books, 1971), p. 115.

CHAPTER 7: PSYCHOLOGY INFORMING LITERATURE

I
I. C. Baker, Ernest Hemingway: A Life St01y (New York: Charles Scrib-
ner's Sons, 1969).
I1
2. E. Hemingway to Charles T. Lanham, letter, 27 November 1947. I

_,. E. Hemingway, "The Earnest Liberal's Lament," Der Querschnitt, au-

tumn 1924.
4. J .. Hemingway, A1y Brother, Ernest Hemingway (Cleveland: World
Publishing, 1y62).
5. M. H. Sanford, At the Hemingu/ays: A Family Portrait (Boston: Little,
Brown, 19(>2).
 6. I. D. Yalom, The Theory and Practice of Group Psychotherapy (New
York: Basic Books, 1970), pp. 121-23.
7. C. Rycroft, Psychoanalysis Observed (London: Constable & Company,
c966), P: 18.
8. Baker, ErnestHemingway [r], p. 268.
9. Ibid., p. 392.
IO. Ibid., p. 465.
I I.R. P. Weeks, ed., introduction to Hemingway: A Collection of Critical
Essays(Englewood Cliffs, N.J.: Prentice-Hall, 1962), pp. 1-16.
12. C. T. Lanham, written communication, 22 August 1967.

13· Ibid.
14. E. Hemingway, "The Snows of Kilimanjaro: A Long Story," Esquire 6,
no. 27 (1936): 194-201.
15. K. Horney, Neurosis and Human Growth (New York: \V. W. Norton,
1950).
16. Baker,Ernest Hemingway [1].
17. Ibid., p. 461.
18. E. Hemingway to Charles T. Lanham, letters, 20 April I 945,
7 August 1949, 18 June 1952, and 18 December 1952.
19. Baker, Ernest Hemingway (I].
20. E. Hemingway to Charles T. Lanham, letter, 22 September 1950.
21. Bickford Sylvester, unpublished observations.
22. Marcelline Sanford, cited in Baker, Ernest Hemingway [ 1],
P· 193·
23. Ibid., p. 79.
24. E. Hemingway, "Cross Country Snow," in The Short Stories of Ernest
Hemingway (New York: Charles Scribner's Sons, 1966).
25. E. Hemingway, "In Another Country," ibid.
26. P. Young, Ernest Hemingway: A Reconsideration (University Park:
Pennsylvania State University Press, 1952).
27. S. Freud, Three Contributions to the Theory of Sex (New York: E. P.
Dutton, 1962).
28. Young, Ernest Hemingway [25} p. 165.
29. E. Hemingway, Across the River and Into the Trees (New York: Charles
Scribner's Sons, 1950), P: 33·
30. C. T. Lanham, written communication, 22 August 1967.
31. E. Hemingway to F. Scott Fitzgerald, letter, December 192(>.
32. Baker, Ernest Hemingway r I l, p. 642.
33. C. T. Lanham, oral communication, April 1967.
 490 Notes

34- E. Hemingway, The Sun Also Rises (New York: Charles Scribner's
Sons, 1950), p. 26.

35. E. Hemingway, For Whom the Bell Tolls (New York: Charles Scrib-
ner's Sons, 1940), p. 471.
36. Baker, Ernest Hemingway { 1 J, p. 5.
37. Ibid.
38. Ibid., pp. 315 and 477.
39. 0. Fallaci, ed., "Interview with Mary Hemingway: My Husband,
Ernest Hemingway," Look 30 (1966): 62-68.
40. C. T. Lanham, written communication, 22 August 1967.
41. Baker, Ernest Hemingway r I l, p. 175.
42. E. Hemingway to Charles T. Lanham, letter, r 1 September 1950.
43. C. T. Lanham, written communication, 22 August 1967.
44. Baker, Ernest Hemingway [ 1 l, pp. 545-48.
45. Ibid., pp. 476 and 547.
46. A. E. Hotchner, Papa Hemingway (New York: Random House, 1966),
p. 268.
47. Baker, Ernest Hl·mingway f I I, p. 552.

CHAPTER 8: THE JOURNEY FROM PSYCHOTHERAPY TO FICTION

1. E. M. Forster, Aspects of the Novel (San Diego, Calif.: Harcourt, Brace,

1927), p. 66.

CHAPTER 9: THE TEACHING NOVEL

1. Portable Nietzsche, edited by Walter Kaufman (New York: Viking

Press, 1954), p. 468.
2. Ibid., p. 430.
3. F. Nietzsche to Malwida Von Mesenburg, letter, May 1884-
4- F. Nietzsche, Human, All Too Human, translated by Erich Heller
(Cambridge: Cambridge University Press, 1986), p. 250.
5. F. Nietzsche, The Gay Science, translated hy Walter Kaufman (New
York: Vintage Books, 1974), p. 198.
6. I hid., p. 321.
7. Portable Nietzsche I I L p. 1 89.
8. Ihid., p. 181. j
9· Ibid., p. , 69.
I 0. Nietzsche, Gay Science [ 5J, p. 89. I
 Notes 491

11. Ibid., p. 43.

12. Portable Nietzsche [ 1 ], p. 152.

13. Ibid.,p.351.
14. Nietzsche, Gay Science [5], p. 104.
15. E. Jones, The Life and lVork of Sigmund Freud, 3 vols. (New York: Basic
Books, 1953-57).
16. F. Nietzsche to F. Overbeck, letter, 5 August r98(l, in P. Fuss and H.
Shapiro, eds .• Nietzsche, a Self-Portraitfrom His Letters (Cambridge: Harvard
University Press, 1971 ), pp. 87 and 90.
17. H. Kaiser, EffectivePsychotherapy: The Contribution of Helmuth Kaiser,
edited by L. Fierman (New York: Free Press, 1965).

CHAPTER 10: THE PSYCHOLOGICAL NOVEL

1. S. Ferenczi, The ClinicalJournals of Sandor Ferencz: (Cambridge: Har-

vard University Press, 1988).
2. I. D. Yalom and J. Han<llon, "The Use of Multiple Therapists in the

Teaching of Psychiatric Residents," in Journal of Neruous and Mental Disorders

141 (1966): 684-92.
3. I. D. Yalom, The Theory and Practice of Group Psychotherapy, 4th ed.
(New York: Basic Books, 1995), pp. 514-15.
4. I. D. Yalom, Inpatient Group Psychotherapy (New York: Basic Books,
1983), pp. 259-74.
5. F. Nietzsche, The Will to Power, edited by Walter Kaufman (New
York: Vintage Books, 1968), p. 272.

