Creatures of a Day: And Other Tales of Psychotherapy (15 page)

Ellie jousted with death using an arsenal of denial-free ideas—ideas so effective she compared them to cancer drugs:

I’m alive now and that’s what matters.

Life is temporary—always, for everyone.

My work is to live until I die.

My work is to make peace with my body and to love it, whole and entire, so that, from that stable core, I can reach out with strength and generosity.

Each of these ideas had a peculiar life cycle. As she put it:

After a while each one stops working. It loses its power. Ideas are just like the cancer drugs. Except that the ideas are more resilient—they wear out, lay low for some time, as though they are taking a rest, and then come back revitalized, and also better and stronger new ones keep coming.

Often, especially early in the course of her illness, Ellie was plagued by envy of the living and healthy. She knew these mean-spirited sentiments were unhealthy to her mind and body and struggled to overcome them. The very last time I saw Ellie she told me something remarkable: “Now no more envy. It is gone. In fact, I’m able to feel generous. Maybe I can be a kind of pioneer of dying for my friends and siblings. It sounds weird, maybe Pollyannaish, but it sustains me and is a thought that doesn’t fade like the others.”

A pioneer of dying—
what an extraordinary phrase! This took me back forty years, to the first time I encountered this idea in my work as a therapist. In my first group of patients with cancer, I tried hard, week after week, to comfort a gravely ill woman. I’ve forgotten her name, but I remember her essence and still, with great clarity, can see her despondent, deeply lined face and her sad, downcast grey eyes. One day she startled all of us in the group when she arrived looking bright and revitalized. She announced: “I’ve made a big decision this week. I’ve decided to be a model for my children—a model of how to die!” And indeed, until she died, she modeled grace and dignity, not only for her children but also for the group members and for everyone who came in contact with her. The idea of modeling how to die permits one to imbue life with meaning until the very last moment. Over the years, I passed her insight along to many patients, but Ellie’s strong language (“a pioneer of dying”) gave it even greater force. As Nietzsche said, “If we have our own ‘why’ of life, we shall get along with any ‘how.’”

When Ellie described positive effects of her illness, I was not surprised, since I had heard many such comments from terminally ill patients. But, still, Ellie’s words had unusual power:

For family and friends I’m more of a scarce commodity. And I feel special to myself also. My time feels more valuable. I feel a sense of importance, gravitas, confidence. I think I’m actually less afraid of dying than I was before cancer, but I’m more preoccupied with it. I don’t worry about getting old. I don’t give myself a hard time about what I’m doing or not doing. I feel like I have not just permission but almost a mandate to enjoy myself. I love the advice I came across on some cancer website: “Enjoy every sandwich.”

Throughout all of this, she never lost her droll sense of humor.

On raising the bar.

Never in my life have I heard so often, from so many people, how good I look.

Of course there’s the unspoken “considering you have cancer”—but hey, never mind, I’ll take it! I give myself the same extra credit, patting myself on the back and think ‘wasn’t I nice to that grumpy salesperson, considering that I have cancer? Aren’t I so wonderfully upbeat, for someone who has cancer?’

I didn’t get much done today (or all week, come to that), but after all, I have cancer.

It’s nice, but I’m getting spoiled. Time to raise the bar.

Almost all of Ellie’s comments on her death were arresting. I reread each one several times. Over and again I wondered how I could have read them before and yet have so little memory of them.

Childhood Thoughts of Death

Having been one of those exhausting children who can’t let a subject drop, I pinned Mom down on the death question when I was four or five. She spoke of heaven but it didn’t really help. When I looked at the sky all I saw was sky. I ran and hid behind my father’s big leather armchair, the one that was pushed up against a corner. I figured I would just stay there forever and death wouldn’t find me.

The Buddhists advise living with death on your left shoulder; sometimes I feel like it’s sitting on both shoulders and in fact has climbed right inside my body. Which of course is exactly where it has always been.

No, these lines were too strong to have been forgotten. The truth is
I hadn’t truly let them into me the first time
. I marveled at the power of denial,
my
denial. So now I read Ellie’s words yet again, but this time with eyes and heart wide open. This time, the power of her words took my breath away:

My work is to love my body, all of it. Whole and entire. The whole aging mortal troublesome failing miraculous intricate breathing doomed cancerous warm mortifying unreliable hard-working imperfect beautiful appalling living
struggling tender frightened frightening living dying
living breathing temporary wondrous mystifying afflicted mortally-ill assemblage of the atoms of the universe that is my self, is me, for this space of time. This body that is screwing up. That is growing terrible and dangerous tumors. That is failing to turn them back, destroy them, dissolve them, annihilate them. This body that is failing at the one essential job of life, to stay alive, to stay alive.

