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Are these six psychotherapy tales true? Or fictional? The first story (Momma and the Meaning of Life) is a true autobiographical fantasy (that is, the dream and the events in the story are true, the precise conversation a fantasy), the next three (Southern Comfort, Seven Advanced Lessons, Travels with Paula) are pure nonfiction flecked only with fiction to conceal the patients’ identity, and the final two (Double Exposure and The Hungarian Catcurse) contain a nonfictional nucleus around which I constructed a fictional tale. But a confusion inheres in any fiction-nonfiction codification. Not only does fiction have its own truth, but every story, no matter how “true,” is a lie because it omits so much. In each narrative I have eliminated the quotidian details of the therapy encounter. Not only is such close-cropping required for dramatic impact, but for vision as well. As Nietzsche put it, we must blind ourselves to many things in order to see the one thing. Hence, to uncover underlying truths we must clear away obscuring distractions. The narrowing of focus, the core lie of storytelling, is always an attempt to see better—to achieve a clearer and deeper vision of the world. Why have I written these particular tales? In this work, as in all my writing endeavors, I have been both pushed and pulled: pushed by unconscious forces—by primitive self-serving motives and by buried events from my past which strain for expression; and pulled by the future—by the ideals I have constructed and to which I aspire and by the goals of edifying and entertaining my audience. In this discussion of the six tales I shall focus more on pull than on push—my reasons are not only more accessible to me but in better taste. The title story, “Momma and the Meaning of Life,” had its inception in a dream, which I accurately reproduced in the opening paragraphs. Upon awakening from that dream, I was haunted the rest of the day by the dream phrase, “Momma, how’d I do?” The image made me shudder, it seemed ripe with possibility and stirred up many thoughts about meaning in life. I turned on my computer to jot down my ruminations but something else entirely happened. I had the eerie, writerly experience of being only a midwife or a scribe to a rapidly emerging story that insisted upon writing itself. The ‘push’ in writing this story is unambiguous: my conversation with my mother’s ghost, a conversation that, alas, I never had in life, was an attempt to resolve some unfinished and tormented business from the past. The same theme reverberates with somewhat less clamor, in the next two tales as well—“Travels with Paula” and “Southern Comfort.” In this, I join a long line of writers who have unabashedly used their medium to work through personal conflicts. Even Hemingway, who was no aficionado of the search within and who always denigrated psychotherapy and its “effete wet-thinking” practitioners, acknowledged that his corona (i.e. his typewriter) was his psychiatrist. I meant the second tale, “Travels with Paula,” to be an encomium to a remarkable woman, a memoir of my apprenticeship in working with the dying, and a guide to practitioners who consult with cancer patients. It is also a historical account of the first therapy group for cancer patients. Though such groups are exceedingly common today, they were entirely unknown when Paula and I first embarked on the venture. The professional reader may obtain more information about such groups from my book Existential Psychotherapy (Basic Books, N.Y, 1980). I recommend this text to readers interested in pursuing all the existential themes discussed in Momma and the Meaning of Life as well as in other books: Love’s Executioner, When Nietzsche Wept and Lying on the Couch. It is the mother book for all my literary writing. Despite its ponderous title it is easily read by nonprofessionals since I have made every effort to avoid jargon and to write lucidly and engagingly. Many therapists have recommended this book to patients struggling with urgent life issues. See also the following descriptions of groups for cancer patients: Yalom, I., Greaves, C., Group therapy with the terminally ill, American Journal of Psychiatry, 134:4, April 1977, pp. 396-400.The third tale, “Southern Comfort,” examines the consolation obtained by transforming another into a comforting icon as well as the restrictive effects of that process upon both the transformed and the transformer. Set in an acute, rapid turn-over, hospital therapy group, the story describes the radical modifications required to adapt a group to the demands of contemporary managed care treatment. Leaders of such groups must change their values, must settle for less, must strive to offer something in brief, more impersonal contacts. This is not an easy transition for therapists accustomed to more ambitious goals and more intimate caring relationships; many fall prey, as I did in this tale, to the professional hazard of grandiose rescue fantasies. For more information about leading such acute inpatient groups see my text: Inpatient Group Psychotherapy (Basic Books, N.Y.) 1983. “Seven Advanced Lessons in the Therapy of Grief,” my longest and most complex tale, is an undistorted account of treatment (aside from omission of prosaic details and for disguised identity) containing a myriad of psychotherapy themes. The therapist as student and, conversely, the patient as teacher, a theme introduced in “Travels with Paula,” is more fully developed in this story. The saddest psychotherapy story I’ve ever heard occurred twenty-five years ago during a sabbatical year at a clinic in London where I studied with an eminent group therapist. Once he described a group meeting to me in which the members (most of them in the