It is remarkable, considering Breuer’s vast influence on the development of psychotherapy, that he turned his attention to psychology for only a short segment of his career. Medicine best remembers Josef Breuer not only as an important research investigator in the physiology of respiration and equilibrium, but also as a brilliant diagnostician who was physician to an entire generation of great figures in fin de siècle Vienna.
Nietzsche suffered from poor health for most of his life. Although, in 1889, he collapsed and slipped irrevocably into the severe dementia of paresis (a form of tertiary syphilis, from which he died in 1900), there is general consensus that for most of his earlier life he suffered from another illness. It is likely that Nietzsche (whose clinical picture I have portrayed following Stefan Zweig’s vivid 1939 biographical sketch) suffered from severe migraine. For this condition, Nietzsche had consulted many physicians throughout Europe and might easily have been persuaded to seek medical consultation with the eminent Josef Breuer.
It would have been out of character for a distressed Lou Salomé to have applied to Breuer to help Nietzsche. She was not, according to her biographers, a woman significantly burdened by guilt and is known to have ended many love affairs with apparently little remorse. In most matters, she guarded her privacy and did not, as far as I can ascertain, speak publicly of her personal relationship with Nietzsche. Her letters to him have not survived. Most likely they were destroyed by Elisabeth, Nietzsche’s sister, whose feud with Lou Salomé lasted a lifetime. Lou Salomé did indeed have a brother, Jenia, who was studying medicine in Vienna in 1882. It is highly unlikely, however, that Breuer would have presented the case of Anna O. at a student conference in that year. Nietzsche’s letter (following chapter 12) to Peter Gast, a friend and editor, and Elisabeth Nietzsche’s letter (following chapter 7) to Nietzsche are fictional, as is the Lauzon Clinic and the characters of Fischmann and Breuer’s brother-in-law Max. (Breuer was, however, an avid chess player.) All of the dreams reported are fictional, except two of Nietzsche’s: those of his father rising from the grave and the old man’s death rattle.
In 1882, psychotherapy had not yet been born; and Nietzsche, of course, never formally turned his attention in that direction. Yet in my reading of Nietzsche, he was deeply and significantly concerned with self understanding and personal change. For chronological consistency, I have confined myself to citing Nietzsche’s pre-1882 works, primarily Human, All Too Human, Untimely Meditations, Dawn, and The Gay Science. I have, however, assumed as well that the great thoughts of Thus Spake Zarathustra, much of which he wrote a few months after the close of this book, were already percolating in Nietzsche’s mind.
I am indebted to Van Harvey, Professor of Religious Studies at Stanford University, for permitting me to attend his superb Nietzsche course, for many hours of collegial discussion, and for a critical reading of my manuscript. My gratitude to colleagues in the Department of Philosophy, especially Eckart Förster and Dagfinn Føllesdal, for permitting me to attend related courses in German philosophy and phenomenology. Many have given suggestions on this manuscript: Morton Rose, Herbert Kotz, David Spiegel, Gertrud and George Blau, Kurt Steiner, Isabel Davis, Ben Yalom, Joseph Frank, members of the Stanford Biography Seminar under the guidance of Barbara Babcock and Diane Middlebrook—to all my thanks. Betty Vadeboncoeur, Stanford University history of medicine librarian, was invaluable in my research. Timothy K. Donahue-Bombosch translated the letters cited from Nietzsche to Lou Salomé. Many offered editorial instruction and assistance along the way: Alan Rinzler, Sara Blackburn, Richard Ellman, and Leslie Becker. The Basic Books staff, especially Jo Ann Miller, offered enormous support; Phoebe Hoss, in this as in previous books, was an enabling editor. My wife, Marilyn, who has always been my first, most thorough, and most merciless critic, surpassed herself in this book—providing not only continuous critique from the first to the final draft, but also suggesting the book’s title.
About the author
2 Meet Irvin D. Yalom
About the book
3 On Writing a Teaching Novel: When Nietzsche Wept
22 A Conversation with Irvin D. Yalom
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More by Irvin D. Yalom
About the author
Meet Irvin D. Yalom
IRVIN D. YALOM, M.D., is the bestselling author of Love’s Executioner, Momma and the Meaning of Life, and The Schopenhauer Cure, as well as several classic textbooks on psychotherapy, including the monumental work that has long been the standard text in the field, The Theory and Practice of Group Psychotherapy.
About the book
On Writing a Teaching Novel
When Nietzsche Wept
IN A MANNER I COULD NEVER have anticipated, my unconscious played a key role in the writing of Love’s Executioner: as I approached the end of each of the first nine stories, the next one mysteriously wafted into my mind, as though I had unknowingly constructed in advance an outline and table of contents. While I worked on the ending of the tenth story, “In Search of the Dreamer,” another surprise was in store for me: I found myself unaccountably thinking not of another story, but of Friedrich Nietzsche. Soon it was obvious what my next project would be and even before Love’s Executioner was fully edited I began work on a novel about Nietzsche and his relationship to psychotherapy.