6. J. Cooper, Speak of Ale as I Am: The Life and f.Vork of Masud Khan (Lon-
don: Karnac Books, 1993).
7. F. Nietzsche, Beyond Good and Evil (New York: Vintage Books, 1989),
p. 80.
 Index

AA (Alcoholics Anonymous), 10. 16, formulation. 101-5

18,42,43-+1, 118, 136 go-round, 98-101
acceptance therapist's tasks in, I 02-10

and cohesiveness of group, 2j, 28, 30 agmg, 242-.+3

need for, 32 alcohol addiction group

and universality, 11-12 agenda for each session, 127-28

adolescent anger, problem of expressing, 12 3, 126

anxiety, 2.p anxiety provoked by group work and

death detoxifying, 345 drinking, 117, 126, 127, 128

groups, development of anxiety reducing tactics, 127-33

socializing techniques in, 20 avoidance behavior, 127

Adult Survivors of Incest, 13 crisis, problem of constant, 125

advice giving/ad vicc-sccki ng didactic instruction, r 28-29

behaviors, 15-16, 144 difficult nature of, 117

Aeschylus, 269 dilemma of group, 125-2;

affect diminishing anxiety with session
acceptance of vulnerability, 263 summaries. 11i

decatastrophizing of weeping, 150 divergence from AA. 12:;

evocation and integration during drinking patient, 135-.F

.
session, 429-30 early meetings, 121

expression of, in group, 23 here-and-now approach in, 122-25

Afterthe Fall (Camus), 273-74 initial interview. 11.>i · 11

agendas for group work initial session, 121-22

"final product" clinical examples, rcsul ts, 137

110-1 I, I 15-16 self-monitoring goal. 1.22, 12 ~

493
 494 Index

alcohol addiction group icont.) Frankl on, r 45

strategy and tactics of group leader, and loneliness of death, LB, 352
121-25 management, 264-65
subgrouping, 133-35 need for, in therapeutic work, 93, 238,
summaries for patients, 129-32, 259

136-3j. ·P9 pnmary, 93

videotape playback, 12, 132-33, 136 -reducing tactics, 127-33
Allen. Woody, 347 secondary, 93
altruism uncertainty, role of in producing, 15
in healing systems, 17-18 approval, desire: for and concept of self, 30
and self-actualization, 18 Aquinas, Sc. Thomas, 74
as therapeutic factor in group therapy, "Attitudes of Psychoncurotics toward
16-18, qo Death" (Bromberg & Schilder),
anger 199--202
in alcohol ad.liction group, r 23, 126 authorship (responsibility), 112, 137
existential, 161-63 avoidance
fear of, 28-29, 320 group, of issues, 37
in group life, 28-29. 123 leaving group as, 127
and self-disclosure, 29
Anna Karenina (Tolstoy). 218 Baker, Carlos, 283, 286, 291
"anticipated regret," 152-53 Bandura, A., 21
anxiety Beauvoir, Simone de, 340
alcoholic drinking as response to, 117, Becker, Ernest, 203-4, 219
119-20, 126, 127, 128 Beckett, Samuel, .440
clinical manifestation of death behavior
anxiety, 194-98 changing, through agenda work,
creative. 2 37 113-16
and death, 138, '45, r76. 191-92, 234 fear of change, 75-76
death anxiety as determinant of expe- motivations for, ?{>-77
rience and behavior, 192-94, self-defeating, 75, 77
205-28,2~9-50,251-55,259-63 and unconscious motivations and
death anxiety in long-term therapy, drives, 73
25t;-56 and will, 73-78, 349-59
death as primary source of, 248-49 behavior-shaping groups, 379
did aerie instruction to reduce, r 5 direct advice in, 16
displacement of, 249-50 Being and Time (Heidegger), 178
dreams, 243 bereavement
existential sources of, 138, q3. 176, fast pain, 156
202-_3, 241. See also death parental, 24 I
and fusion, 35 1 slow pain, 156-63

·'·
 Index 495
bereavement group, 14, 24, q8 cancer
anger, 161-62 confrontation with death and change,
"anticipated regret, .. 152-53 19o, 231-3(>, 243. 245-48, 259-l>3,
benefits of, q7-48 345.354-72.450
cohesion, 15~51, 152 death anxiety and psychopathology,
early meetings, q9-52 205-8~211-12,221-22,259-63,
first meeting, 149 347
general principles, 148-49 cancer patient group, 138-39. See also
norms, 149-.50 bereavement group
obituary exercise, I 54 anger, 141-42
picture-showing exercise. 151-52 altruism, 140
. . .
post-termmauon group meetmgs. 155 anxiety. 145
"re-pair" issue, 161 denial, q5-46, 257-58
social isolation, q8 description of group. qo
terrrunanon, 154-55 first published description, I 38

themes, I 55-63 isolation and loneliness, feelings of,

"who are you" exercise, 153-54 142-43, LH, 352
"Bereavement Groups: Techniques and objectives. 139-40
Themes" (Yalorn and Vino- observation of. by everyday psy~
gradov), 147-48 chorherapy patients, 245-48
Berne, Eric, 445 therapeutic factors. 14~-H
Bernheim, Hippolyte, 386 therapist in the group, 145-46
biography, as fiction, 44~41 two-way mirror observation of, I39,
Boston Psychoanalytic Institute. xi 140,245-48.258
boundary or border situations, I 72, cancer support groups .. p, 44
186-87 and increased survival time, r 39
commitment, 241 Carroll, Lewis, 2j2-73
death, 2 3~48 case histories, in textbooks,
marital separation/divorce. 241 fictionalizing of. ++o
Breuer, Josef, 22, 387-88, 400. See also castration, fears of, 1 W, 196, 250
When Nietzsche ~Vept catharsis, as therapeutic factor. 22-23
Bromberg, Walter, 199 Cervantes Saavedra. de. ~liguel. 176
Buber, Martin, 179 change
Bugental, James, 154, 2350, 259 communication wishes to change to
bulimic patients others. I 14-15
cognitive therapy approach in, q death, confronting. and, 188-<.jJ,
importance of universality, 12 231-.~6, 243, 245- .. H. 2'59-(1 {, .{·Vi·
-~54-72. 45°
Camus, Albert, 179. 269, 273-74, 340, identifying aspect of sdf to change,
375 114
 496 Index