group for ten years!) reviewed the progress of their group and concluded that every single group member had undergone considerable change—save the therapist who, ten years later, was exactly the same. The therapist then turned to me, eyes sparkling, and said, tapping his forefinger on the desk for emphasis, “That, my boy, is good technique!” I’ve always viewed this saga of the perdurable therapist as a sad story because it portrays such a fundamental misunderstanding—namely that therapists are mechanics tinkering with the apparatus of the mind but remaining outside of the field or, alternatively, are inert chemical catalysts, enabling the process of change while untouched personally by the reaction. These highly misleading metaphors ignore the vast numbers of inquiries into the process of therapeutic change that support the axiom—and axiom is not too strong a term—that it is the relationship that heals. Therapeutic change ensues from a genuine, authentic engagement—and that, by definition, implies mutuality. Therapists facilitate change in the patient and, in the process, are themselves changed. Good therapists are perpetual students on a never-ending voyage of self discovery and, as they feel more secure in their own skins and are able to relinquish the garb of authority, they will welcome, as a blessing, a deeply intelligent, sensitive and challenging patient like Irene. The existential frame of reference described throughout this volume posits that many patients fall into despair because of an encounter with some of the ultimate concerns of existence. The particular concerns most salient to clinical work are death, isolation, freedom, and meaninglessness— themes which form the spine of my text, Existential Psychotherapy, (Basic Books 1980). Since these sources of angst are universal—inherent in the human condition—psychotherapists cannot pretend that it is only ‘they,’ the patients, who face these threats; instead it is ‘we,’ all of us, who share a common destiny. Accordingly the metaphor of “fellow travelers” more aptly describes the therapist-patient relationship I strive for in my therapy work. I first met with Irene shortly after completing three years of research in which I and my colleagues studied the dynamics and clinical course of eighty bereaved spouses. See the following for the description and results of this research: Yalom, I.D., Vinogradov, S., Bereavement Groups: Techniques and Themes, International Journal of Group Psychotherapy, 38:4, October 1988.My research experience proved less relevant to the treatment course than I had expected; in fact there were many counterproductive instances—times when Irene felt, quite justifiably, that my reliance on the experience of other bereaved individuals impeded my appreciation of her unique experience. The effective therapist must be able to empty his/her mind of the expectations and stereotypes which obstruct vision in order to facilitate the patient’s unique narrative to unfold freshly in the relationship. And so, too, for therapy technique. Not only in “Seven Advanced Lessons in the Therapy of Grief,” but in the other tales as well I urge the therapist to create a new therapy for each patient. Hyperbolic though that may sound, I sincerely mean that the therapeutic venture must be organic: the therapist and patient must together shape the form of therapy—indeed, the joint process of shaping the work is an integral part of the work. The contemporary managed care trend toward brief, ready-made, protocol-driven therapy is a wrong turn and is deeply threatening to the whole therapeutic enterprise; it is based on a profound misunderstanding of the process of personal growth, namely that therapy consists of information or advice. Ernest Lash, the therapist in the last two stories “Double Exposure” and “The Hungarian Cat Curse” had an earlier life as the protagonist of my last novel, Lying on the Couch. His encore appearance is meant to signify that these two last tales are heavily fictionalized. “Double Exposure” is a ‘what if’ story. Years ago, I regularly audio-taped the sessions of a patient who had a two hour commute to my office and handed her the cassette to listen to on the drive to the following session. (I routinely do this with patients who come to see me from great distances. It makes good use of the commute time by priming the patient for the next hour. Therapy is always more effective if the sessions are continuous rather than episodic—I much prefer sessions which explore ongoing themes at ever deeper levels to sessions which are focused outwards, upon the external events of the preceding week). Well, one week I forgot to give my patient the tape. She realized this fifteen minutes later and promptly returned to my office to retrieve the tape. Next week on her commute she listened to the tape of the session on the way and was startled to hear my dictation of the hour (I had been unaware the tape recorder had been left running.) Whenever I have told professional colleagues of this incident, they’ve gasped—it is a scenario for disaster. As things turned out in real life, however, it was a benign experience—my dictation contained nothing unsettling and therapy continued unaffected. But what if? What if there had been something deeply disturbing in the dictation? Or, worse, what if there had been the most disturbing content imaginable—what if the therapist had been presenting her to a professional conference focusing on countertransference—that is, all the deeply personal, irrational, dark, rageful, lustful, non-professional feelings to the patient? This ‘what if’ is the fictional scaffolding upon which the events and dreams of this tale are draped. “Double Exposure” explores several themes including counter-transference and the role of causality