I never regarded the writing of Love’s Executioner as a radical departure from my role as an academician; I was simply fulfilling the job description—making a contribution to the professional literature of my field. I meant Love’s Executioner to be a pedagogical device—a collection of teaching tales to be used in psychotherapy training programs.
It was with that same sentiment that I began When Nietzsche Wept. My target audience was still the professional psychotherapy community and my intention was to introduce the student to the fundamentals of existential therapy by way of a new pedagogical device, a teaching novel.
I am preoccupied with stories and have always begun my lectures, articles, and books with some brief narrative, often a description of a recent therapy encounter, which I use as a springboard for pedagogical instruction. I shall begin this discussion of When Nietzsche Wept accordingly—by describing several stories about the basic nature of the patient-therapist relationship which have rattled about in my mind for many years. In one way or another, the echoes of these tales ring throughout the pages of the novel.
The Story of the Two Healers
Hermann Hesse, in his novel Magister Ludi, tells a tale about two renowned healers, one of whom lived in North India and the other in the southern part of the subcontinent. Though they were both powerful healers, they worked in different ways, one through offering sagacious advice, and the other through quiet and inspired listening.
Though they never met, they worked as rivals for many years until the younger healer, the one who lived in the North, grew spiritually ill and fell into despair. He tried unsuccessfully to heal himself using his own therapeutic methods and, ultimately, in desperation, set out on a journey to South India to seek help from his rival healer.
Week after week he journeyed on his pilgrimage. One evening he settled into an oasis and fell into a conversation with an older traveler to whom he described the purpose and goal of his pilgrimage. Imagine his astonishment when the older man replied, “Oh, this is indeed a miracle. I am the very man you seek.”
Without hesitation the older healer invited his younger rival into his home where they lived and worked together for many years, first as student and teacher, then as full colleagues. Years later the older man fell ill and on his deathbed called his young colleague to him. “I have a great secret to tell you,” he said, “a secret that I have long kept. Do you remember that night we met on the oasis and you told me you were on your way to see me?”
The younger man replied, “Of course, I remember. How could I forget that night? It was the turning point of my entire life.”
The dying man took the hand of his yo
unger colleague and said, “My secret is that I, too, was in despair, and on the night of our meeting I was traveling to seek help from you.”
Hesse’s tale has always moved me in a preternatural way. I think it’s an illuminating statement about giving and receiving help, about honesty and duplicity, and about the relationship between the healer and patient. For years I found it so compelling that I never wanted to tamper with it or even read it again. Yet at the same time I have been drawn to the idea of composing variations on its basic theme: it strikes so deep into the very heart of the therapy relationship. Consider, for example, how each man received help. The younger healer was nurtured, nursed, taught, mentored, and parented. The older healer, on the other hand, received help in a different manner—through serving another, through obtaining a disciple from whom he received filial love, respect, and salve for his isolation.
But I’ve often wondered whether these two wounded healers took advantage of the best therapy available to them. Perhaps they missed the opportunity for something deeper, something more powerfully mutative. Perhaps the real therapy occurred at the deathbed scene when they moved into honesty with the admission that they were both simply human, all too human. Though the twenty years of secrecy may have been helpful, it may also have prevented a more profound kind of help. What would have happened, what manner of growth might have taken place, if the conversation at the deathbed had occurred twenty years earlier?
Another Story of a Wounded Healer
Thirty-five years ago I read a fragment of a play, Emergency, by Hellmuth Kaiser, published in a psychiatric journal (and later in Effective Psychotherapy, a volume of Kaiser’s collected papers). Although I’ve never seen a reference to it or, until recently, reread it, Kaiser’s delicious plot has stayed in my mind all these years. It begins with a woman visiting a therapist to plead with him to help her husband, also a therapist, who is deeply depressed and likely to kill himself.
The therapist replied that he, of course, would be glad to help and advised her to tell her husband to call for an appointment. The woman responded that therein lay the problem: her husband denies that he is troubled and rejects all suggestions to obtain help. The therapist wonders how he can be of service. How can he help anyone who is unwilling to see him?
“I have a plan,” the woman said and then proceeded to suggest that he should pretend to be a patient, enter into treatment with her husband and, through a gradual role reversal, smuggle help for her husband into their meetings.
The rest of the play fragment is poorly executed and fails to fulfill its promise. But the central conceit—the patient becoming the therapist—seemed a gorgeous idea, and I yearned to finish that play someday.
Turning the Tables—Another Version
When I first came to Stanford in 1962, Don Jackson, a highly gifted therapist, offered a weekly teaching seminar in which he demonstrated interview techniques. He had an innovative, intuitive interviewing style and never failed to use some unexpected, quirky (and effective) approach. One day Paul Watzlawick, a psychologist with equally quirky tendencies, arranged a mischievous stunt involving a visiting psychologist from Germany. He asked the visitor to demonstrate his interviewing approach at the seminar and informed him that the patient he was to interview had a delusion that he was the famous psychiatrist, Don Jackson. Conversely he told Don Jackson that the patient he was to interview had a delusion that he was a famous psychologist from Germany. I don’t remember the resolution of the situation but I do recall a riotous and crazy-making beginning of the session in which the two interviewers scrambled wildly for roles.
