Lying On The Couch

by Irvin D. Yalom

A few years ago, they answered his cry of distress when, after his residency training, he fell into lockstep with every ambitious young neuropsychiatrist and applied himself to neurochemistry 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 psychopharmacological practice.

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.”

“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, but good journals. Did you know that?”

“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.”

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 hospitalizations—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 Uproar. You remember Eric Berne’s Games People Play?

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 further 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.

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.

“The main recollections I have are that in the beginning things went far better than I could have imagined. Not sure why, but Belle took to me immediately. Couldn’t have been my good looks. I had just had cataract surgery and my eye looked like hell. And my ataxia did not improve my sex appeal . . . this is familial cerebellar ataxia, if you’re curious. Definitely progressive . . . a walker in my 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 exactly what you’re doing now—and I want to tell you, Dr. Lash, I appreciate 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 borderline, not an eating disorder, not a compulsive or antisocial disorder. That’s the way I approach all my patients. And I hope I will never become a diagnosis to you.

“Was I too important? No, Dr. Lash, the therapist can’t be too important early in therapy. Even Freud used the strategy of

trying to replace a psychoneurosis with a transference neurosis—that’s a powerful way of gaining control over destructive symptoms.

“Earlier you asked what my technique was. Maybe my best answer is simply: I told the truth.

“Insight? Not a major player in Belle’s therapy. Oh, she grew to recognize that more often than not her impulsive behavior was preceded by a feeling state of great deadness or emptiness and that the risk taking, the cutting, the sex, the bingeing, were all attempts to fill herself up or to bring herself back to life.

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.

Sometimes she’d end the session by giving me a hug—always friendly, not sexual. The next session she’d chide me about my behavior, about my formality, about the way I’d stiffen up when she hugged me. And ‘stiffen’ refers to my body, not my 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.

“How did her campaign for sexual contact make me feel? Good question, Ernest, but is it germane to this investigation? “You’re not sure? What seems to be germane is what I did—that’s 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, I’ll tell you. Consider it instruction. You’ve read Rilke’s Letters to a Young Poet, haven’t you? Well, consider this my letter 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 obsessed 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. I’m only human. It 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 competitive 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.

“What? ‘Borderline patients play games’? That what you said? Ernest, you’ll never be a real therapist if you think like that. That’s exactly 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.

“Good! I appreciate your honesty. Nothing to be 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 my job: to introduce her to reality, to help her grow away from me. Even, God save us, to forget me.

“You shake your head. Of course! But I don’t speak to your head. I aim straight at your heart, and the time may come when you open yourself 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.

“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! Compare her outcome with any drug therapy: Risperidone, Prozac, Paxil, Effexor, Wellbutrin—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 anyone about it. Until now! You’re my first real audience.

“So what would you have done in this situation, Ernest? What? 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’m a different kind of therapist. 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 my whole career. You know my reputation? Ask around. Ask your chairman. He knows. He’s sent me dozens of patients. 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.

‘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 arrangement? 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 swallowing 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 leave nothing but fragmented DNA chains.

And my attraction toward Belle? I won’t deny it: I adored her. And when she told me she was going to give me the fuck of my life, I could hear my worn-out gonadal engines cranking up and turning over again.

“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 many years of disuse. But Belle was a master plumber, and after some rattling and clanging everything began to work again.

“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 looking 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 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 husband 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.

“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 depression. No biological markers: psychomotor symptoms, insomnia, weight loss—none of that. Thanks for offering.

Nor point out that, five years ago, Laura would have been about fourteen and Justin couldn’t have wiped his ass without asking Carol’s permission, couldn’t get to noon without calling his therapist, couldn’t order from a menu without his wife’s guidance, couldn’t dress in the morning if she didn’t lay out his clothes. And it was his wife’s money, anyway, that paid the bills, not his—Carol earned three times as much as he did. If not for five years of therapy, he’d have eighty thousand dollars in his pocket! Shit, five years ago Justin couldn’t have figured out which pocket to put it in!

Carol was a wildcat, a wolverine, a madwoman who tyrannized through her irrationality. Ernest remembered another car adventure that Justin had described a couple of years ago. While driving on a warm summer night, she and Justin had argued about the choice of a movie—she for The Witches of Eastwick, he for Terminator II. Her voice rose, but Justin, who had been encouraged by Ernest that week to assert himself, refused to give in. Finally she opened the car door, again in moving traffic, and said, “You miserable fucker, I’m not going to spend another minute with you.” Justin grabbed at her, but she sank her nails into his forearm and, as she jumped out into the traffic, plowed four violent red furrows into his flesh.