change (co12t.) death. See also anxiety; berea vernent

and near-death experiences, 189-90,
243
groups
and anxiety, 139, 145, 184-85, 191-98,
'
process of, bereavement group, 159--00 248-50,281,405
realization of need for, I I 3 and anxiety in long-term therapy,
responsibility for, 118 255--56
and therapeutic relationship. 413-14, awareness, a rti fie ia I a ids to increase,
416, .po 2 43-45
and will of patient, 74-78, 349-50 awareness and everyday psychother-
Christmas Carol, A (Dickens), 230 apy, 236-45. 363
cogniti\'e therapy groups, 42 and the child, 184, 372
cohesiveness of group, 24-30 Cicero on, r 85
alcohol addiction group, 13 1, 13j clinical manifestation of death anxiety,
bereavement group, 150-51, 152 194-98, 199-202,212-13,236-38,
characteristics of, 25-26 251-55. See also Love's Executioner
and expression of strong affect, 23 confronting, and bereavement
measuring, 26 groups, 147
as precondition for success, 26-27 confronting, and personal change,
variable nature of, 26 188-91,231-36,243,345,354-72
Comfort, Alex, 167 defenses/transcendence, and psy-
commitment, fears of, 241 chopathy, 184, 196, 205-28
cornmurucanon desensitization, 263-65
displacement, 68 detoxifying, 345
metacomrnunication, 45. 68 Epicureans on, 196
pa rataxic distortion, 68 existential awareness and death of an-
relationship messages in, 68 other, 239--41, 424-25
communicational skills groups existential psychodynarnics of, 172
direct advice in, 16 experienced on many levels, 250
compulsive heroism, 2q-16 fear of, 192-94, 229-30
Conrad, Joseph. 300 Heidegger on, 185-86, 233
content of group session inattention to, in psychotherapy the-
focus, versus process, 45, 46, 48-49, 50 ory and practice, I 98-202
interrupting, 62 life-death interdependence, 185-88
Cooper. Judy, 4_p loneliness of, 1.p-43, 144, 270-71, 352
counrcrther apv, .p7 Lucretius on, 196
countertransferencc, 3.35, .3.36-38, 467 Manilius on, 185
curative factors. See therapeutic factors Montaigne on, 185, 187-88, 263--64
and psychopathology, 205-28
Dante Aligheri, 255 and psychotherapy issues, 139-40,
dasein, 181 184,258-59
 Index 497
and reappraisal of one's life, 139, Diggory, James. 1 92

162--03,245-48,259-63,363-72 disidentification, 371, 372

role played by in psychotherapy, basic exercise, 234-36
postulates, 18 3-84, 258-59 displacement, 68
Saint Augustine on, 185 of death anxiety. 195, 196--98, 203,

Santayana on, 234 205-8.249

Seneca on, I 85 of responsibility (victimization), 112

and sex, 251-55 Divine Comedy, The (Dante), 255

and shamans/healers in primitive cul- Donne. John, 239
tures, 258 Dostoevsky. Feodor Mikhailovich, 269,
simulating for psychotherapy, 2 36--45 300

Stoics on, 185, 2 34 Grand Inquisitor .. p7

"Death of Ivan Ilych" (Tolstoy}, 188- Double, The (Dostoeveskv), 300

89, 2IO, 230, 261 dreams

decision-making, 281, 350 amnesiac response, .p5
defenses anxiety dreams, 24 3, 251. 366
and milestones, 241-45 importance to tbeurapeutic process,
multiple, interlaced, 228-30 423-27
and psychopathology, 184, 196, 203-4. interpretation, 201-2, 231-32, 238,
2 55 240,321-22.336-37,366--68,
rescuer, and fatal illness, 221-22 401-2,422-27
rescuer, and interpersonal difficulties, nightmares. 346
226--28 recall/repression of, 425
rescuer, and personality restriction, symbolism, 254

220-21,245 drinking patient, r 35-3;

specialness (belief in one's own om- Duffy,\\' arden of San Quentin Prison,
nipotence), 203, 208, 210-19, 228 17-18
denial dynamic formulation, 285
in alcoholism, 1 19-20 dynamic interactional therapy groups.
and death, 140, 145-46, 202, 203-4, See also alcohol addiction group
245,256-s8,341-42,345,363
reincarnation as, 368 ego boundaries, loss of, qo, 321
depression Egyptians, killing and burying servants
"dominant goal" and "dominant with the pharaoh, 270
,.
ot her, 222 Emergency (Kaiser}, .-N8, 435
treatment in interpersonal terms, 31 "empty nest" syndrome. 237
de-repressing, task of, 179 encounter groups, 2-3. 22, 2++
despair, 39<>--91 Encounter Groups: First Facts (Yalorn). 3
diagnosis, place of, 448 Epicurus, 269
Dickens, Charles, 230-31 Euripides, 269
 Index

evaluations, by patient of group, 7-9 boundary or border situations, 172,

Every Day Gets a Little Closer (Y alorn 186-87,230-48
and Elkins), 316-38, 401 clinical examples, 194-95, 19~8,
counterrransference, 335, 336--38 211-13,251-55,261-63
dreams, _pr, 336-37 death, 172, 176, 183-265. See also
effectiveness of therapy, 338 death main entry
Ginny's (patient's) Foreword, 325-30 death awareness and everyday psy-
interpersonal relationships, 32 3, chotherapy, 236--45
329-3°,331-32 definition and position, 169-70,
meeting of therapist and patient, 319, 172
327 denial, 176, 345
patient's issues, overview, 319-21 de-repressing, task of, 179
patient-therapist relationship, 321-22, as dynamic pyschotherapy, 170-71
324,33o,332-34,335-38 and empirical research, conflict with,
resistance to change. 322-23 179-83

self-disclosure, 324 and existentialism, I 78

therapeutic approaches in, 3 1 6- r 7, factors, in group therapy, 23-24,
324,.335-36 23n
third session, Ginny's notes, 333-35 and fear, 162-63, 345
third session, Yalorn 's notes, 330-33 freedom, 172, 265, 273, 345, 347-48,
transference, 324, 337 406, 4II
"transference cure," 338 here-and-no~'approach,42,43-64,
writer's block, 316-17, 320, 324 121-25
writing of, 316-18 advice giving/advice-seeking behav-
. .
Yalom's Afteword, 335-38 tors rn, 15
Yalom's Foreword, 318-25 development of socializing tech-
. .
Everyman, 270-71 n1ques1n,20-21,44
existential crisis, 259, 346 first meeting, typical, 57-58
existential dilemma, 353 and interpersonal learning, 42
existentialism, overview of, 176-79 and process, 45-51
defined, 180 trammg in interactions, 125
existential pyschotherapy. See also isolation/loneliness, 173, 265, 270,
process illumination 271-73,345,35°
and academic community, 179-82 and Love's Executioner, 344-54
and anger, 161-63 meaninglessness, 173, 176, 265,
anxiety used in, r 38, 176, 259. See also 276-81
. .
anxiety main entry orientation, 173-76
assumptions about the source of dys- therapist's role, 238-45
phoria, 43 and Yalom, 43, 138
 Index 499
Existential Pyschotherapy (Yalorn), freedom, existential psychodvnamics of,
167--68, 183,270-73,2j6-81, 1i2 -73· r82,273,345,J47-48,4o6,
313-16, 375 .p I