Upon first learning that her cancer had spread she had written:

I stared at a mirror and I saw a human face, vulnerable, living, beloved, transitory. I didn’t examine my skin for clogged pores or fluff my bangs or form any opinion at all about my appearance. I looked straight into the eyes that looked straight back and I thought, oh, poor darling, poor kid. I think it was the first time I ever saw my face like that—whole
.

These lines brought tears to my eyes. The image of Ellie staring at herself in the mirror and saying, “oh, poor darling, poor kid,” tugged at my heart and also ignited my fears for myself. Death anxiety never really disappears, especially for those like me who continue to poke around in their unconscious. Even after all that work on myself, I continue to have my occasional three am awakenings during which I replay scenes in which I learn of my own fatal diagnosis, or lie on my deathbed, or imagine my wife’s grief.

Yet Ellie had said I was fully present, fully willing to enter the darkest places with her. I knew there was truth to that but wasn’t sure how I had managed to do it. Part of an answer came as I monitored my reactions while rereading these written reflections in one of her summaries.

Life is temporary—always, for everyone. We always carry our death in our bodies. But to feel it, to feel a particular death with a particular name—that is very different.

As I read these words, I observed myself understanding, nodding, agreeing with Ellie’s words, but when I turned up the volume and listened even more closely, I heard a muffled voice from the depths of my mind saying,
Yes, yes, all that is very well, Ellie, but let’s be frank, you and I . . . we’re not the same. You, poor thing, are the afflicted one, the one with the cancer, and I feel for you, and I’ll help in every way I can. But me, I’m healthy—cancer free. Alive. Free from danger.

Yet Ellie was a perceptive woman. How could she have said repeatedly I was the one person she could really relate to? She said that I looked directly into her eyes without flinching, that I received her and could hold everything she said to me.

What a conundrum. As I poured over her messages, I gradually began to understand. I
did
get close to Ellie. But not
too
close! Not dangerously close. I had falsely blamed her for our lack of intimacy. But she was
not
the problem. She had enormous capacity for intimacy.
I was the problem.
I was protecting myself.

Am I pleased with myself? No, of course not. But perhaps my denial allowed me to do my work. I now believe that all of us who work with the terminally ill must hold these contradictions. We must continually work on ourselves. We must coax ourselves to stay connected and not be too hard on ourselves for being human, all too human.

I look back on my time with Ellie with many regrets. I have regrets for Ellie, regrets that she never lived boldly, that she died young, and that she never took that grand tour. But now, as I look back at my experience with Ellie, I feel regret for myself. In our meetings it was I, not Ellie, who was shortchanged. I missed an extraordinary opportunity for a deeper encounter with a great-souled woman.

~ 9 ~

Three Cries

T
hough I met her only once for a single consultation many
years ago, our hour together remains sharply etched in my mind. A lovely, saddened, well-spoken woman, Helena came to talk about her friend Billy and cried three times during our talk.

Billy, who had died three months earlier, loomed large in her life. Their worlds had been different—he swirling in the Soho gay world, she ensconced in a fifteen-year bourgeois marriage—but
they had been lifelong friends, meeting in the second grade
and living together during their twenties in a Brooklyn commune. She was poor, he rich; she cautious, he devil-may-care; she awkward, he brimming with savoir faire. He was blond and beautiful and taught her to drive a motorcycle.

“Once,” she reminisced with sparkle in her eyes, “we motorcycled for six months throughout South America with nothing but small packs on our back. That trip was the zenith of my life. Billy used to say, ‘Let’s experience everything; let’s leave no regrets; let’s use up all there is and leave death nothing to claim.’ And then, suddenly, four months ago, brain cancer, and my poor Billy was dead in a few weeks.”

But
that
was not when she cried—that happened a few minutes later.

“Last week I reached an important milestone in my life. I passed my state exams and am now a licensed clinical
psychologist
.”

“Congratulations. That
is
a milestone.”

“Milestones aren’t always good.”

“How so?”

“Last weekend my husband took our two sons and their best friends camping, and I spent much of the weekend assimilating this milestone and reviewing my life. I cleaned house, I sorted through closet after closet packed full of useless possessions, and I came upon an old forgotten album of photos of Billy that I hadn’t seen for years. I took a deep breath, fixed myself a drink, sat on the floor in a corner, and slowly turned the pages, but this time with starkly different vision—with a therapist’s vision. I gazed at my favorite picture of Billy. He was sitting on his cycle, leather jacket unzipped, flashing that miraculous midsummer smile, saluting me with a bottle of beer, and beckoning me to join him. I always loved that photo, but suddenly it dawned on me, for the very first time, that Billy was manic, that Billy had bipolar disorder! I was staggered by the thought. All those treasured adventures, the crazy wild things we did, maybe it all was nothing but . . . ”

And it was here that she cried for the first time. She sobbed for several minutes. I prompted her, “Can you finish that sentence, Helena? It all was nothing but? . . .”