While she was at it, she carved out the faces of her in-laws from the wedding photos. If it hadn’t been for them and their promises, empty promises, of big, big money, she’d probably never have married Justin. A snowy day in hell before they would see their grandchildren again.

Dr. Cooke also comforted her by helping her to assume a different perspective—to consider the loss of Rusty in her entire life trajectory: she was only nineteen, memories of Rusty would fade away. A few months hence she would rarely think of him; in a few years she would have only a vague recollection of a nice young lad named Rusty. Other men would come along. In fact, another man was coming along, for, as he spoke, Dr. Cooke insidiously edged his chair closer. He assured Carol that she was an attractive, a very attractive woman, held her hand when she wept, hugged her tightly at the end of the sessions, and assured her that a woman with her grace would have no difficulty attracting other men. He spoke for himself, he said, and told her that he was drawn toward her.

Whatever the transition, the remainder of the session was the same. He’d slip off his chair, down to the frayed Persian rug, crook his finger at her to follow him. After holding and caressing her for a few minutes, he’d hold out his hands, a different-colored condom in each, and ask her to choose. Perhaps her choosing allowed him to rationalize that she was in control of the act. Carol would then open the condom, slip it on his primed cock, the same color as his scrubbed pink cheeks. Dr. Cooke always took a passive position, lying on his back and allowing Carol to impale herself on him and to control the pace and depth of their sexual dance. Perhaps that, too, was to foster the illusion that she was in charge.

Terminate therapy! His desertion dumped her back to where she had begun. Though she had not regarded their relationship as permanent, she had never, not for a moment, anticipated being cast off in this fashion. She phoned Dr. Cooke daily. At first cordial and gentle, he grew sharper and more impatient as the calls continued. He reminded her that the student health service only provided brief therapy, and discouraged her from calling him again. Carol was convinced that he had found another patient to treat with sexual affirmation. So everything had been a lie: his concern, his caring for her, his calling her attractive. Everything had been manipulation, everything had been for his gratification, not for her benefit. She no longer knew what or whom to trust.

“Just get on with it,” Carol snapped. “Easy to say. But not so simple to do. He sucked up nine years! I was stupid enough to get sucked in by promises of things to come. When we married, his father was ill and was about to turn over their shoe-store chain to him—worth millions. Here it is nine years later and his goddamn father is healthier than ever! Hasn’t even retired. And Justin’s still working for peanuts as Daddy’s bookkeeper. Guess what I’m going to get now when Daddy croaks? After all these years of waiting? As an ex-daughter-in-law? Nothing! Absolutely nothing.

Ernest, he admonished himself, there are millions, billions, of women in the world. There are probably a dozen in the audience tonight who’d love to make it with you, if you had enough guts to approach them. Just stay away from patients! Stay away from patients! But she’s not a patient. She’s a free woman. She saw you, and still sees you, unrealistically. You helped her; she trusted you. The transference was powerful. And you’re trying to exploit it! Ten years! Transference is immortal? Where is that writ? Look at her! She’s gorgeous. She adores you. When has a woman like that ever picked you out of a crowd and come on to you like that? Look at yourself. Look at your paunch. A few more pounds and you won’t be able to see your fly. You want proof? There’s your proof!

Though Ernest was old, at thirty-eight, to be still in supervision, Marshal considered that a strength, not a weakness. During Ernest’s psychiatric residency, completed over ten years ago, he had staunchly resisted learning anything about psychotherapy. Instead, heeding the siren call of biological psychiatry, he had focused on pharmacological treatment of mental illness, and after residency had elected to spend several years in molecular biological laboratory research. Ernest was not alone in this. Most of his peers had taken the same stance. Ten years ago psychiatry appeared to be poised on the brink of major biological breakthroughs in biochemical causes of mental disease, in psychopharmacology, in new imaging methods of studying brain anatomy and function, in psychogenetics and the imminent discovery of the chromosomal location of the specific gene for each of the major mental disorders. But Marshal had not been swayed by these new developments. At sixty-three, he had been a psychiatrist long enough to have lived through several such positivistic swings. He remembered wave after wave of ecstatic optimism (and subsequent disappointment) surrounding the introduction of Thorazine, psychosurgery, Miltown, Reserpine, Pacatal, LSD, Tofranil, lithium, Ecstasy, beta-blockers, Xanax, and Prozac—and was not surprised when some of the molecular biological fervor began to wane, when many extravagant research claims were not substantiated and when scientists began to acknowledge th...