extragroup meetings. See subgrouping and will. 349-50

Freedman, S., 23
farnilv Freud, Sigmund
'
conflict played out in group, 54 ambititions of, 382-83
corrective recapitulation of the pri- blank-screen mandate, 417
mary family group, I 8-20, 39-40 case studies. 340
male/female therapists to simulate daily schedule, 3~2
parental configuration, 18 and death, r 87
sibling rivalr y, 69 and denial by patient, 257
Farber, Leslie, 73, 434-35, 436 developmental theory, 294
fear on dreams, .p4--25
and anxiety, 193-94, 249-50 dynamic model of mental function-
ofchange,75-76 ing, 1;1

of death, 192-94,229-30,263-65 insights of, literary/philosophical ori-

and systematic desensitization, 761 gins, 269
263--65 joke, 202
feedback, 2er-21, 37 member-leader relationship, 275
and here-and-now approach, 44 and ~ietzsche, 374, 380-83. 385
summaries for patients, 129-32, 136-37 psychiatry as science, 340
therapist's instruction of patients in, as psychological archaeologist, 434
58-s9 romantic image of. 38 3
videotaping of sessions, I 22, 132-33, and Salome, Lou. 381-82, 386
136, 190-91 on sex, 253
Ferenczi, Sandor, .p 5-17 on success neurosis, 219
Fifty-Minute Hour, The (Lindner), 340 on taboos, 11
fishbowl format, 419 and therapy technique, .:p 5
Fitzgerald, F. Scott, 301 and transference neurosis, 449
fixed false beliefs, 347 treatise on hysteria, 22

Flies, The (Sartre), 276-79 treatment of Fraulein Elisabet von R ..

Forster, Bernhard, 377 169• 2.u
Foster, E.11., 342 writings, 380
Frank, Jerome, 1 Freudian interpretation of group
. .
on anger, 29 interactions. 34
study of reactions to schistosorniasis, Fromm, Erich, 30, 20S. 220

15 Fromm-Reichman, Frieda. 1-5

Frankl, Victor, 18, 145, 180 F rost, Robe rt, 2 r 3
 500 Index

fusion, 229, 3 5 1 and managed health care, 2

and anxiety, 351 and narcissistic patients, 308-10
outcome, compared to individual
Gamblers Anonymous, I 3 therapy, 24-25
Games People Play (Berne), 445 psycho-education in, 12

Ganser syndrome, 438 resistance to practice of, 2

Gardner, John, 281, 350 Rutari's bridge analogy, 400
Gardner, Richard, 241 as social microcosm, 33-41, 44, 364-71
Gide, Andre, 374 success of, 24-25
goals of psychotherapy structured exercises, effectiveness
case vignette, 312-13 of, 6 3, 99, 34 3-44
change,42,77-80, 134, 188-91 therapeutic factors, 6---41
clear picture of, and investment of pa- transparency techniques with, 418-20
tient, 90 two-way mirror, use of, 1, 139,
existential, 236-45, 379-80 245-48,258,328,418
focus on, 103 group therapy, specialized population,
real i ry testing, 4 17 See also specific specialized groups
relief of suffering.31, 42, 134, 241, 379 appraising the treatment environ-
shift of focus to interpersonal rela- ment, 82
tionships, 31 immutable and arbitrary conditions,
go-rounds 82
agenda,98-101 modifying techniques, 82
bereavement, J 49 therapy goals, 82
Greaves, Carlos, 138 "Group Therapy with the Terminally
Green Tree in Geddes, A (Sharp), 197n Ill" (Yalorn with Greaves), 138
Grendel (Gardner), 28 r , 350 growth, personal, 158-59
"Group Therapy and Alcoholism"
(Yalom), II 7 Hardy, Thomas, 176, 354
group therapy, prototypic. See also Harrison, George, 434
here-and-now approach; thera- Has id ic story, 1 6- I 7
peutic factors Hegel, Georg Wilhelm Friedrich, 393
effectiveness of, determining, 7-9 Heidegger, Martin, 178, 181, 185-86,
exercises, structured, 61, 63, 99, 192, 195,221,233, 241
151-54,234-36,244-45 "help-rejecting complainer," 15
first meeting, typical, 57 Hemingway, Ernest
focus, versus individual therapy, 372 and aging, 302
focus, versus self-help groups, 42, alcoholism, 300-30 I
43-44 artistic vision, limitation of, 282, 285
here-and-now approach, 41-64 attitude toward psychological in-
and interpersonal theory, 31 quiry/psychologists, 286, 297
 Index 501

autobiographical nature of his writ- "Cat in the Rain," 292

ing, 287 A Faretocll to .4mu, 284, 292, 293.
bigotry of, 300 297.298
castration/emasculation fears, 292. For Jf 'hom the Hell Toth. 284, 292,
294-95,296 293. 29;-( 299
childhood and early years, 286 "Hills Like \Vhite Elephants," 292
and compulsive heroism, 215, 288-89, "In Another Country," 293-94
295 ''The Killers." 284
couragc,299 .-! .\foi·cable Feast. 291. 298
criticism, adverse, and anger, 290 "Mr. and Mrs. Elliot," 292

death anxiety, 295-96 .'.'\ick Adams stories. 293

dependency on praise, 290 "Xow I Lay ~k." 292
depression, 297, 301-2, 303-4 The Old xto» and the Sea, 215. 28.i,
film versions of hooks, stars of. 284 291.298.300.301
Fossalta, big wound, 295-96. 298 "Out of Season." 292
grandiosity, 303 poem, 1924. 284
health, preoccupation with, 303 "The Short Happy Life of Francis
as heroic model/public figure, 283-84 Macomber." 292
hypochondriasis, 302 "The Snows of Kilimanjaro," 28+
image/idealized self, 287-90. 295, 297. 288-89,292.293,29;,298
300,302 The Sun Also Ri.se.s. 284. 292, 293.
and Lanham, General Charles, 283. 296,297.299,300
288,290a-91~297.299.301 "The Three Day Blo\\', .. 292
love and male-female relationships in To Haer and To Hare Xot. 284. 292,

his fiction, 291-94 298, 299--300

and Mary (wife), 288, 301 ":\ Verv Short Story," 293, 297
paran01a, 290, 303, 304 ·'.-\ Wav You'll '.\."eYer Re." 298
and parents, 293 writing as psychotherapy and carhar-
"projective identification" in. 300 sis, 297. 298-99
rejection by Agnes von Kurowsky, Hemingway . .\lary, 288
293,297 here-and-now approach
relationships with women, 291-94 activating phase, 52. 5(>-64
and Stein, Gertrude, 291 and agenda turmul.uion, ro5-;
as stylistic genius, 284-85 ahiswric nature of. ')5-5(1

suicide, 28 3, 296, 304 and assumption of rcsponxibilirv.

wives of, 291, 293 _347-48
women, views of, 29 r-94 clinical vignettes, 4()-- ~ 1. 54-5.:;.
WORKS OF 59-6 t , (>5-()(l, fr;, (19-70, I 2. )--:q,