In another conference a few weeks later, Don Jackson was asked to interview a highly delusional, three-hundred-fifty-pound Hawaiian chronic patient who believed he was the celestial emperor of the ward and dressed accordingly, in magenta trousers and a long flowing purple cape. Every day, perched imperiously on his velvet-draped chair, regarding patients and staff alike as supplicants and vassals, he held court on the ward. After a few minutes of exposure to the patient’s regal demeanor, Don Jackson suddenly fell to his knees, bowed his head to the ground, took his keys out of his pocket, and, arms outstretched, offered them to the patient saying, “Your highness, you, not I, should possess the keys to this ward.”
The patient, his left eye twitching, pulled his cape about him and stared hard at the genuflecting psychiatrist. For a moment, just for a moment, he appeared perfectly sane, as he said, “Mistah, one of us here is very, very crazy.”
Note, incidentally, that I could have made this point using professional psychiatric prose by describing Don Jackson’s technique of creating a therapeutic alliance by entering a patient’s delusional system and undermining the delusion by a reductio ad absurdum approach. But dramatization—that is, fictionalization (I did not personally witness this incident, which took place nearly fifty years ago)—conveys the information more vividly and memorably.
Patient and Therapist—Other Perspectives
Harry Stack Sullivan, one of the most influential American psychiatric theorists, defined psychotherapy as a discussion of personal issues between two people, one of them more anxious than the other. And if the therapist develops more anxiety than the patient, Sullivan went on, he becomes the patient and the patient the therapist.
Or consider Jung’s view that only the wounded doctor can truly heal. Jung took it so far as to suggest that the ideal condition obtains when the patient brings the perfect salve for the therapist’s lesion.
Or consider how often it happens that therapists begin a therapy session with a heavy heart, with anxiety that exceeds that of the patient sitting with them. I certainly have. And often have finished a therapy session feeling much better. In fact, like the older healer in the Magister Ludi story, I may have profited as much as my patient. How does this come about? How did I receive benefit without explicitly addressing my discomfort? Perhaps I received help as a byproduct of altruistic behavior—i.e., being helped through the act of helping others. Or is it that I feel better about myself because of my effectiveness as a leader—I end up feeling I am good at what I do. Or perhaps I feel better because I have dipped into the healing waters of an intimate relationship that I myself have helped to construct.
I have found this to be particularly true in my group therapy practice. Many times I have started a therapy group session feeling troubled about some personal issue and finished the meeting feeling considerably relieved. The intimate healing ambience of a good therapy group is almost tangible. Scott Rutan, an eminent group therapist, once compared the therapy group to a bridge built during a battle. Though there may be some casualties sustained during the building (i.e., group therapy dropouts), the bridge once in place can transport a great many people to a better place.
And how many therapists have shared my experience of being called upon to offer aid to past teachers or mentors, to consult with family members of past therapists, or even to be therapist or caretaker of one’s own prior therapist?
These themes—the parameters of the relationship between patient and therapist—were some of the particular issues I wanted to explore in a teaching novel. But there was more. On a more ambitious level I wanted to introduce the reader to the fundamentals of an existential approach to psychotherapy. I decided to experiment with an unorthodox teaching method: to invite the reader to be present at the fictional conception and birth of existential therapy.
The novel invites the reader to participate in some thought experiments. Suppose Freud had never lived: what type of psychotherapy might have evolved? Or perhaps a better question: Suppose Freud had lived and left us only his topographical model of the mind (that is, his posited structure of the psyche encompassing the dynamic unconscious and the mechanisms of defense) without his psychoanalytic content—without the idea of anxiety issuing from the vagaries of psychosexual development? And imagine, further, the nature of psychotherapy if the content were based on an existential model—that is, that anxiety issues from a confrontati
on with the terrifying facts of life inherent in existence?
But all this was too airy, too dry and abstract for an engrossing novel. I needed not just ideas but flesh and blood human beings who had lived these ideas. But who? And when? I wanted to clothe the development of these ideas in fictional garb. I knew I wanted to write fiction, but a special kind of fiction: fiction which would serve a rhetorical, pedagogical purpose. In thinking about the nature of fiction, I ran across a phrase in a novel by Gide, Lafcadio’s Adventures, (also translated as The Vatican Cellars). “History,” Gide said, “is fiction that did happen. Whereas fiction is history that might have happened.”
Fiction is history that might have happened. Perfect! That was precisely the fiction I wanted to write. My novel When Nietzsche Wept could have happened. Given the very improbable history of the field of psychotherapy, all the events of this book could have come to pass if history had rotated only slightly on its axis.