Lying On The Couch

by Irvin D. Yalom

But deep therapy was losing the battle: the barbarian hordes of expediency were everywhere. Marching to the starched new banners of managed care, the battalions of brief therapy darkened the landscape and hammered at the gates of the analytic institutes, the last armed enclaves of wisdom, truth, and reason in psychotherapy. The enemy was close enough for Marshal to see its many faces: biofeedback and muscular relaxation for anxiety disorders; implosion or desensitization for phobias; drugs for dysthymia and obsessive/compulsive disorders; cognitive group therapy for eating disorders; assertiveness training for the timid; diaphragmatic breathing groups for panicked patients; social skills training for the socially avoidant; one-session hypnotic interventions for smoking; and those goddamned twelve-step groups for everything else! The economic juggernaut of managed care had overwhelmed medical defenses in many parts of the country. Therapists in subjugated states were forced, if they wished to stay in practice, to genuflect to the conqueror, who paid them a fraction of their customary fee and assigned them patients to treat for five or maybe six sessions when, in actuality, fifty or sixty sessions were needed. When therapists used up their meager allotted rations, the charade began in earnest and they were forced to beg their case manager for additional sessions to continue treatment. And, of course, they had to document their request with mountains of phony, time-consuming ...

Did that change Marshal’s opinion about the efficacy of brief therapy? In no way! The explanation for Peter Macondo’s remarkable success was simple and clear: Mr. Macondo had no significant neurotic or characterological problems. He was an unusually resourceful, well-integrated individual whose symptoms emanated from stress that was, for the most part, situation-bound.

The children, in their early twenties, openly accused Adriana of scheming to take over the family fortune. Nor were they timid in expressing their resentment toward their father. Even though Peter had put almost three million dollars into trust for each, they insisted he had not done right by them. To bolster their claim, they pointed to a recent story in the London Financial Times describing a highly profitable two-hundred-million-pound venture of his.

Marshal read the fax twice, slowly, sorting out his feelings. The Marshal Streider endowed lecture series—a memorial that would extend into perpetuity. Who wouldn’t be pleased? The perfect self-esteem insurance policy. Years from now, whenever he felt diminished, he could think of his endowed lecture series. Or fly to Mexico City for the lecture and rise, reluctantly, hand held aloft, turning slowly and modestly to acknowledge the applause of a grateful audience.

Marshal reached into the envelope and extracted a Shreve’s Jewelry Store box. He opened it, gasped, and gleefully put on his first jewel-spangled Rolex watch.

Ernest sat down next to her. “Can you talk?” “Too late. No more words. Just hold me.” Ernest took Eva’s hand, but she shook her head. “No, please, just hold me,” she whispered. Ernest sat on the bed and leaned over to hold her but could find no workable position. There was nothing to do but to get on the bed, lie next to her, and put his arms around her. He kept his suit jacket and shoes on and nervously eyed the door, worried that some misunderstanding person would enter. He felt awkward at first and was grateful for the layers between them—sheet, comforter, coverlet, suit jacket. Eva pulled him to her. Gradually his tension dissipated. He loosened up, took off his jacket, pulled back the comforter, and clutched Eva closely. She clutched back. For an instant he felt an unwelcome warm purring inside, the foreshadowing of sexual arousal, but, furious at himself, managed to banish it and to devote himself to hugging Eva in a loving fashion. After a few minutes he asked: “Is this better, Eva?” No answer. Eva’s breathing had become labored. Ernest jumped up from the bed, bent over her, and called out her name. Still no answer. Eva’s sister, hearing his call, rushed into the room. Ernest reached for Eva’s wrist but could feel no pulse. He put his hand on her chest, gently pressing her heavy breast aside, and felt for an apical pulse. Discovering her heartbeat to be thready and wildly irregular, he pronounced: “Ventricular fibrillation. It’s very bad.” The two of them sat vigil ...

“Same problem with multiple personality disorder,” Paul continued. “I know therapists, really good ones, who have reported two hundred cases of it, and I know other good therapists who have been in practice for thirty years and still claim they have never encountered a single case.”

“Yeah, yeah. I’m working on it. Paul, stop with the bean sprouts. You in serious training for the anorexic Olympics? Here, try some of these sizzling scallops—house specialty. Why is it always left to me to do the work of two at dinner? Look at this halibut—it’s beautiful.” “No, thanks, I get my mercury from chewing on thermometers.”

During the previous week Ernest had spent time in the library reviewing the literature on eroticized transference. He had been struck by some of Freud’s cautionary words regarding the treatment of “women of an elemental passionateness.” Freud referred to these patients as “children of nature” who refused to accept the spiritual instead of the physical and were amenable only to the “logic of gruel and the argument of dumplings.” Pessimistic about treating such patients, Freud claimed that the therapist had only two, unacceptable choices: returning the patient’s love or being the target of the mortified woman’s fury. In either case, Freud said, one must acknowledge failure and withdraw from the case.