Across the River and Into the Trees, 308-16

292,296,298,300 cognitive bridges in. 1.2~-.24
 502 Index

here-and-now approach icont.) 89-90, 9on

personal style of therapist,
I
common group tensions, 68-70 single-session time frame, 85-86, 102
data sources during individual ther- spatial and temporal boundaries,
apy session, 429 87-89
definition of process, 45 structure, 86-87
"experiencing" tier, ·H, 55, 56 support in, 94-96
"illumination of process" tier, ·H-45, hospitalized (inpatient) group, higher
52-53,56,64-65 level working model, 96
in individual therapy, 428-30 agenda, "final product" clinical exam-
and manifesting of maladaptive ples, 110-11, 115-16

behaviors by group members, 34-41 agenda formulation, 101-5

patient's observations of, 55 agenda go-round, 98-101
process commentary: a theoretical basic procedure, 98
overview, 70-80 blueprint of session, 97, 97n
process as pm,ver source of group, change, reaching goal of, 113-15
51-52 general strategies, 107-9
recognition of process, 65-68 orientation statement, 97-98
summary, 56 purpose of the group, 98
therapist's tasks in, 52-56 resistance to agenda task, I 11-13
and transparency,418 transforming interpersonal agenda
Yalorn's contribution to, 42- ..u into here-and-now agenda, 105--9

Hesse, Herman, 396 Hoss, Phoebe, 34 3

Hill, Lewis, 452 hostility
Hinton, John, 260 between group members, 20-21, 28,

HIV-positive patient groups, 14, 450 29-30

hope, as therapeutic factor, 9-1 o toward therapist, 36, 38
Horney, Karen, 30, 34, 129, 289, 453 Hotchner, A. E., 303
hospitalized (inpatient) group human potential movement, 376
case 3 12-1 3
'"1 gnette, Hurley, J., 23
characteristics of patients, 84
clinical setting of, 84-85 imitative behavior, as therapeutic factor
consistent, coherent group procedure, in group therapy, 21-22. See also
93-94 modeling
fish howl format, .p 9 imparting information, as therapeutic
goals, 3 1 2- 1 3 factor in group therapy, 12-16

interpersonal relationships, 271-73 advice giving/acfrice-seeking behav-

latecomers and "boltcrs," dealing iors, 15-16

with, 87-88 as anxiety-reducing technique, 15

orientation and preparation, 90-9 r didactic instruction, 12-13, 128-29

patient preparation, 91-93 provide a sense of mastery, 78-79
!,
I
1:
I
 [ndex

self-he Ip groups, 1 3 "Jonah complex," 219

specialized groups, and cognitive Joy of Sex (Comfort), 167

therapy approach, 13-14 Jung, Carl, 2.p, 307, 399, 446
indifference or detachment, 33
individuation, 205-6, 208, 2 1 8, 229. See Kafka, Franz, 253
also specialness Kaiser, Helmuth, 398
Inpatient Group Psychotherapy (Yalom), Kazantzakis, =",Tikos, 214
83,970,312-13 Keyes, John Maynard, 2I7

interpersonal learning, 30-33. See also Khan, Masud, 432

here-and-now focus Kierkegaard,Soren, 177-78, 192, 193-94,
alcohol addiction group, 129 203,22Cr-21,233,237,340,375
case vignette, 3 12-1 3 Kluckholm, Florence, 216
group as social microcosm, 33-41, 44, Kubler-Ross, Elisabeth, 142, 222

364-71
and group therapy, 312 Lafcadio'sAdventures (Gide), 374
pathological display, 40 Lan<lsburg, Paul, 239
and small dynamic group, 42, 51-52 language
interpersonal pathology existential jargon, 178
advice giving/advice-seeking behav- relationship messages in, 68
iors, 15-16 use of conditional/subjective tenses by
clinical vignettes, 34-41, 46--51, therapist, 58
5~1,65--66,6j,69-70,308-18 Y alom on, 308
and existential isolation, 2j1-73, 345, Letters to a Young Poet (Rilke), 456
351 Lewis, C.S., 157
manifesting in group, 34 Liebault, A. A., 386
interpersonal theory of psychiatry, Lieberman, Morton, 2, 14 7
30-31 "Life Fear and Death Fear" (Rank),
. . .
mterviewmg 229-30
initial, II 8-21 Lifton, R., 204
principles of, 444 Lindner, Robert, 340
isolation, existential, 173, 219, 254, 270, literature and psychology, 269-70
271-73,345,350 Lives of a Cell, The (Thomas), 34 I
isolation, social/interpersonal, 148, 313, loneliness and aloneness, 156-58, 240,
351,357 27°,345

loss issues, 148, 206-8. See also bereave-

Jackson, Don, 398-99 ment group; cancer patient group;
James, P. D., 413 death
James, William, 427 of child, 240-4 1
Jaques, 255 of parent, 239-.p>
Jaspers, Karl, 178, 1~)2, 375 of spouse, 240
 Index

Lourdes, shrine at, 17 patient-therapist relationship,

love 414-20
in interpersonal relationships, 273-74, and exploration of therapeutic bound-
466 aries, 420-23
and obsession, 352 and Ferenczi's experiment, 415-17
therapy and a state of love-rnergcr , here-and-now focus in, 428-30
351-52 limitations on artistic vision of, 431
Love's Executioner (Yalom) prologue, 441-74
conception and writing of, 340-43, review of, 431-32
373,434,440 title, 434-35
death anxiety, 346 truth versus fiction in, 432-33
"Do i\ot Go Gentle," 346, 348, 352
dreams, real patients' used in, 426 Magister Ludi (Hesse), 396-97, 400, 435
existential psychotherapy, Make Today Count, r 3
underpinnings of, 344-54 Malraux, Andre, 175
"Fat Lady," 347-48, 349 manic patient, 89
first vignette, death denial, "I Never Mann, Thomas, 269
Thought It Would Happen to Maslow, Abraham, 219
~1e," .H 1-.p, 347 masochism, 223-26, 3 r 9
"If Rape \Vere Legal ... ," 346, 34 7, Masserman, Jules, 220, 433
354-72 May, Rollo, 73, 180, 181, 193, 194
"In Search of the Dreamer," 346, 373 McCallum, ~l, 23
"Love's Executioner," 348, 350, meaning, search for, 352-53
351-52 meaninglessness, existential, 173, 176,
Prologue, 343-54 255,276--81,345

