Creatures of a Day: And Other Tales of Psychotherapy (13 page)

For many weeks she read through her work and painstakingly entered everything, every word, into her computer. The task proved to be a treasure trove for the work of therapy, in that she arrived at each session brimming with vivid recollections about her relationships with her parents, siblings, friends, and past lovers. In her early twenties a series of poems, each
sounding more pained and more desperate, presaged the
collapse
of her first marriage. One day she appeared at my office holding a bundle of sixty-six love poems written to Austin, a demon lover with whom she had had a brief passionate affair in her youth. The poems sang of soaring, unending love, but all too soon her relationship with Austin peaked and then ended badly with a foul aftertaste. She had misjudged him and ended up feeling exploited and traumatized. Hence, when she discovered those poems, her first impulse was disgust, and she considered burning them but desisted until she spoke to me. I was horrified at the thought. I never burn anything and have a large folder entitled “Cuts,” holding all the material cut from my novels and stories. I told all of this to Sally in my appeal to save the poems from the fire. I stalled for time by asking Sally to read aloud some of the poems about Austin. With quavering voice she read a few passages.

“I think they’re lovely,” I said.

She began to weep. “But they’re fraudulent. And I’m fraudulent too. The few months during which I wrote these was the most glorious time of my life—and yet these poems are rooted in a dung heap.” We spent the last fifteen minutes of the session discussing the many great works of art that had unsavory beginnings. I presented arguments, one after the other, pleading for the life of these innocent poems. I told her the transformation of dung into beauty is artistic triumph, and that if it weren’t for errant passion, death, despair, and loss, the great bulk of art would never have been born. She eventually acquiesced and ultimately transcribed the sixty-six poems to Austin into her computer. I felt like a hero who had rescued a precious ancient manuscript from the flames.

Much later, when we were reviewing our therapy, I was to learn that this episode was far more than a short subject accompanying the main attraction of unpacking the mysterious sealed box. Because Sally was so ashamed of the affair and her participation in Austin’s elaborate bondage rituals, she had never shared this with a living soul in all these decades. Revealing all to me and getting a supportive response had great impact. She felt enormously liberated and, for the first time, asked for and received a hug at the end of the session.

That night she had a dream. “I found a pile of folded laundry by my door that someone, possibly my husband, had placed there. I started to put it back in the washing machine—it might have gathered dust sitting there—but then I decided against it and put the clothes in my dresser.” The dream message was all too clear: she had no more dirty laundry to wash.

All the while, as Sally sifted through her stories and poems, and we discussed all the variegated and rich issues contained therein, I anticipated the uncovering of more portentous themes. Where were all those dark works that had caused her to bury her writing for a lifetime? Where, for example, was that dreaded bus story?

And then one day it arrived. She entered my office holding a folder. “Here’s the story. Would you please read this?”

I opened the folder. The five-page story was entitled “Riding on the Bus.” It was a simply told story of a young girl hugely upset by a fight with her parents and by taunting from cruel classmates. She decides to cut the rest of the school day and, for the first time, seriously considers suicide. It is a freezing winter day, far too cold for the hour’s walk home, and yet she has no money to take the bus. Her father’s office is nearby, but the previous day he refused to come to her assistance during a heated confrontation with her mother, and she was still too enraged with him to ask for a ride home or for bus money. And so the young girl steps onto the bus and pulls her pockets inside out to indicate she has no money. The bus driver starts to refuse her entry but, seeing how she shivers from the cold, simply nods for her to board. She sits in the back of the bus and weeps softly the entire trip. At the end of the route all the passengers disembark, and the driver turns the engine off. He is about to get off the bus for his ten-minute coffee break when he notices the sobbing young girl and asks why she hasn’t gotten off. She tells him she lives at the other end of the route, and he not only lets her stay on the bus but also buys her a Coke and invites her to sit near him by the heater in the front. For the rest of the day the girl and the driver ride back and forth together on the bus.

I looked up from the story. “
This
is the dark story you dreaded so much?”

“No, I never found that story.”

“And
this
story?”

“I wrote it yesterday.”

I was speechless. We sat in silence for a few minutes until I ventured, “You know what I’ve been thinking? Remember what I said to you a few weeks ago, when you had come to realize that your parents weren’t cruelly withholding love but that they simply didn’t have it to give?”

