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Dr. Yalom’s Foreword to Every Day Gets a Little Closer

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 many fine moments. What has happened to them?

My many-tiered file cabinets, my 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 imbues me with a keen sense of transience.Even as I find myself immersed 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 desire to relate my experience with Ginny is a very compelling one; I am intrigued by the opportunity to stave off decay, to prolong the span of our brief life together. How much better to know that it will exist in the 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 meeting 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 an Oriental wife she followed a few noiseless steps behind. She did not belong to herself, nothing 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, tattered 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 one-time 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 continue the therapy she had begun last year, and, in a confusing unsystematic 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 occasional 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 disembodied spirit—a chirping canary hopping back 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.

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 feelings—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 cliché: ‘If you can’t say anything nice about people, don’t say anything at all.”’ She remembers getting angry only once in her adult life: years ago she yelled at a co-worker who was insolently ordering her around. She trembled for hours afterward. She has no rights. It doesn’t occur to her to be angry. 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 spontaneously, the pleasure-stripping voice brings her back sharply to her casket of self-consciousness.In the interview she could not permit herself a single prideful sentiment. No sooner had she mentioned her creative 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 men. 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 men (she had no right to say “no!”) and lamented that she had hurled herself through the bedroom window without even entering the adolescent antechamber of dating and petting. She enjoys being physically close to a man but cannot release herself sexually. She has experienced orgasm 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 always been unusually close. Ginny told her mother everything. She remembers how she and mother used to read and chuckle over 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 breakfast 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 my mouth. I would try then to swallow it all at once.”

She has horrible nightmares in which she is sexually violated, usually by a woman, but sometimes by a man. Also a recurrent dream in which either she is a large breast with clusters of people clinging to her or she herself clings to some mammoth breast. About three years ago she began having frightening dreams where it was difficult for her to ascertain if she were asleep or awake. She senses people staring at her through the window and touching her; as soon as she starts to experience pleasure from the touching, it turns to pain as though her breasts are being tugged off. Throughout all of these dreams there is a far away voice reminding her that none of this is really happening.

By the end of the hour I felt considerable alarm about Ginny. Despite many strengths—a soft charm, deep sensitivity, wit, a highly developed comic sense, a remarkable gift for verbal imagery—I found pathology wherever I turned: too much primitive material, dreams which obscured the reality-fantasy border, but above all a strange diffuseness, a blurring of “ego boundaries.” She seemed incompletely differentiated from her mother, and her feeding problems suggested a feeble and pathetic attempt at liberation. I experienced her as feeling trapped between the terrors of an infantile dependency which required a relinquishment of selfhood—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 know that because of her ego boundary blurring, her autism, her dream life, the inaccessibility of affect, most clinicians would affix to her a label of “schizoid” or, perhaps,“borderline.” I knew that she was seriously troubled and that therapy would be long and chancy. It seemed to me that she had too much familiarity already with her unconscious and that I must guide her to reality rather than escort her more deeply into her underworld. I was at that moment hurriedly 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 individually. In particular I felt some disquiet at the depth of her admiration for me, which, like some ready-made mantle, was thrust over me as soon as she entered my office. Consider her dream dreamt the night before 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 tide, the rest from parts unknown. But the over evaluation was so extreme that I suspected it would prove an impediment in individual therapy. Participation in group therapy, I reasoned, 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.Terrifying 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 accidentally cut a part of the brain be hadn’t intended to.” Another dream involved her going to a party with me and our rolling on the grass together in sexual play.

After the first month my co-therapist and I both felt that a once-a-week group was not enough for Ginny and that some supportive individual therapy was necessary, both to prevent Ginny from decompensating even further and to help her pass through the difficult early stage of the group.She expressed a wish to see me individually, but I felt that it would be more complicating than helpful to see her both individually and in a group and thus referred her to another psychiatrist in our clinic. She saw him individually twice a week for approximately nine months and continued to attend the group therapy meetings for approximately eighteen months. Her individual therapist noted that Ginny was “beleaguered by frightening masochistic sexual fantasies and manifestly borderline schizophrenic thought processes.” He attempted in his therapy to be “ego-supportive and to focus on reality testing and distortions in her interpersonal relationships.”

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 primarily 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 therapists 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 remained tense, withdrawn and often non-communicative in the group. The other members were intrigued by her; when she did speak,she was 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 express her feelings freely or to interact with the others.

During the eighteen months Ginny was in the group I had two co-therapists, each male, each remaining with the group for approximately nine months. Their observations about Ginny closely parallel my own: “ethereal...wistful...a haughty but self-conscious amusement at the whole proceedings...reality would never fully engage her energies....A ‘presence’ in the group...a tortured transference to Dr.Yalom which withstood all interpretative efforts...everything she did in the group was considered in the light of his approval or disapproval ... alternated between being someone who was extraordinarily sensitive and reactive to others, to someone who simply was not there at all...a mystery in the group...a borderline schizophrenic yet she never came close to the border of psychosis...schizoid...too much awareness of primary process...”

During the period of her group therapy, Ginny searched for other methods to escape from the dungeon of self-consciousness she had constructed 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 instantaneously:nude marathons to overcome her reserve and hiddenness, psychodrama techniques and psychological karate to alter her meekness and unassertiveness, and vaginal stimulation with an electric vibrator to awake her slumbering orgasm.All to no avail! She was an excellent actress and could easily assume another role on stage. 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 myco-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 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 relentlessly 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 conditional that any foolish word or false move would tip the balance against her. Consequently, she derived little pleasure from the creature comforts she shared with Karl.

I considered referring Ginny for individual therapy to a public clinic in San Francisco (she could not afford to see a therapist in private practice), but many doubts nagged me.The waiting lists were long, the therapists 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 at the same time permit me to capitalize, 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 financial payment, to write an honest summary of each session, containing 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. (Incidentally, this plan entailed no personal financial sacrifice since I was on a full-time salary status with Stanford University and any money I earned from clinical work was turned over to the University.)

Because of my wife’s interest in literature and the creative process, I mentioned this plan to her and she suggested that I, too, write an impressionistic nonclinical note following each session. I thought this idea was an inspired one, though for an entirely different reason from that of my wife: she was interested in the literary aspect of the endeavor; I, on the other hand, was intrigued by a potentially powerful exercise in self-disclosure. Ginny could not disclose herself to me, or anyone, in a face-to-face encounter. She regarded me as infallible, omniscient, untroubled, perfectly 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 release 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 reports for several months and my secretary would store them for us. Artificial? 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 one another, that if we could relate in an honest, human fashion, then all other desired changes would follow.