Creatures of a Day: And Other Tales of Psychotherapy (14 page)

“I know you mean that well, Ellie, and what you say is entirely, indisputably true: I
am
old, quite old, and I
have
thought much about my death. But still I’m a bit rattled by your comment. How to put it?” I thought for a few seconds and continued, “You know what it is? I think it’s because
I just don’t want to be defined as an old person.
 . . . Yes, yes, I’m sure that’s it, and there’s a parallel here with what you said earlier. This helps me understand exactly what you meant about not wanting to be defined as a cancer patient.”

As the hour ended, she asked if we could meet for a second session. It turned out that Fridays, the day I was always in San Francisco, were often not good for Ellie because of her chemotherapy schedule. Nor did she have transportation to meet me in my Palo Alto office, thirty-five miles away. When I offered to refer her to another therapist in San Francisco, she demurred: “I’ve gotten much from this hour. I feel enlivened, as though I’ve been reacquainted with living. I know that in my email I asked for only one or two meetings. But now . . . ” She stopped, took a deep breath, collected her thoughts, turned to me, and said, “Now I want to ask you something big. I don’t want to put you on the spot. I know that you may not be able, or willing, to do this, and I know our schedules don’t fit well, and we can’t meet every week.” She drew a deep breath. “But I wonder if you’d be willing to meet with me until I die?”

Willing to meet with me until I die?
What a question! I’ve never had anyone pose that to me so . . . so boldly. I felt honored by her invitation and quickly gave assent.

In our second session Ellie entered with a stack of old family photos and the agenda of filling me in completely about her family. Rummaging in the distant past, I was sure, was not the best direction for us to take, and I wondered if Ellie, trying to please me, had mistakenly believed that I wanted her to provide an extensive family history. While I searched for a tactful way of saying this, she commenced to speak with much feeling of her deep love for her sister and brothers. Her eyes grew moist, and when I inquired about her tears, she began to sob about the unbearable pain of never seeing them again. Then, when she regained her composure, she said, “Maybe the Buddhists had it right when they said, ‘no attachments, no suffering.’”

Propelled to say something helpful, I clumsily fumbled about trying to make a distinction between “love” and “attachment.” That went absolutely nowhere. Then I commented on the richness and fulfillment that flowed from her family relationships, and she gently let me know that such reminders were unnecessary, for she already fully appreciated her loving family and was much comforted by the thought that when she needed them at the time of dying, her sister and brothers would all be there for her.

This sequence of events reminded me of an important axiom of psychotherapy that I have learned (and forgotten) so many times from so many patients:
the most valuable thing I have to offer is my sheer presence
.
Just
be
with her,
I thought.
Stop trying to think of something wise and clever to say. Let go of the search for some dynamite interpretation that will make all the difference. Your job is simply to offer her your full presence. Trust her to find the things she needs from the session.

A bit later, Ellie spoke of her strong desire to find some income-producing work. As she described the details of her life, I grew more aware of her truly marginal economic status. She rented a small, one-bedroom apartment in one of San Francisco’s most inexpensive areas and adhered to a frugal budget, refusing even the luxury of a taxi to visit my hilltop office. Too ill to hold a paying position for the last two years, she now earned only a few dollars from babysitting and minor editing for a friend. I realized that even my greatly reduced fee was a significant burden and threatened her plan of the grand tour she yearned for. I was rooting for her to take that trip, and I knew that she would be far more likely to afford the splurge if I saw her pro bono, but I sensed her pride would not permit her to accept paying no fee at all. Then an idea occurred to me that might make Ellie more comfortable.

Forty years earlier I had seen a very shy patient, also a writer and also unable to pay for therapy. I had suggested an experimental format in which she would write a summary after each session in lieu of payment, and I would do the same, and every few weeks we would read each other’s summaries. I had originally considered that exercise only as a learning tool for both of us—I wanted her to learn to be more honest in her comments about our relationship, and I personally wanted to free myself up as a writer. But the resulting summaries proved to be of such significant value in teaching student therapists, that the patient and I jointly published them as a book (
Every Day Gets a Little Closer
). I told Ellie about this project and proposed that she and I try to rerun this experiment. Given this would not be long-term therapy, I suggested that we both write a summary of each session and email it to the other before the next meeting. Ellie was delighted with this idea, and we agreed to commence immediately.

In her first summary, Ellie reflected on the problems of speaking to others about her illness:

It’s a relief to talk to Irv because he has really faced the question of his own death. It’s often pretty hard to speak to others about my cancer. I have a number of pet peeves. Many folks are overly solicitous. They can’t do enough for you. There’s that Kaiser nurse who keeps asking “Isn’t there someone who can drive you here?” And some people are too prying. I think they are voyeuristic and attempt to satisfy their morbid curiosity about having cancer. I don’t like that and have sometimes wanted to say, “Go get your own damn fatal illness.”

During our following session I made the mistake of saying that I admired her courage, and that touched off a spirited response in her next summary:

Too many people are overly respectful, braying, ‘You’re so brave’ and Irv fell smack into that trap. After all what’s so courageous about having cancer? Once we have it, what choice do we have? But the worst thing of all—and thank God Irv doesn’t do this, at least not yet—is all this nonsensical talk about a patient’s courageous struggle with cancer that all too often ends in defeat. How many obituaries do you see stating that so-and-so lost their courageous battle with cancer? I hate that! I absolutely hate it! If someone put that in my obituary, I’d come back and kill him!