"Thera peuric Monogaru v." 351 member-leader relationship, 275-76

therapist as ohserver-partici pant, mernorrcs
353-54 implanted, 4-32
"Three Unopened Letters," 350 and unconscious, 433-37
I .ow, Abraham, 13 unreliability, 439-40
Lucretius, 196, 269 Mended Hearts, I 3
Lying, Despair,Jealousy, Envy, Sex, Sui- Mental Health Through Will Training
cide, Drugs, and the Good Life (Far- (Low), q
ber), ·B5 rnetacommunication, 45, 68
lying and duplicity of patients, 437-4 I Meyer, Ado! ph, t 84
"Lying on the Couch" (Farber), 4H-35 midlife crisis, 242, 255-56
tying on the Couch (Yalorn) Miles, Matthew, 2

characters, origins of, 4.P-.B milestones, 241-43

dreams in, 423-27 modeling
and exploration of core aspects of by parents, 372
 Index

by therapist, 21, 88, 96, 118-19, 419 and superman concept, 376
Montaigne, de, Michel, 185, 187-88, on truth, 432
263-64 iVhen Nietzsche Wept, excerpt, 38~6,
Morin, H., 2 3 401-12

multicultural groups When Nietzsche Wept, premise of,

and universality, 12 374-76,385-88,400-401
multiple personality disorder, 351 WORKS OF
multiple therapy, 418 The Antichrist, 385
mutual analysis, 415 The Gay Science, 395
Human, All Too Human, 395, 407
narcissism, 35 Thus Spake Zarathustra, 380, 386, 401
case vignette, 308- 1 o Noyes, Russell, I 89, 24 3
Narrative Truth and Historical Truth
(Spence), 434 obituary exercise, 154, 34
National Institute of Alcohol Abuse object constancy, 452
and Alcoholism, 117-18 object-relations theorists, interpretation
near-death experiences, 189-90, 346 of group interactions, 34
Neurosis and Human Growth (Hor- observer-participant, therapist role as,
ney), 289, 453 53-55,353-54,379
Nietzsche, Friedrich Wilhelm, 234, Oedipal issues, 365
260,340,430 O'Neill, Eugene, 286
aphorisms, 377, 378-79 "ontological mode," 186
Archive at Weimar, 381 open group rehash, 418-19
. .
and fascism, 377, 381 orientanon
andFreud,374,380-83,385 initial interview, alcohol addiction
"granite" sentences, 377, 378 group, 1I8-21

as healer, 375 and instilling hope, 9, I 84

health, 381, 384, 385, 386-87 typical, in group therapy, 9<>-91
influence of, 378 Orrnont, L., 64
lack of public recognition, 380 Ortega y Gasset, 340
life of, 383-85 outcasts, and group therapy, 31-32
loneliness of, 384, 385
on memory, 439 Palo Alto Medical Clinic, 148
and nihilism, 375 Pane th, Joseph, 381
philosophic background, 383 panic disorder group, 14
and psychoanalysis, anticipation of, 382 Pappenheim, Bertha (Anna 0.), 387,
Psychoanalytic Society, Vienna, meet- 400

ings devoted to, 382 parataxic distortion, 68

and Salome, Lou, 381-82, 386, 387 Parents Anonymous, 13
and sister, Elisabeth, 377, 381 Parents Without Partners, 13
 506 Index

partial hospitalization groups in alcohol addiction group, 127

developmen t of social skills in, 20 characteristics for success, 25
direct advice in, 16 clinical vignette, 223-26, 354-72
patients. See also specific types (i.c., bu- countertransference, 335, 336-38
limic; hospitalized) Freud's blank screen mandate, 417
advice giving/advice-seeking behav- ideal, 27, ..po
iors, 15-16 legal concerns,421-22
denial, of death anxiety, 256-59, lying and duplicity by patient, 437-41
341-42, _346 and Magister Ludi (Hesse), 396----s,7
development of social skills, 20-21 mistrust of/hostility, 53
didactic instruction and reduction of and Nietzsche, 379
anxiety, 14-1 5 patienthood as ubiquitous, 354
dreams, 425 and personal style of therapist, 89--90
dynamic formulation of, 285 revelations during therapist's absence,
evaluation of group experience, 7-8 67-68
high expectation of help and positive Rogers' dictum, ..p3-14
outcome of therapy, 9 therapeutic alliance, 398-99, 417
imitative behavior of, 21-22 therapeutic boundaries, 420-23, 433,
impoverished group history of, 28 454
indifference/detachment of, 33 and transference, 274-]{>, 324, 337, 428
interaction with therapist, patterns of, Yalorn's in Every Day Gets a Little
19 Closer, 316-38
interpersonal distortions, 31-32 Pavlov, Ivan, 269
lying and duplicity of, 437-41 physicians, as rescuers, 221-22

observation of improvement in others, 9 Piper, W., 23

process observations by, 55 preparation of patient for therapy,
quitting group, reasons, 33 91-93
and resistance, 18, 59-61, 64, 314 and instilling hope, 9, 184
responsibility, 313-116 and outcomes, 1 c8-19
secrets of, common, 11-12 an<l transparency issues, 418
sense of uniqueness, 10 pnsoner groups, 31-32
struggle for dominance in group, 53, process and process illumination,
68-70 clinical vignettes, 46-5 1, 54-55,
patient-therapist relationship. See also 65-66,67,69-70
Every Day Gets a Little Closer definition, 45
(Yalom and Elkins); Love's Execu- focusing on, versus content, 45, 46,
tioner; Lying on the Couch (Y alom); 48-49,5o
When Nietzsche Wept (Yalorn) guidelines for recognizing, 66--67
addressing each other, variations, 90, in here-and-now approach, 44,
9011 428-30
 ln<lex 507

and individual therapy, .p8-30 quitting group, reasons, 33

patient observations of, 55
patient response/resistance to, 52-53 Rank, Otto, 73, 203, 208, 219, 229-30, 382
as power source of group, 5 1-52 rationalization, 196
recognition of, 65-70 Recovery, Inc., IO, 13, 16, 43-.l4
series of process comments, 70-73 reincarnation. 367-68
therapist's tasks in, 52-56, 64-65, 70, relationship issues. 226-28, 320

131-.P, .P4, .p8 religion, 203

"projective identification," 300 repression, 196, 203

Proust, Marcel, 197 of death anxiety. 248, 249-50

psychoeducational groups, 42, 4J-+f resistance
psychopathology clinical vignette. 59-61
and agenda task, 1I1-13 and feelings of uselessness/no value, 18
and death, 184, 196, 202-4 forms of, 59, 449
death anxiety: a paradigm of psy- and healing impact of other group
chopathology, 205-28, 259-63 members, 18
definition, 203-4 importance of, 64
and existential psychotherapy, 174, and responsibility assumption,
174n, 184 347-48
J J 1-13,
integrated view, 228-30 transforming into agenda work,
primary anxiety, 93, 196, 209, 230 109-IO
psychotherapy. See also goals of psy- responsibility
chotherapy; Lying on the Couch assumption of, 111-13, 313-16,
(Yalom); When Nietzsche fVept 347-48
(Yalom) case vignette, 313-16
activities of, 420 displacement of, 12

analytic one-to-one model, 2 and drinking patient, 137

boundary between fiction and per- and here-and-now focus, 349
sonal history in, 434-37 Rilke, Rainer Maria, 386, 456
catharsis in, 22-23 ritual, importance of, 160

definition, 93-94, 399 Rogers, Carl, 181, ..p3. 446

existential, 43. See also existential psy- Rome, Howard. 286
chotherapy Rosencrantz and Gulldcnstern Are Dead
patient-therapist relationship, ideal, (Stoppard), 434
27, 420. See also patient-ther apisr Rothman, Doreen, 192

relationship Rutan, Scott, 400

transparency in one-to-one format, Rycroft, Charles, 4.P
419-20
universality in, 11 Salome, Lou, 381-82. 38(>, 387
Pudney, John, 287 Santayana, George. 2.H
 508 Index
I