“I remember clear as a bell. That was when you said that I had to give up the hope for a better past. That phrase caught my attention and has been circling in my mind ever since. I didn’t like it, but it was helpful. It got me over a tough spot.”

“Giving up the hope for a better past is a potent idea. I’ve uttered it to help many others, and it’s also helped me personally. But today, here,” I handed her back the story, “you’ve given it a creative and unexpected twist. You didn’t give up the hope for a better past; instead you’ve written a new past for yourself. Pretty impressive route you’ve taken.”

Sally put the story back into her briefcase, looked up, smiled, and offered one of the loveliest compliments I’ve ever received: “It’s not so hard if you’ve got a kind bus driver.”

~ 8 ~

Get Your Own Damn Fatal Illness: Homage to Ellie

W
hile on a monthlong writing retreat in Hawaii, I was shocked to receive this email from my patient Ellie:

Hello Irv,

I’m sorry I’ll have to say goodbye this way, not in person. My symptoms got a lot worse a week or so ago and I decided to do a process of VSED (voluntarily stopping eating and drinking) in order to die faster and with less suffering. I haven’t drunk anything for over 72 hours now and should (according to what I have read and been told) start “fading” soon, and die within a couple weeks at most. I’ve also stopped my chemotherapy. Goodbye Irv.

I’d known from the onset of our work that Ellie would die from her cancer, but, even so, I was stunned by this message. I closed my computer, put my work aside, and stared at the ocean.

Ellie first entered my life five months earlier, also via email.

Dear Doctor Yalom,

About a year or so ago I attended your radio interview at The Marsh Theater in San Francisco and felt immediately that you would be a great person to consult. I also liked your book “Staring at the Sun.” My situation is that I’m 63 years old and have a fatal illness (recurrent ovarian cancer, initially diagnosed about 3 years ago). I’m currently feeling quite well physically, but I’m in the process of going through all the known chemo drugs that keep the disease in check and, as each drug outwears its usefulness, I can feel that endpoint drawing nearer. I feel I could use some help figuring out what’s the best way to live under the circumstances. I think, no, I’m certain, that I think too much about dying. I’m not thinking of on-going therapy but perhaps one or two sessions.

I didn’t experience Ellie’s email as unwelcome or unusual (aside from being well written and fastidiously punctuated). I almost always have one or two terminally ill patients in my practice and have grown confident that I can offer something of value even in a brief consultation. I replied immediately, offering her an appointment a week later, giving my address, and informing her of my fee.

Her first words as she appeared in the doorway of my San Francisco office, perspiring profusely and fanning herself with a folded newspaper, were “Water, please!” She had raced to catch a bus at the corner near her apartment in the Mission district and then climbed two steep blocks to my office at the top of Russian Hill.

Aging and small in stature, about five foot two, apparently inattentive to her appearance, with tangled hair that cried out for brushing, loose, shapeless clothing, and no jewelry or makeup, Ellie struck me as a faded, wistful flower child, a refugee from the sixties. Her lips were pale and cracked, her face showed weariness, perhaps even despair, but her eyes—her wide, brown eyes—gleamed with intensity.

After fetching a glass of ice water and placing it on a small table next to the chair where she would sit, I took my seat across from her. “I know what a climb you’ve had to get here, so catch your breath, cool off a bit, and then let’s begin.”

She took no recovery time. “I’ve read some of your books, and I can hardly believe I’m here in your office. I’m grateful, most grateful, to you for responding so quickly.”

“Tell me more of what I should know about you and how I might be helpful.”

Ellie chose to begin with her medical history and described at length, in a mechanical tone, the course of her ovarian cancer. When I commented that she almost seemed detached from her own words, she nodded her head and responded, “Sometimes I go on automatic pilot. So many times have I gone over this story. Too many times! But hey, hey,” she hastened to add, “I’m cooperating. I know you need to know my medical history. I know you
must
know it.
And yet, still, I don’t want you to define me as a cancer patient.
”

“That I shan’t do, Ellie. I promise. But, still, fill me in a bit more. Your email states that you’ve exhausted the usefulness of several chemotherapy drugs. What does your oncologist tell you? How sick are you?”