Helena continued to weep, shaking her head and apologizing for going through most of my box of Kleenex. Collecting her thoughts, she ignored my question and continued, “It was at that point I phoned you for an appointment. The thought that he was bipolar was bad enough, but later in the day it got even worse as I reread my last emails with Billy. Toward the very end, he wrote me a loving message telling me how much I meant to him, how he treasured my friendship, how he clung to images of me even though chunks of his brain were crumbling away. And then . . . ”

At this point Helena broke down and cried for the second time. She reached again for tissues as she sobbed heavily.

“Try to keep talking, Helena.”

“And then, as I looked at the email more carefully,” she said between sobs, “I realized that his letter had been sent to over a hundred people. That I was just one of a hundred, one hundred and thirteen to be exact.”

She continued to cry effusively for several more minutes. As the sobs grew quieter, I said, “And then, Helena?”

“And then I turned to a page in the album I had completely forgotten. Pasted on the page was an invitation to one of the joint wild birthday parties we used to give in Brooklyn. I was born on June 11 and he on June 12. We were born only a few hours apart, and we used to celebrate our birthdays together, and . . . ”

Here, for the third time, Helena broke down into tears.

I waited a few moments and then finished the sentence for her, “
We were born only a few hours apart, and now he’s dead
. Must be a frightening thought.”

“Yes, yes,” Helena nodded vigorously as she sobbed.

I checked my watch. She had asked for a single session, and there were only twenty minutes left. “Helena, let’s focus on these last tears first: you and Billy the same age, born within hours of one another. And now he’s dead. Tell me more of what you’re thinking.”

“It’s just chance that I’m here and he’s dead. It could have been the other way around. I remember one day we went to the horse races. It was my first time. I was surprised that Billy refused to bet, and when I asked about that, he gave a quirky answer. He said that he had already used up his luck by winning the lottery of life—all those millions of other eggs and sperm cells, and he was the one lucky enough to have pulled the winning ticket. He pointed to all the torn losing tickets on the ground and said he owed it to the ‘lottery of life’ not to throw away his money or to snatch more from others but, instead, to use it to live life to the fullest.”

“And did he do that?”

“Oh yes. Oh yes. I never knew anyone so fully alive, so fearless, so exuberant in the sheer act of being alive.”

“And,” I said, “if that brilliant life spark could be extinguished, then your own life seems precarious.”

Helena looked up at me with a bit of surprise in her eyes at my bluntness. “Exactly, exactly.” She grabbed another handful of Kleenex.

“So your tears are also for yourself. His death makes your own death more vivid, more real. Is this the first time you’ve had such an encounter with death?”

“No, no. I think there were many times as a kid when the thought of death thundered down upon me. Every time I attended funerals I had bad sleepless nights thinking about being dead. Also when my oldest son was being born. His first cry hit me hard.”

“Why then?”

“It brought home the obvious: that life has a start and then proceeds in linear fashion. I’m just a carrier passing it on to my son, who will pass life along, and then he, too, will face death. I guess it brought home that we’re on a schedule, every one of us, and I sure ain’t no exception.”

“I’ll tell you what’s on my mind,” I said. “It’s Billy’s statement, ‘Leave no regrets.’ It seems from what you’re saying that your life with Billy was lived fully. Right?”

“Right.”

“I see that from the excitement in your eyes as you discuss it. No regrets from that time of life?”

“None at all.”

“Well, what about your life
now
with your husband and your sons?”

“Ah, yes. You don’t waste time. Different story. I’m not
in
life now. I seem to be postponing it. I’m not really experiencing and savoring life as it happens in the moment. And I’m so weighed down with things: clothes and linen and bedspreads and too many lamps and baseball gloves and golf clubs and tents and sleeping bags.”

“Not like your motorcycle trip with Billy—six months of South America with just a small pack on your back.”

“Oh, that was heaven. Sheer heaven. Now I’m married to a good man. I do love him, but, oh, I wish I weren’t so weighed down. I wish I could go on with just a pack on my back. Too many things. Sometimes I visualize a giant steam shovel breaking through my roof and filling its jaws with our things—giant TVs and DVD players and sofas and dishwashers—and, as it rises to take things away, I see some striped canvas lawn chairs dangling from its teeth.”

“And so? Speak more of your regrets about life in the past few years.”

