Most of this book was written during a well-traveled sabbatical year. I am grateful
to many individuals and institutions who hosted me and facilitated my writing: the Stanford University Humanities Center, the Rockefeller Foundation Bellagio Study Center, Drs. Mikiko and Tsunehito Hasegawa in Tokyo and Hawaii, the Caffé Malvina in San Francisco, the Bennington College Creative Writing Program.

I am grateful to my wife, Marilyn (always my toughest critic and staunchest support); to my Basic Books editor, Phoebe Hoss, an enabling editor in this as in my previous books at Basic; and to my project editor at Basic Books, Linda Carbone. Thanks also to many, many colleagues and friends who did not bolt when they saw me approaching, a new story in hand, and offered criticism, encouragement, or consolation. The process has been long and I’ve no doubt lost names along the way. But my gratitude to: Pat Baumgardner, Helen Blau, Michele Carter, Isabel Davis, Stanely Elkin, John Felstiner, Albert Guerard, Maclin Guerard, Ruthellen Josselson, Herant Katchadourian, Stina Katchadourian, Marguerite Lederberg, John L’Heureux, Morton Lieberman, Dee Lum, K. Y. Lum, Mary Jane Moffatt, Nan Robinson, my sister Jean Rose, Gena Sorensen, David Spiegel, Winfried Weiss, my son Benjamin Yalom, the 1988 class of Stanford residents and psychology interns, my secretary Bea Mitchell who, for ten years, typed the clinical notes and ideas from which these stories spring. As always, I am grateful to Stanford University for providing me with the support, academic freedom, and intellectual community so essential for my work.

I owe a great debt to the ten patients who grace these pages. Each read every line of his or her story (except for one patient who died before I finished) and gave me approval for publication. Each checked and approved the disguise, many offered editorial help, one (Dave) gave me the title of his story, some commented that the disguise was unnecessarily extensive and urged me to be more accurate, a couple were unsettled by my personal self-revelation or by some of the dramatic liberties I took but, nonetheless, in the hope that the tale would be useful to therapists and/or other patients, gave me both their consent and their blessing. To all, my deepest gratitude.

These are true stories, but I have had to make many changes to protect the identity of the patients. I have often made symbolically equivalent substitutes for aspects of a patient’s identity and life circumstances; occasionally I have grafted part of another patient’s identity onto the protagonist. Often dialogue is fictional, and my personal reflections post hoc. The disguise is deep, penetrable in each case only by the patient. Any readers who believe they recognize one of the ten will, I am certain, be mistaken.

PROLOGUE

Imagine this scene: three to four hundred people, strangers to each other, are told
to pair up and ask their partner one single question, “What do you want?” over and over and over again.

Could anything be simpler? One innocent question and its answer. And yet, time after time, I have seen this group exercise evoke unexpectedly powerful feelings. Often, within minutes, the room rocks with emotion. Men and women—and these are by no means desperate or needy but successful, well-functioning, well-dressed people who glitter as they walk—are stirred to their depths. They call out to those who are forever lost—dead or absent parents, spouses, children, friends: “I want to see you again.” “I want your love.” “I want to know you’re proud of me.” “I want you to know I love you and how sorry I am I never told you.” “I want you back—I am so lonely.” “I want the childhood I never had.” “I want to be healthy—to be young again. I want to be loved, to be respected. I want my life to mean something. I want to accomplish something. I want to matter, to be important, to be remembered.”

So much wanting. So much longing. And so much pain, so close to the surface, only minutes deep. Destiny pain. Existence pain. Pain that is always there, whirring continuously just beneath the membrane of life. Pain that is all too easily accessible. Many things—a simple group exercise, a few minutes of deep reflection, a work of art, a sermon, a personal crisis, a loss—remind us that our deepest wants can never be fulfilled: our wants for youth, for a halt to aging, for the return of vanished ones, for eternal love, protection, significance, for immortality itself.

It is when these unattainable wants come to dominate our lives that we turn for help to family, to friends, to religion—sometimes to psychotherapists.

In this book I tell the stories of ten patients who turned to therapy, and in the course of their work struggled with existence pain. This was not the reason they came to me for help; on the contrary, all ten were suffering the common problems of everyday life: loneliness, self-contempt, impotence, migraine headaches, sexual compulsivity, obesity, hypertension, grief, a consuming love obsession, mood swings, depression. Yet somehow (a “somehow” that unfolds differently in each story), therapy uncovered deep roots of these everyday problems—roots stretching down to the bedrock of existence.