“His words to me a month ago at our last visit were ‘We’re running out of options.’ I know him well. I’ve studied him a long time. I know his sanitized, coded way of speaking. I knew he was really saying, ‘This cancer is eating you alive, Ellie, and I can’t stop it.’ He’s tried all the new drugs, and each one had its day in the sun: each one worked for a while and then weakened and finally grew entirely ineffective. A month ago at our visit, I pressed him hard, really hard, for straight info. He fidgeted a bit. He looked so uncomfortable and so sad, I felt guilty for pressuring him. He’s a really good guy. Finally, he replied, ‘I’m so sorry, but I don’t think we have more than a year.’”

“A hard message to hear, Ellie.”

“In one way, yes, very hard. But in another way I almost felt relief. Relief at finally, finally getting a straight message from the medical profession. I knew it was coming. He didn’t tell me anything I didn’t know. After all, I heard him say two years ago that it was highly unlikely I would survive this cancer. During this time I’ve had a whole parade of feelings. At first I was appalled by the word ‘cancer.’ I felt polluted. Terrorized. Ruined. It’s hard to remember those times, but I’m a writer by trade and jotted down descriptions of my feelings during that period. I’ll gladly email them to you if you’d like.”

“I’d very much like to see them.” And indeed I meant it. Ellie struck me as uncommonly lucid and articulate. Rarely had I heard a patient discuss mortal issues so forthrightly.

“Gradually,” she continued, “much of that terror has lifted, though there are still times I scare myself by imagining what my cancer looks like, and I search the web for hours for pictures of ovaries infested with cancer. I wonder if it’s bulging, if it’s about to burst open and spew cancer seeds all over my abdomen. Of course I’m just guessing about all this, but one thing I know for sure is that the idea of limited time has changed the way I plan to live.”

“How so?”

“So many ways. For one thing, I feel different about money, way different. I don’t have much money, but I figure I might as well spend what I have. I’ve never had much. I’ve worked most of my life at low-paying jobs as a science writer and editor . . . ”

“Oh, that explains that beautifully written, meticulously punctuated email.”

“Yes. God, I abhor what email is doing to language!” Ellie’s voice grew more charged. “No one cares about spelling or punctuation or happy, fulfilled sentences. Be careful—I could talk forever about that.”

“Sorry, I’ve gotten you off track. You were speaking of your attitude toward money.”

“Right. I’ve never made much, never focused on it. And having never married nor had children, I see no point in leaving money behind. So, after my last talk with my oncologist, I made a big decision: I’m going to blow my savings and take a trip with a friend to all the places I’ve always wanted to see in Europe. It’s going to be a grand tour, a real first-class splurge.” Ellie’s face sparkled, and her voice grew enlivened. “I am so looking forward to this. I suppose I’m gambling, making a bet that my doctor is right. He said one year, so I’ve given myself a bit of a margin and put aside enough money to keep me going for a year and a half, and I am going to blow all the rest on my trip. It’ll be a blast.”

“And if your doctor’s wrong? If you live longer than that?”

“If he is wrong, then, to put it in technical terms, I’m totally fucked.” Ellie flashed a big mischievous grin, and I grinned right back.

I got a big kick out of her bet. I’ve always been a betting man myself, never turning down an offer to bet with my friends, even my children, on baseball or football games, enjoying my few trips to the horse races, and always relishing my ongoing poker game. Moreover, I felt delighted at the thought of Ellie’s grand tour.

She described the busyness in her mind. “I have some good days, but too often I picture myself in the future: weak, declining, close to death. I often ask myself, ‘Will I crave to have people with me at the end? Will I be afraid to be alone? Will I be a burden to others?’ Sometimes I imagine behaving like a dying animal and crawling off into a cave to hide from the world. I live alone. I don’t like it, and sometimes I think of doing what I used to do, renting a huge place and getting a whole new set of roommates. But how could I manage that now? Imagine advertising for roommates and saying, ‘Oh, and by the way, I’ll be dying soon of cancer.’ So those are the bad days. But, as I say, there are good days too.”

“And the good-day thoughts?”

“I check into myself often. I ask, ‘How’re you doing, Ellie?’ I tell myself the story of myself. I remind myself of helpful perspectives, for example, that I’m alive now, that I’m happy to be involved in life, not paralyzed with worries as I was a year ago. But in the background there is growing darkness. I’m always aware that I have a fatal condition.”

“Always there?”

