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 betterto 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 forcesby
primitive self-serving motives and by buried events from my past which strain
for expression; and pulled by the futureby 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 pushmy
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, howd 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
The push in writing this story is unambiguous: my conversation
with my mothers 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 wellTravels 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: Loves 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
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.
Spiegel, D., Yalom, I., A support group for dying patients, International
Journal of Group Psychotherapy, 28:2, April 1978.
Spiegel, D., Bloom, J., Yalom, I., Group support for metastatic cancer
patients: a randomized prospective outcome study, Archives of General
Psychiatry, 38:527-534, May 1981.
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 Ive 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 changesave 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!
viewed this saga of the perdurable therapist as a sad story because it portrays
such a fundamental misunderstandingnamely 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 axiomand axiom is not too strong a termthat
it is the relationship that heals. Therapeutic change ensues from a genuine,
authentic engagementand 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 universalinherent in the human
conditionpsychotherapists 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
Yalom, I.D., Lieberman, M. Bereavement and heightened Existential Awareness,
Lieberman, M., Yalom, I.D., Brief Psychotherapy for the Spousally Bereaved:
A Controlled Study, International Journal of Group Psychiatry, vol 42,
My research experience proved less relevant to the treatment course than
I had expected; in fact there were many counterproductive instancestimes
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 patients
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 therapyindeed, 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 episodicI 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,
theyve gaspedit is a scenario for disaster. As things turned
out in real life, however, it was a benign experiencemy 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 imaginablewhat
if the therapist had been presenting her to a professional conference focusing
on countertransferencethat 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 transparencya 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 shouldnt 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 therapists 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 categorythe
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 usefulnessthe
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 modelthe
real two person relationshipand published clinical investigations
of that phenomenon intersubjectivity or two person
psychologyare 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 patients 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 therapists 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 therapists chagrin at the damage his patient has inflicted
on another, his yearning to redress that wrong, lapses in which he loses
sight of his patients best interests, his grandiose rescue fantasies,
his lustful fascination with a character in a patients life, his dilemma
about whether healers are ever off dutyall 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 trutha 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.