Ernest shuddered. Shit! She saw me with Nan Carlin. This is a goddamn quagmire. What have I gotten myself into?

“So, what do you feel now?” he asked. “Well, this is exactly what I mean by arbitrary, Ernest. A slightly different toss of the dice and you and I might be lovers now, rather than therapist and patient. And I honestly believe you could do more for me as a lover now than as a therapist. I wouldn’t ask much of you, Ernest, just meet once or twice a week—to hold me and get rid of this sexual frustration that’s killing me.” “I hear you, Carolyn, but I am your therapist and not your lover.” “But that is purely arbitrary. Nothing is necessary. Everything could be otherwise. Ernest, let’s roll back the clock—go back to the bookstore and toss the dice again. Become my lover; I am dying with frustration.” As she spoke, Carol slipped off her chair, glided over to Ernest, sat on the floor next to his chair, and rested her hand on his knee. Ernest once again placed his hand on Carolyn’s head. God, I like to touch this woman. And her burning desire to make love to me—Christ knows I can empathize. How many times have I been overcome by lust? I feel sorry for her. And I understood what she means about the arbitrariness of our meeting. It’s too bad for me, too. I’d rather be her lover than her therapist. I’d love to crawl off this chair and take off her clothes. I’d love to caress her body. And who knows? Suppose I had met her in the bookstore? Suppose we had become lovers? Maybe she’s right—maybe I would have offered her more that way than as a therapist! But we’ll never know—that’s an e...

Three years ago Marshal had grown so concerned about the impact of ikebana and Vipassnia (about which Marshal also chose to remain uninformed) on their marriage that he pleaded with Shirley to enter graduate school in clinical psychology. He hoped that sharing the same field would bring them closer together. He hoped also that, once Shirley entered his field, she would be able to appreciate his professional artistry. Then, too, it would not be long before he could refer patients to her, and the idea of a second income was sweet.

“All right, enough of this!” Dr. Sunderland continued. “What’s done is done. The future is pressing in on me: I have an immediate decision to make and I want your input. This Shelly Merriman is threatening suit. He’s willing to back off for a seventy-thousand settlement. Our attorneys believe he’d settle for half of that. We fear precedent setting, of course. What’s your reading on this? How serious is the threat? Will seventy or even thirty-five thousand dollars make Mr. Merriman go away? And stay away? Will that money buy silence? How discreet is your Mr. Merriman?” Marshal responded quickly, in his most self-assured voice: “My advice is to do nothing, Dr. Sunderland. Leave this to me. You may count on me to handle the matter effectively and efficiently. The threat is empty, I assure you. The man is bluffing. And as for money buying his silence and discretion? No chance of that. Forget it—there is significant sociopathy. We must take a firm stance.”

“How does therapy fit in with this?” he asked Shelly. “I trust you’re not expecting me to play poker with you. I’m not a gambler, certainly not a poker player. How could you possibly learn anything from playing poker with me?”

“You want me to go to your poker game and watch you play?” Marshal felt relieved. As bizarre as this request was, it was not as bad as what he had feared a few minutes ago. Right now he’d accede to any request that would get Dr. Sunderland off his back, and get Shelly out of his office forever. “Are you kidding? You come to the game with the guys? Man, that would be a scene—coming to the game with my own private shrink!” Shelly slapped his knees as he guffawed. “Oh, man . . . great . . . Doc, that would make us legends, you and me—me bringing my shrink and his couch to the game . . . the guys would be talking about that into the next millennium.”

A knock on the door and Shelly entered and sat down again. “Forgot to tell you something, Doc. It’s against the rules to stand around and watch poker at Avocado Joe’s. You will have to play in the game with me. Here, I brought you a book.” Shelly handed Marshal a copy of Texas Hold ’Em—the Texas Way. “No sweat, Doc,” said Shelly in response to the look of horror on Marshal’s face. Simple game. Two down and then five open common cards. The book will explain all. I’ll tell you what you need to know next week, before we play. You drop out of every hand—you just lose the ante. Won’t amount to much.” “Are you serious? I have to play?” “Tell you what, Doc—I’ll share your losses. And if you have a ballbreaker hand, stay in and bet and you can keep the winnings. Read the book first and I’ll explain more to you when we meet. It’s a good deal for you.”