“I want! I want!” is heard throughout these tales. One patient cried, “I want my dead darling daughter back,” as she neglected her two living sons. Another insisted, “I want to fuck every woman I see,” as his lymphatic cancer invaded the crawl spaces of his body. And another pleaded, “I want the parents, the childhood I never had,” as he agonized over three letters he could not bring himself to open. And another declared, “I want to be young forever,” as she, an old woman, could not relinquish her obsessive love for a man thirty-five years younger.

I believe that the primal stuff of psychotherapy is always such existence pain—and not, as is often claimed, repressed instinctual strivings or imperfectly buried shards of a tragic personal past. In my therapy with each of these ten patients, my primary clinical assumption—an assumption on which I based my technique—is that basic anxiety emerges from a person’s endeavors, conscious and unconscious, to cope with the harsh facts of life, the “givens” of existence.
¹

I have found that four givens are particularly relevant to psychotherapy: the inevitability of death for each of us and for those we love; the freedom to make our lives as we will; our ultimate aloneness; and, finally, the absence of any obvious meaning or sense to life. However grim these givens may seem, they contain the seeds of wisdom and redemption. I hope to demonstrate, in these ten tales of psychotherapy, that it is possible to confront the truths of existence and harness their power in the service of personal change and growth.

Of these facts of life, death is the most obvious, most intuitively apparent. At an early age, far earlier than is often thought, we learn that death will come, and that from it there is no escape. Nonetheless, “everything,” in Spinoza’s words, “endeavors to persist in its own being.” At one’s core there is an ever-present conflict between the wish to continue to exist and the awareness of inevitable death.

To adapt to the reality of death, we are endlessly ingenious in devising ways to deny or escape it. When we are young, we deny death with the help of parental reassurances and secular and religious myths; later, we personify it by transforming it into an entity, a monster, a sandman, a demon. After all, if death is some pursuing entity, then one may yet find a way to elude it; besides, frightening as a death-bearing monster may be, it is less frightening than the truth—that one carries within the spores of one’s own death. Later, children experiment with other ways to attenuate death anxiety: they detoxify death by taunting it, challenge it through daredevilry, or desensitize it by exposing themselves, in the reassuring company of peers and warm buttered popcorn, to ghost stories and horror films.

As we grow older, we learn to put death out of mind; we distract ourselves; we transform it into something positive (passing on, going home, rejoining God, peace at last); we deny it with sustaining myths; we strive for immortality through imperishable works, by projecting our seed into the future through our children, or by embracing a religious system that offers spiritual perpetuation.

Many people take issue with this description of death denial. “Nonsense!” they say. “We don’t deny death. Everyone’s going to die. We know that. The facts are obvious. But is there any point to dwelling on it?”

The truth is that we know but do not know. We know
about
death, intellectually we know the facts, but we—that is, the unconscious portion of the mind that protects us from overwhelming anxiety—have split off, or dissociated, the terror associated with death. This dissociative process is unconscious, invisible to us, but we can be convinced of its existence in those rare episodes when the machinery of denial fails and death anxiety breaks through in full force. That may happen only rarely, sometimes only once or twice in a lifetime. Occasionally it happens during waking life, sometimes after a personal brush with death, or when a loved one has died; but more commonly death anxiety surfaces in nightmares.

A nightmare is a failed dream, a dream that, by not “handling” anxiety, has failed in its role as the guardian of sleep. Though nightmares differ in manifest content, the underlying process of every nightmare is the same: raw death anxiety has escaped its keepers and exploded into consciousness. The story “In Search of the Dreamer” offers a unique backstage view of the escape of death anxiety and the mind’s last-ditch attempt to contain it: here, amidst the pervasive, dark death imagery of Marvin’s nightmare is one life-promoting, death-defying instrument—the glowing white-tipped cane with which the dreamer engages in a sexual duel with death.

The sexual act is seen also by the protagonists of other stories as a talisman to ward off diminishment, aging, and approaching death: thus, the compulsive promiscuity of a young man in the face of his killing cancer (“If Rape Were Legal . . . “); and an old man’s clinging to yellowing thirty-year-old letters from his dead lover (“Do Not Go Gentle”).

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