“Always there . . . it’s the static that never goes away. When I meet a friend who is pregnant, I start calculating whether I will still be alive when the baby is born. The chemo I take makes me feel awful. I keep asking myself, ‘Is it worth it?’ I often play with the thought of decreasing my dose, of trying to fine-tune it so that I could feel better and live a couple of months less, say nine or ten months of good life rather than a year of bad life. And then, there’s something else: sometimes I think I grieve for the life I haven’t had. I guess I have regrets.”

That statement instantly caught my attention. An exploration of regrets almost always takes the discussion deeper.

“What kind of regrets, Ellie?”

“I guess regrets for not being bold enough.”

“Bold? How?”

She sighed and thought for a minute. “I’m too introverted; I’ve stayed hidden too much, never married, never stood up for myself at work, never asked for more money. Never spoke out.”

I considered pursuing the longing and sadness in her voice but instead chose a bolder path. “Ellie, this may seem like a strange question, but let me ask you, Have you been bold enough in this conversation with me today?”

I was taking a chance. Though Ellie was being honest and sharing difficult things, somehow, for reasons I couldn’t quite put my finger on, I felt a certain distance between us. Perhaps it was my fault, but somehow we weren’t fully engaged, and I wanted to remedy that. Many individuals with a fatal illness feel isolated and think that others hold them at arm’s length, and I wanted to make certain that wasn’t happening here. Redirecting the flow of the interview into the here and now almost always enlivens therapy by tightening the connection between therapist and patient.

Ellie was startled by my question. Whispering aloud to herself two or three times, ‘Have I been bold enough here?’ she closed her eyes, thought for a few seconds, and then suddenly opened them, turned to look directly into my eyes, and declared firmly, “No. Certainly not.”

“And if you
were
to be bold here, what would you say to me?”

“I’d say, ‘Why are you charging me so much? Why do you need so much money?’”

I was flabbergasted. As I often do, I had deliberately phrased my words in the conditional tense to encourage boldness, but never, not in the farthest realm of my imagination, did I expect such a bold response from this wounded, docile, soft-spoken woman, who seemed overwhelmed with gratitude that I would see her at all.

“Uh . . . uh,” I stuttered, “I’m a bit uh, uh . . . flustered. I don’t quite know how to answer you.” I couldn’t think clearly and paused to collect my thoughts. I felt a flush of shame about my fee, especially when I thought of how she was scrimping, taking the bus to my office, scraping money together for her grand tour. In dilemmas like this I eventually turn to my own personal mantra,
tell the truth, tell the truth, tell the truth
(at least insofar as I deem it helpful to my patient). After a short time I collected myself.

“Well, Ellie, obviously I’m uncomfortable at your saying this to me, but first I want you to know—
and I really mean this
—I’m absolutely thrilled at your boldness just now. And the reason I’m flustered is because you’ve touched on one of my own personal dilemmas. My immediate reflex was to defend myself and say to you, ‘My fee is the going rate for San Francisco psychiatrists,’ but I know that’s not your point. The fee
is
high, and your implication is right on:
I don’t need the money.
So you’re confronting me with my own personal ambivalence about money. I can’t work this through right now, but I do know one thing for sure: I want to make a proposal. I’d like to cut your fee in half. Is that okay? Will that be affordable?”

Ellie showed a flash of surprise but then simply nodded appreciatively and then quickly changed the subject by discussing her daily routine and how she often makes things harder for herself by thinking she has to do something very substantial with her limited time, like writing her memoirs or starting a blog. I agreed that this represented an area for work if she were to pursue therapy, but it seemed apparent to me that she had jumped too quickly away from our discussion about fees. For a moment I considered suggesting that we reexamine our feelings about what had just happened, but then I thought,
Slow down—you’re asking too much of her. This is only a first session
.

Ellie looked at the clock on the table between our chairs. Our hour was nearly up. She hurriedly offered me some compliments. “It’s been good to talk with you today. You really do listen. You do receive me. I feel comfortable with you.”

“Can you say what I’ve done that’s made it comfortable for you today?”

Ellie paused for a few seconds, stared at the ceiling, and then ventured, “Maybe it’s because of your age. I’ve often found it easier to talk about dying with an old person. Maybe it’s because I sense that old persons have thought about their own death.”

Her would-be compliment ruffled me. It was appropriate to talk about her death, but had I signed on to talk about
mine
? I decided to air my feelings. After all, if I weren’t going to be honest, how could I expect it of her? I chose my words
carefully
.