Sartre, Jean-Paul, 55, 179, 269, 276--80, techniques, in group therapy, :i

340,348,375 20-21
Schilder, Paul, 199 and here-and-now approach, 44
Scrooge, Ebenezer, 230-31, 233 Socrates, 376
Secret Sharer, The (Conrad), 300 Sophocles, 269
self-disclosure specialness (belief in one's own omnipo-
case vignette, 310-12 tence), 203, 208, 210-19, 228, 347.
and here-and-now approach, 44 See also Love's Executioner: "I Never
"horizontal," 312 Thought It Would Happen to Me"
therapist, Every Day Gets a Little clinical vignette, 341-42
Closer, 324 spectator therapy, 21
therapist, in summaries, 131-32, Spence, Donald, 434
419 Spiegel, David, 1 39

therapist, transparency issues, 415-20 Spinoza,Baruch,219,345

self-dynamism, 30 Stanford Medical Center, 148
self-help groups, 13, 43 step groups, 93
separation issues, 139, 148 Stone, Irving, 287
sex and death anxiety, 251-55 Stoppard, Tom, 434
compulsive promiscuity, 251-55, 346 stress, universality of, 175
and "]f Rape Were Legal ... ," structure, use of in groups
354-72 of alcohol addiction group, 1 I 8-33

sexual abuse groups disadvantages of, 94

experience of universality in, 12 highly structured programs, 93
sexual energy/misconduct between structured exercises, 61, 63, 99,
patient-therapist, 422-23, 433, 151-54,234-36,244-45,343-44
441-74 videotaping of sessions, I 22, 132-33,
sexual involvement between group 136
members, 35-38, 54, 273-74 Studies in Hysteria (Freud and Breuer),
sexuality, compulsive, case study, 380,387
251 -ss subgroups
Shakespeare, William, 269 extragroup socializing, 39, 133-35
shamans, 258 norms conflict with larger group, 135
Sharp, Allen, 197n romantic pairing, 35-38, 54, 273-74,
"shoulds" and "tyranny of the shoulds," 323
129, 150,289-90 use of during session, 58
silence, exercise to deal with, 61 success neurosis, 219
single-session groups, 85-96, 102 suicide, 215-16. See also Hemingway,
Smith, Olive, 337 Ernest
snake phobias, 21 Sullivan, Harry Stack, 30-3 I, 73, 93-94,
social learning/acquisition of socializing 399
 Index

summaries for patients, 129-32, 136--37, patient-therapist relationship, .p3-q,

419 420

support secondary factors, 41 3

cancer support groups. 42, 4+ therapist's intuitive qualities, 168-tl9,
function of in groups, 94--96, 130 174,338.353
and therapist, 95 universality, 10-12
su ppress1on, 203 therapists. See also therapists, group
systematic desensitization, 76. q5. casks
263-65,298-99 authentic/genuine behavior, 414, 428
authoritarian, 417-18
Tennyson, Alfred Lord, 163 death anxiety, as explanatory system,
tensions, common group, 68-70 250-51
terminally ill, interactions with, 245-48. and death, denial of, 202, 256--58,
354-72. See also cancer; cancer pa- 341-42, .345
tient group; Love's Executioner "disciplined naivety." 181

(Yalom) dynamic formulation, 285

Thackeray, William Makepeace, 343 empathy of, 95, 181

Theory and Practice of Group Psychother- existential, assumptions about source

apy, The (Yalom), 5, 42, 273-75. of dysphoria, 43
308-12 and here-and-now focus, 428-30
therapeutic alliance, 398-99, 417, 449 intuitive qualities (Yalom 's "throw-
therapeutic boundaries, 420-23, 433, ins"). 168-69, 174, 338, 353, 446-47
454 legal concerns, 421-22, 455
therapeutic factors, 6-4 I, 70 and Magister Ludi (Hesse), 396-97
altruism, 16--18, 140-41 modeling by, 21, 88, 96, 118-19. 4 r9.
cancer patient group, 140-44 428
catharsis, 22-23 as observer-participant. 53-55,
corrective recapitulation of the pri- 353-54,379
mary family group, 18-20 as patient, 397-40 r
development of socializing tech- and patient responsibility, 314-16
niques, 2~21, 44 privileged knowledge. 439
existential factors, 2 3-24, 24n. See also Rogers on, 446
existential psychotherapy role, and cxistcnti.il issues. 2 ~8-41.
group cohesiveness, 24-30, 142 353-54
group as social microcosm, 33-4 I, 44, self-disclosure, q 1-p, p4. 415-20
364-71 structure versus unccrr.unrv, )')~
imitative behavior, 21-22 therapeutic boundar ic ~ .. pn-2 ~
imparting information, 12-16, 141-42 therapy as part of training, )78
instillation of hope, 9-10, 184 transparency. 4 q ···20

interpersonal learning, 30-33, q4 "wounded," ·N8-400. -HI

 510 Index

therapists, group tasks time issues. See also existential psychol-

agenda formulation, tasks in, 102-10 ogy
in alcoholism group, 121-25 bereavement group, 160
anxiety of leader, 93 Tolstoy, Leo, 188-89, 210, 218, 230,
basic question to consider, 70 275-76

belief in self and group efficacy, training for group psychotherapists

importance of, 10 dynamic formulation, 285
in cancer patient group, 145-46 identifying and using maladaptive in-
and explanation or interpretation of terpersonal behavior, 34-41
patient's behavior, 77-80 therapy as part of training, 378
as group historian, 53 transference, 274-76, 324, 337, 428, 450,
interrupting content flow of group, 47°
62-63 erotic, 458
male/female team to simulate .. transference cure," 338, 449
parental configuration, I 8 transparency, 414-20
mistrust of/hostility toward, 53 concerning preparation of patient, 418
norm creation by, 95-96, 419 and Ferenczi's experiment, 415-17
personal Hyle, 89-90, 9on and here-and-now experience, 418
recognition of process by, 65-68 techniques, 418-20
school of conviction, influence of in Travesties (Stoppard), 4 34
interpretation and practice, 7, 25, Trial, The (Kafka), 253
34,78-79 Twain, Mark, 287, 440
self-disclosure by, 131-32, 324- See two-way mirror, use of in observation,
also transparency 1, 328
series of process comments, 70-73 cancer pauent group, 139, 140,
strategies and techniques with inpa- 245-48,258
tients, 85-96 and transparency, 4 I 8
structured exercises, effectiveness of,
63,343-44 ultimate rescuer, 219-28, 245, 246, 341,
and support, 95 347
tasks in the here-and-now, 52-56, Unamuno, de, Miguel, 179, 340
64-65 uncertainty, existential, 182, 250-51
techniques of here-and-now activa- universality, as therapeutic factor,
tion, 56-64 10-12, 174-75,370-71
trairung, 34-41 and acceptance, J 1-12, 27
and will, removing encumbrances and bereavement groups, 151
from patient's, 74-78 and bulimic patients, 12