Perhaps he had made a tactical mistake in agreeing to treat her, even for brief therapy. She may have harbored more reservations about marriage than she had acknowledged to Peter, and perhaps felt awkward discussing them. After all, he was Peter’s ex-therapist, he had been paid by Peter, and he was now an investor with Peter. Yes, the more Marshal thought about it, the more he suspected that he had made an error in judgment. That, he reminded himself, is precisely the problem with boundary violations—the slippery slope: one slip begets another.

Marshal opened the refrigerator door. Nothing there. Shirley was still not cooking. As usual she had left a new flower arrangement on the kitchen table for him. Under the bowl was a note stating she’d be back before ten. Marshal glanced quickly at the arrangement: a simple motif containing three calla lilies, two white, one saffron. The long graceful stalks of a white and a saffron calla lily were entwined and separated by a dense growth of crimson nambia berries from the third lily, which swooped away as far as possible from the other lilies and leaned dangerously far over the edge of the crackled lavender ceramic basin. Why did she leave him these flower arrangements? For a moment, just for a moment, the thought occurred to Marshal that Shirley had been using saffron and white calla lilies a great deal lately. Almost as though she were sending him a message. But he dismissed the thought quickly. The time spent on such evanescent nonsense galled him. So many better ways to use one’s time. Like cooking dinner. Like sewing some buttons on his shirts. Like finishing her dissertation, which, flaky as it was, had to be completed before she could start billing patients. Shirley was very good at demanding equal rights, Marshal thought, but was good also at giving her time away and, as long as her husband was around to pay the bills, was content to postpone indefinitely the moment of entry into the adult, billable world. Well, he knew how to use time. Pushing the flower arrangeme...

And Peter? Was he of that world? He would not profit financially, of course—or, if he did, that was between him and the bank. But, Marshal thought, if Peter had no financial motive, what were his motives? To ridicule psychoanalysis? Could there be a tie-in with Seth Pande? Or Shelly Merriman? Or even the whole breakaway faction of the Psychoanalytic Institute? Could this possibly be a prank? Sheer sociopathic maliciousness? But, whatever the game, whatever the motive, why hadn’t I spotted it earlier? I’ve been a fucking fool. A fucking, greedy fool!

“The second, and the last point I’m going to have time to make today—I’ve another client waiting—is that, as I look over your financial situation from the information you’ve supplied me, I see no devastation. You’ve been a good provider—an excellent provider—for your family, and you’ve been a successful investor. The truth is, this loss will not materially change your life in any fashion!” “You don’t understand—my son’s education, my art—” “Next time, Dr. Streider. I must stop now.” “When is the next time? Do you have any time tomorrow? I don’t know how I’m going to get through the next few days.” “Yes, three o’clock tomorrow? Is that okay?” “I’ll make it okay. I’ll cancel whatever I have. If you knew me better, Dr. Astrid—”

Yet she ached to tell him. Maybe, someday, there would be a way. But for now she had to be content with whatever meager nourishment she could extract from the thin gruel of honoring her professional code of behavior. And to be content, also, with behaving as Jess would have wanted her to behave—to offer all possible aid to his former therapist. This would not be easy. Carol had never met a shrink she liked. And she liked this particular shrink, Dr. Streider, less than most: he whined too much, took himself too seriously, and resorted to puerile macho football images. And, even though he was momentarily humbled by this swindle, she could sense his underlying arrogance. Not hard to understand why he had enemies.

“You want my advice? The meter’s turned off—no further charge for this: kiss that money off. Consider it one of life’s hard lessons.” “Well, Bat,” Marshal said over his shoulder as he walked out of the office. “I don’t give up that easy. That fucker’s picked the wrong guy.” “Doc,” Bat called down the stairs as Marshal descended, “if you’re thinking of playing Lone Ranger—don’t! That’s guy’s smarter than you are! A whole lot smarter!” “Fuck you,” Marshal muttered as he walked out of the doorway onto Fillmore.

“Of course. How could any analyst maintain therapeutic neutrality toward me? Any analyst I saw would secretly gloat about my misfortune. I probably would if I were in their place. Everyone likes to see the collapse of the mighty. And word would get around I was in therapy—in a month everyone in town would know about it.” “How?” “No way to conceal it. Analytic offices are clustered together. Someone would spot me in the waiting room.” “So? Is it a disgrace to be in therapy? I’ve heard of people speak with admiration of therapists still willing to work on themselves.”

Ernest nodded. “Nothing more important than our being honest with each other.” “And anything I say here is acceptable, right? Anything is acceptable as long as it’s honest.” “Of course.” “Then I have a confession to make,” said Carol. Ernest nodded, reassuringly. “You ready, Ernest?” Ernest nodded again. “You sure, Ernest?” Ernest smiled knowingly. And a little smugly—he had always suspected that Carolyn had kept some parts of herself concealed. He picked up his notepad, snuggled back cozily into his chair, and said, “Always ready for the truth.”