But Ellie’s health soon began to deteriorate rapidly. Her chemotherapy was no longer effective, and she grew fatigued and anorexic, and required several hospitalizations to deal with her ascites—an accumulation of abdominal fluid. It soon became apparent that Ellie’s dream of the grand tour was not to be, and neither she nor I spoke of it again. And neither would there be a book of our post-session summaries. We ended up meeting for only six sessions, and our summaries were stilted and uninspired. Though hers had a bit of sparkle, her fatigue showed through, and her summaries were burdened with repetitive expressions of gratitude to me for seeing her without a fee. My summaries were cautious and superficial because it was so apparent that Ellie had little energy for engagement. She was obviously dying, and I felt it inappropriate to comment on nuances of our relationship. And so we missed one another and never experienced the authentic encounter I had originally sought.

Moreover, during this period I was entirely consumed with the task of finishing a novel (
The Spinoza Problem
); I departed on a long-planned one-month retreat during which I put all else out of mind and worked nonstop on my final pages until the day I was jolted by Ellie’s email letting me know she had stopped all eating and drinking and soon would be dead. I felt both shocked and guilty. Shocked because, even though I knew she was terminally ill, I evidently compartmentalized the knowledge that she was so close to death so as to have all my energy available for writing. And guilty because I knew I could have offered her more of myself. I could have paid home visits when she was too ill to travel, and I could have engaged her more fully in the sessions and in the summaries I sent to her.

Why had we not connected more fully? My first answer to that question was that Ellie simply lacked the ability for deep relationships. After all, she had never married nor maintained a deep and lengthy love connection with any partner. She had moved many times and had had a great number of roommates but few truly intimate friendships. But I failed to convince myself: I knew this wasn’t the whole story. I knew that for some reason I had withheld myself from her. Truly shaken by her email, I felt compelled to put my novel on hold for a while and devote myself to Ellie by rereading, meticulously, all our summaries and correspondence. It was an eye-opening experience—so many of her statements staggered me with their great power and wisdom. Again and again I checked the dates of her emails. Had I
really
read these messages before? How could that be? Why did these strikingly poignant words seem unfamiliar, as though I were seeing them for the first time?

I decided to collect Ellie’s wisest and most powerful words and write this remembrance of her. I phoned Ellie and told her what I wanted to do and asked her permission. She was pleased and had only one request: that I use her real name rather than a pseudonym.

As I pored over her summaries, I was surprised at how often Ellie wrote about her deep sense of connection with me. Several times she wrote that she spoke more openly to me than to anyone else in the world. To take one example from her fourth summary:

I hate having to explain my situation to people who are novices to dying. Irv puts me at ease and he’s not afraid to go into the darkness with me. I can’t speak this way to others. It’s hard work, too hard, explaining to them that my cancer is incurable. People can’t help asking, “How long will you be on chemo?” which is an upsetting question. Don’t they get it? Don’t they get that my illness is
not
going to go away? I need people who can look straight into my eyes. Irv is good at that. He doesn’t look away.

These and a great many similar comments persuaded me that, despite my sense that I had failed to connect with her, I
had
offered her something precious by my willingness to accompany her into the darkness and not flinching when she discussed her death. The more I read, the more I wondered how I was able to do that.

I do my best thinking on my bicycle, so I took a long ride along the southern Kauai coast pondering that question. For sure it was not because I had entirely overcome my own fear of death. That had been a work in progress, an ongoing project, for a very long time.

Forty years ago, when I first began working with patients with terminal cancer, I was buffeted by storms of death anxiety and frequent nightmares. At that time, seeking solace, I sifted through memories of my personal psychotherapy, a seven-hundred-hour personal psychoanalysis during my residency in psychiatry, and was stunned to realize that
not once in those seven hundred hours did the topic of death arise.
Incredible! My ultimate perishing—the most terrifying fact of my life—had never surfaced, never once spoken of, in that long personal analysis. (Perhaps my analyst, at that time in her late seventies, was protecting herself from her own death anxiety.) I realized that, if I were going to work with terminally ill patients, I needed to do some personal work on my own mortal fears, and I reentered therapy with a psychologist, Rollo May, whose writings suggested a keen sensibility to existential issues.

I can’t pinpoint exactly how my therapy with him helped, but I do know that I wrestled with the fact of my death again and again in our work. Rollo was older than I, and looking back on our meetings, I am certain that I often made him anxious. But, to his credit, he never backed away and, instead, consistently pressed me to go ever deeper. Perhaps it was simply the process of opening closed doors and examining and embracing every aspect of my existential situation in the presence of a gentle and sensitive guide that made the difference. Gradually, over the course of several months, my death anxiety diminished, and I grew more comfortable in my work with terminally ill patients.

This life experience made it possible for me to be so present with Ellie, and there is no question that she was appreciative of my honesty. Denial was the enemy, and she voiced impatience with any form of it. In one of her summaries she wrote:

Other people, even others who also have cancer, tell me “You’re going to live 30 years.” They tell themselves, “I’m not going to die of this.” Even Nancy in my support group, so wise and clear-sighted, e-mailed yesterday “All we can hope for is to hang on long enough until better treatments are developed.”

But this isn’t what I want to hear. This is a safety net with an enormous hole right in the middle. Whether I will live a long time or a short time, I’m alive now, at this moment. What I want is to know that there are other things to hope for besides length of life. What I want to know is that it isn’t necessary to turn away from thoughts of suffering or death but neither is it necessary to give these thoughts too much time and space. What I want is to be intimate with the knowledge that life is temporary. And then, in the light (or shadow) of that knowledge, to know how to live. How to live now. Here’s the thing I’ve learned about cancer—it shows you mortal illness and then spits you back, back to the world, to your life, to all its pleasure and sweetness, which you feel now so much more than ever. And you know that something has been given and something has been taken away.

“Something has been given and something taken away.”
I knew what Ellie meant. It was a simple yet complex
thought—a thought that must be unpacked slowly. What has been given is a new perspective on living life, and what has been taken away is the illusion of limitless life and the belief in a personal specialness exempting us from natural law.