“It’s coming back to me. Wasn’t she the borderline who threw herself out of the car to stop him from buying bagels and lox?”

“Well, I was pissed—pissed about his throwing the eighty thousand dollars in my face, pissed that he would just mosey out of that marriage without discussing it with me. He knew how much I had invested in his leaving her. Not even a phone call to me! And, let me tell you, this guy has phoned me about incredibly trivial stuff. Also, he had hidden the other woman from me, and that pissed me off, too. And also I was pissed about her ability, the ability of any woman, to simply crook her finger or twitch her little cunt and enable him to do what I had failed to do for four years.”

“Ten years, then. Because she was a member of your group for a few sessions ten years ago—a goddamned half-generation ago—you can’t have a different relationship with her now. She’s probably sex-starved, and the best thing you could have offered her was your cock.”

Paul’s point struck home. In a curious way it was a close cousin to what Marshal had been saying for years: don’t usurp everyone else’s personal responsibility. Don’t aspire to be the universal breast. If you want people to grow, help them learn to become their own mother and father. Despite Paul’s misanthropic crotchetiness, his insights were invariably incisive and creative.

You want to do something interesting? Go to the library stacks, pick up a nineteenth-century text on hydrotherapy—not a historical overview but the original text. I’ve seen texts of a thousand pages with the most precise instructions—you know, water temperature, length of immersion, force of spray, proper sequence of heat and cold—and all calibrated for each specific kind of diagnosis. Very impressive, very quantitative, very scientific—but it doesn’t have a goddamn thing to do with reality.

But a young, attractive man with long blond hair, dressed in sweat pants, a pink shirt, and an ivory sweater jogged by and charged up the stairs two at a time. Probably Lash’s next sucker, she thought. She began to walk away, then turned to glance up at Ernest’s office window. Goddamnit, she thought, that son of a bitch is trying to help me!

After Ernest’s supervisory hour, Marshal Streider sat back in his chair and thought about victory cigars. Twenty years ago he had heard Dr. Roy Grinker, an eminent Chicago analyst, describe his year on Freud’s couch. That was in the twenties, in the days when analytic respectability required a pilgrimage to the master’s couch—sometimes for a couple of weeks, sometimes, if one dreamed of becoming an analytic mover and shaker, as long as a year. According to Grinker, Freud never concealed his glee when he made an incisive interpretation. And if Freud thought he had made a monumental interpretation, he opened up his box of cheap cigars, offered one to his patient, and suggested they have a “victory” smoke. Marshal smiled at Freud’s lovable, naive handling of the transference. If he still smoked, he would have lit a celebratory cigar after Ernest’s departure.

Goddamnit, he thought, as he shoved the arrangement down to, and almost over the end of, the table. I had eight patient hours and one supervisory hour today—fourteen hundred dollars—and she can’t put dinner out for me because she’s too busy with these fucking flower arrangements!

But Marshal had good reason to be patient: Ernest had an extraordinary literary talent. Graceful sentences flew off his keyboard. Marshal’s ideas and Ernest’s sentences would be an unbeatable combination. All he needed was to restrain Ernest enough to get him accepted into the institute. Persuading Ernest to collaborate on journal articles, even book projects, would be no problem. Marshal had already planted the seeds by systematically exaggerating the difficulty Ernest would face in attaining admission to the institute and the importance of Marshal’s sponsorship. Ernest would be grateful for years. Besides, Ernest was so ambitious, Marshal believed, he would snatch at the opportunity for coauthorship with Marshal.

“Yes,” Seth continued, his one lung laboring, his voice growing hoarse. “I stand by my words that my patients are my closest friends. And that is true for all of you. You too, Morris. My patients and I spend four hours a week in the most intimate possible discussion. Tell me, which of you spends that much intimate time with a friend? I’ll answer for you: not one of you—certainly not you, Morris. We all know about American male friendship patterns. Perhaps some, a few, of you have a weekly lunch with a friend and, between ordering and chewing, spend thirty minutes in intimate congress.

“Nor,” Seth roared, “can we afford to ignore a raw grasping for power by those too mediocre to merit it!”