“I haven’t valued it, haven’t lived it as I should have. Perhaps I’ve hung on too long to the idea that
real life
was back there, with Billy.”

“And that belief makes it all the more difficult to come to terms with your
own
death. It’s always more painful to think of death when you sense you haven’t lived fully.”

Helena nodded. I definitely had her full attention now.

“Let’s go back to the other two times you cried. You cried when you learned that he had sent a farewell email to over a hundred people. Let’s talk more about that.”

“I just didn’t feel special anymore. We were once so close, so very close.”

“You’ve been seeing a great deal of him?”

“I used to but no, not for the last several years. Not since I moved to Oregon about ten years ago. We’ve been on opposite coasts, and I saw him about once or twice a year at most.”

“So,” I mused, “I think of Billy invaded by a brain tumor and perhaps, like so many dying people, feeling isolated and, in desperation, reaching out to touch his entire social network, to contact everyone he knew. That seems understandable and so very human. But by no means, Helena, is his act a comment about his relationship with you.”

“Yes, yes, I know that. God, do I know that! I see a lot of couples in my practice, and almost every single day I’m saying to some client or other that every act is not necessarily a message about the relationship.”

“Precisely, and it is even
more
unlikely that it is a message about the genuineness of your relationship with Billy so many years ago. Relationships end, but that does not obliterate what they once were. And that brings us to the very first time you wept here, when you spoke of your sudden realization that Billy was manic. Try to imagine what your tears were saying then.”

“His mania seems so obvious now. He never stopped. Always at full speed. He never slowed down.
How could I have missed it? Unbelievable.
”

“But let’s look at why it shook you up so.”

“I think it called into question my whole sense of reality. What I used to consider the peak of my life, the glowing exciting center, the time when I, and he, were most thrillingly alive—
none of that was real
. Now I realize that it was all just the mania talking.”

“I can appreciate how destabilized you must feel now, Hel
ena. All these years you saw your life one way, and now
suddenly
you’re faced with a new and different version of reality. To see the past changing before your eyes—what a shock!”

“Exactly. I feel dazed.”

“There’s also something very sad about your comments,
Helena
. It’s sad how Billy, this vital, precious man, this lifelong friend, has been reduced to a diagnosis. And your entire youth with him—all those wonderful exciting experiences—also reduced to being ‘nothing but,’ nothing but an expression of mania. Perhaps he had some mania, but, from what you tell me, he seems so much more than just that label.”

“I know, I know, but I can’t get past that right now.”

“Let me tell you what’s going through my mind now. When you said that your entire youthful life with him was ‘nothing but’ mania, I shuddered a bit. I imagined applying this ‘nothing but’ approach to what’s transpiring right now between you and me. I guess one might say that this is
nothing but
a commercial transaction and that I’m being paid for listening and responding to you. Or perhaps one might say that it helps me to feel stronger and more effective by helping you feel better. Or that I get life meaning from helping you attain meaning. And yes, all these things may be true. But to say therapy is ‘nothing but’ any of these things is so very far from the truth. I feel that you and I have encountered one another, that something real is occurring between us, that you’re sharing so very much of yourself with me, and that I am moved and engaged by your words. I don’t want us to be reduced, and I don’t want Billy reduced. I like the thought of his miraculous midsummer smile. I envy your motorcycle ride through South America, and I’m sad at the thought of your taking all this away from yourself.”

We ended, both of us tired and enlightened. She could reclaim her past and once again treasure her life with him. And, for my part, I had gained a new perspective on my longtime aversion to the act of diagnosis. During my training as a psychiatrist I often found the official diagnostic categories problematic. At case conferences, many of the consultants disagreed on the proper diagnosis of the patient presented, and I eventually grasped that the disagreements generally ensued not from practitioners’ errors but from intrinsic problems in the diagnostic enterprise.

During my tenure as head of the Stanford inpatient ward I relied on diagnosis to inform decisions about effective pharmacological treatment. But in my psychotherapy practice over the last forty years with less-seriously disturbed patients, I have found the diagnostic process to be largely irrelevant, and I have come to believe that the contortions we psychotherapists must go through to meet the demands of insurance companies for precise diagnoses are detriments to both therapist and patient. In the diagnostic procedure we are not carving at the joints of nature. Diagnostic categories are invented and arbitrary: they are a product of committee vote and invariably undergo considerable revision with each passing decade.

But my meeting with Helena brought home to me that the chore of making a formal diagnosis is more than a simple nuisance. It may, in fact,
impede
our work by obscuring, even negating, the full-bodied, multidimensional individual facing us in our office. Billy was a victim of that process, and I was glad to play a part in restoring him to his former complexity and exuberance.