Thomas, Lewis, 341 of existential concerns, I 78-79

Through the Looking Glass (Carroll), 272 and multicultural groups, 12

Tillich, Paul, 192, 203 and sexual abuse groups, I2

 Index 511

unsaid/unexpressed material during clinical manifestation of death anxi-

session, 61 ety, I94-9'5
clinical practice, 339
value formation, and culture, 216--17 core image, 335, 437
ventilation, 22 dreams, own, . p4-25
vicarious therapy, 21 dreams, patients', use of, 425-26
. . . .
victimization, 112 dreams in therapeutic process,
videotaping of sessions, 122, 1 _p-_B, ..p3-27
136, J 9<>---9 I and Emergency (Kaiser), 398. 435
for legal reasons, 421 and encounter groups, 2-3, 22
Vinogradov, Sophia.r . t7-48 and existential psychotherapy, 43, 339,
34°
Wahl, Charles, 215 and existential sources of anxiety,
fVar and Peace (Tolstoy). I 88, 230, interest in, I 38, 339
275-76 and existential thinkers, 375
Weer, Katie, 138 fiction, writing of, 413, 42 3-24,
weight-reduction groups, 44 430-32,433,435
"What do you want?" exercise, 343-44 first patient, x-xi
Wheelis, Allen, 7 3 group psychotherapy. contributions
When Nietzsche Wept (Yalom). See also to, 42-43
Nietzsche, Friedrich Wilhelm and healing of therapist by practice of
characters, 4 30 psychotherapy, 399-400
conception and writing of, 373-88, and here-and-now approach, 42-43,
400-401,430-31,433,434 428-30
excerpts, 388-96, 401-12 journal-keeping of, 340
Wilder, Thornton, 440-41 life narrative, .+36-37
will, concept of, in psychotherapy, 73- literary aspirations, 336. 340
78, 349-50 major professional interests, x, 43
workaholism, 216-19, 261-63 and memory, 433, 435-37
"wounded" healer, 398-400, 44 I military service, 437-38
writer's block, 316-17, 320, 324 office, 429
Wundt, Wilhelm, 269 patients, revealing here-and-now be-
havior of, 429
Ya lorn, Ben, xii parents, -~06-7,43(>--37
Yalorn, Irvin D. psychiatry clerkship, x
analyst of, 337 psychological thinkers/novelists, in-
career choice of medicine, 307, 436-37 fluence of. 2()9, 270 -8 I •. Ho
case vignettes, four, 308-16 Q-sort study, 22, 2_~

case vignettes, writing of, 307-8 reading, love of, 306

childhood, 305-7, 436--37 rescuer fantasy, .P4, _33-;-{(>
 512 Index

Ynlom, I rvin D. (cont.) Existential Pyschotherapy, conception

residency, Johns Hopkins, I and writing of, I 67-68, 183, 339.
and specialness. 2II 375
at Stanford University, 5-6, 83, "Group Therapy and Alcoholism,"
398-99,431 I J7
storytelling ability, xi-xii, 305, 307-8, "Group Therapy with the Termi-
3 I(}-- I 8, 340 nally Ill," 138-39
teaching Freud appreciation course. Inpatient Group Psychotherapy, 83
387 Love's Executioner, conception and
and the teaching novel, 374-75. 431 \Vriting of. 340-43, 373, 426, 434
and textbook writing, 339 Lying on the Couch, conception and
training, early, x, 307 writing of, 41 3-4 I
and transparency/rules of therapist Theory and Practice of Group Psy-
self-disclosure, .p 7-20 chotherapy, The, writing of, 5-6,
types of groups conducted, r 81-82,339
in Vienna, 430 ?-Vhen Nietzsche JVept, conception
and will, concept of, in psychother- and writing of, 373-88, 400-401,

apy, 73,349-5° 430-3 I• 433, 434

\\'< >RKS < >f writing style, 308
"Bereavement Groups: Techniques Yalorn, Marilyn, 282, 318
and Themes:' q 7-48 "yes ... but" patient, 15

"Ernest Hemingway: A Psychiatric Young, P., 294, 295

View." writing of, 282

Etcryday Gets a Little Closer, writing Zilboorg, Gregory, 249

and success of. 3 r (}--18 Zweig, Stefan, 384
PSYCHOLOGY

The bestselling author of Lying on tbe Ccnub and Love's Executioner and
one of the most highly respected authorities in the field of psychotherapy
offers representative selections from his best-known works, as well as dazzling
new personal essays on writing and the art of psychotherapy.

n this anthology of Irvin Yalorn's most influential work to date, readers will

I experience the diversity of his writings with pieces that range from illustrative case
studies, to theoretical models, and, of course, to literature. Included are carefully
edited selections from Dr. Yalom's masterful writings on group and existential therapy
as well as excerpts from Love's Executioner, When Nietzsche Wept, and Lying 011 the Couch. Dr.
Yalom has written an introductory essay for the Reader, new section introductions, and
three new essays on narrative.
In both his nonfiction and his fiction, Dr. Yalom uses the lens of psychotherapy to
explore human nature and shows us that the line between the true and the imagined is
not always easy to distinguish. What _has driven Dr. Yalom from the beginning of his
career is a powerful interest in narrative and it is this passion that ties these selections
together. It is possible to come to The Yalom Reader from many different backgrounds and
be richly rewarded. Readers of Dr. Yalom's clinical texts will be intrigued by the fic-
tional works; general readers will gain a greater understanding of and appreciation for
the practice of psychotherapy. All will find the mark of a master.

IRVIN D. YALOM, M.D., is the author of Lying on tbt

Couch, When Nietzsche Wept, and Love's Executioner, as well
as several classic textbooks on psychotherapy, includ-
ing Existential Psychotherapy and The Theory and Practice of
Group Psychotherapy. He is Professor Emeritus of
Psychiatry at Stanford University and lives and prac-
tices in Palo Alto, California.
BEN YALOM1s fiction, nonfiction, and translations
have appeared in many publications, including Wirtd, Fish Stories, and the San Francisco Bay
Guardian. He and his brother, photographer Reid Yalorn, are currently documenting
traditional parades in the United States.

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