in the formation of psychotherapy theory. The concept of causality, the idea that an event following another chronologically is perceived as being caused by the prior event, is inherent in the neural apparatus through which we experience the world. Such causal attributions highly influence our explanations of behavior but are highly errorful. Double exposure explores the havoc caused to theory by the presence of intervening, invisible events in the causal chain. But these are minor themes: Double Exposure is primarily meant as a rhapsody on therapist transparency—a variation on the theme previously explored in my novel Lying on the Couch. In it I explore many questions which set therapists’ teeth on edge. If we hold that the ideal therapeutic relationship is one of genuineness and authenticity, then shouldn’t the therapist be a real person in the therapy process? As real in the therapy hour as outside of it? Should it be only the patient who self-discloses? What might happen if the therapists were to reveal themselves more extensively? Or, an even more mischievous question, what might happen if that disclosure occurred in a particularly ill-starred situation? The uncomfortable question of therapist self-disclosure can be detoxified by analyzing the concept of self-disclosure. Three categories of therapist self-disclosure are particularly germane to the process of therapy: disclosure about the mechanism of therapy, disclosure about the here-and-now, and disclosure about the personal historical events of the therapist’s life. Disclosing about the mechanism of therapy presents no problem for Ernest Lash. He unhesitatingly lays bare the rationale behind his approach to therapy because he is persuaded that the psychotherapy process is so intrinsically robust that no mystification, no appeal to magic or authority, is required. Ernest Lash also discloses a great deal in the second category—the here-and-now. He openly reveals his own inner experience and his feelings toward his patient in the immediate moment. Such “here-and-now” disclosure is of extraordinary importance and complexity and several tales in this volume contain examples of such self-disclosure. (The “here-and-now” is an ahistoric focus; it refers to what is happening now in the immediate moment of meeting between two people, here in the office, in the space between the therapist and patient.) The most important tool of the therapist is his/her own person and to learn how to use it meaningfully and helpfully in the here-and-now of therapy is perhaps the single most challenging task in the training of therapists. To understand the use of the self properly (and this is the subtext of the seminar discussion in “Double Exposure”) we must discard the old therapist roles that have outlived their usefulness—the “blank screen” therapist, the whitecoated aloof medical practitioner, the therapist as objective non-interactive scientist. Therapy is a two-person relationship demanding both interaction and exploration of that interaction; real feelings and mutual disclosure about the feelings evoked in the therapy interaction are necessary. Today many progressive psychoanalytic institutes have abandoned the old blank screen model in favor of a new model—the real two person relationship—and published clinical investigations of that phenomenon— ‘intersubjectivity’ or ‘two person’ psychology—are now commonplace in the professional literature. Ernest Lash is much more conflicted, as he should be, about disclosing details of his personal, non here-and-now life. In these tales I have presented the view that such disclosure should be served only to the extent that it serves therapy. Therapists must facilitate the formation of a trusting, fellow traveler, relationship, demonstrate understanding and respect for the patient, and set a model to encourage the patient’s deeper participation; if personal disclosure facilitates any of these ends then the effective therapist will not shrink from it. Though “The Hungarian Cat Curse” is my most fictional and fantastical tale, it is studded with real events and issues. The therapist’s delight when a taxing and unpleasant patient decides to terminate, his boredom with a particular patient and the subsequent use of that boredom as a guide in therapy, the therapist’s chagrin at the damage his patient has inflicted on another, his yearning to redress that wrong, lapses in which he loses sight of his patient’s best interests, his grandiose rescue fantasies, his lustful fascination with a character in a patient’s life, his dilemma about whether healers are ever off duty—all of these foibles, and more, are taken from my personal experience. The final surreal dialog between man and ninth-lifer cat is meant to represent a type of truth—a therapeutic inquiry into the ultimate concern of death. A few attributions for that discussion are in order: the psychologist who said that many refuse the loan of life to avoid the debt of death was Otto Rank. The ancient philosopher who said, “Where death is, I am not; where I am, death is not,” was Lucretius, expounding upon Epicurus. And Nabokov was the Russian writer who, in his autobiography, Speak, Memory, pictured life as a brilliant spark between two vast and identical pools of darkness: the darkness existing before birth and the darkness following death. The same image is to be found in Schopenhauer, with whom, I presume, Nabokov was familiar. I have deeply disguised the identity of all the patients and acquaintances who appear in these stories. Some of the events described took place long ago and many of the characters are dead. All those who provided incidents or dreams read the manuscript in both early and final draft and gave me permission to publish it. Copyright © 1999 by Irvin D. Yalom, M.D. |