Two years after Martin’s death, the lightning bolt that struck her sixteen-year-old son once more shattered the illusion that she could protect either others or herself. Grief after the death of a child is the harshest grief of all. It is, in the words of Yeats, “tragedy wrought to its uttermost,” and often there is no outlet beyond tears. Astrid’s tears flowed without cease during our twice-weekly sessions throughout the next year. Gradually she rebounded, once in a while even displaying her infectious joie de vivre, and we moved back to a once-weekly schedule, then to a format where we moved back and forth between supervision and therapy. Finally Astrid regained so much of her tranquility that I raised the question of termination, but we never really ended: she took solace in my presence and called every few weeks for a supervisory session.
Then, a year ago, Astrid left a phone message on a weekend evening telling me that she had fallen from her bicycle earlier in the day, suffering only minor injury, but that now her bruises were growing in size at an alarming rate and she was feeling a bit confused. She couldn’t reach her internist and asked me whether she should go to the emergency room. I called back and told her that these problems definitely warranted a trip to the ER.
Not hearing back from her during the next few days, I left a couple of phone messages inquiring about the ER visit and received a call from her son, who told me his mother was unable to take calls: she was critically ill in the intensive care unit with a diagnosis of autoimmune liver disease. I knew nothing about this disease. It had not been described when I attended medical school fifty years ago, but a quick search of the medical literature informed me that this was a serious, often lethal ailment for which a liver transplant offered the best chance of survival. Two weeks later I received a call from her son informing me that his mother’s condition had deteriorated precipitously; she had severe jaundice and was in acute liver failure. A few days later he called back with great news: the hospital had miraculously located a liver, she had had the transplant, and she was now in serious but stable condition.
Three weeks later I had a brief phone discussion with Astrid, who told me she was getting stronger and was shortly to be released. I visited her at home for a couple of sessions, and soon Astrid was strong enough to travel to my office. “To hell and back,” she told me. “The most awful, frightening, anguished time in my life—and as you know, I’ve had quite a few. For days in the hospital I couldn’t stop trembling, couldn’t stop weeping. I was certain I was going to die. I couldn’t talk to you . . . couldn’t talk to anyone. And then, suddenly, I turned a corner.”
“How did you do it? Was there a specific turning point?”
“Very specific. A conversation with a nurse—a tough-assed, no-nonsense head nurse who had a good heart. It was just before my children were coming to visit. I had been in extremis for days. I was absolutely terrified of dying; I could not stop shivering and sobbing. And then, just before my family entered my room, she leaned over and whispered in my ear, ‘Show some class for your kids.’ That changed everything.”
“Tell me how.”
“I’m not sure how. But it was damned powerful. Somehow it just got me outside of myself. Up to then I just couldn’t stop being terrified. I was so close to death so many times. I couldn’t talk. Couldn’t cope, couldn’t even pick up the phone to have a session with you. All I did was cry. That statement, ‘Show some class for your kids,’ jolted me back to thinking of someone other than myself and let me see that I could still do something for my family, that I could set an example for them. That nurse was something. Tough love.”
Astrid was discharged from the hospital, gradually resumed her previous life, and soon began seeing her patients again. But her reprise from death was short. One day a few months later, she slumped forward in her hairdresser’s chair and died instantly of a ruptured aneurism in her brain. All this passed through my mind as I walked out of the community center with the other celebrants. All that drama, that hard life, that valiant effort: working through her grief for her mother, liberating herself from her father, surviving her brother’s death and, most of all, her son’s death. She had worked through so many knotty situations with her own patients and in her own therapy work with me. She had survived her liver disease by virtue of a liver transplant from a young man killed in a motorcycle accident. And, then, all of this remarkable drama extinguished in an instant by a single small artery exploding in her brain. Everything gone in one moment: her extraordinary universe of self; that lush, layered trove of sense data; her teeming memories of a lifetime; all that pain, that courage, that struggle and transcendence; that army of transplant surgeons and nurses; all that terror, that wailing, those gutsy recoveries. And for what? For what?
I had left the celebration and was approaching my car about a half block away when a light tap on my shoulder yanked me out of my morose reverie. I turned to see an unfamiliar face: a dour, fiftyish woman with stringy yellow hair, dressed in a plain, frumpy black suit. She hesitated, obviously apprehensive about speaking. “Excuse me, but are you Irvin Yalom?”
I nodded, and she continued, “I thought I recognized you from the photo on the cover of your book.”
Wishing to linger in my reverie with Astrid, I felt reluctant to enter into conversation. So I simply smiled and nodded.
“Astrid gave me a copy of your book. I’m Justine Casey. I was one of Astrid’s nurses on the surgery ward, and . . . um, I . . . I wonder if you’re still taking patients?”
Still taking patients? For many years, at least ten or fifteen, maybe more, no one has ever simply asked me if I were taking patients. It’s invariably “Are you still taking patients?” One of the endless, unnecessary, and, by now, slightly irritating reminders of my getting on in years. I told her I’d be glad to see her, gave her my card, and asked her to call me for a consultation. As I watched her stride away, I wondered if this was the nurse Astrid had spoken of. Was it she who had whispered in Astrid’s ear, “Show some class for your kids”?
When Justine entered my office a few days later, I was struck by how ungenerous nature had been to her. Her proportions were off. Her tight pinched face was too small for her large head, and her roundness was incongruous with her ramrod, head-nurse carriage. She brought to my mind the icy, forbidding Miss Markum, the head nurse on my inpatient ward when I was a resident at Johns Hopkins over a half century ago. I smiled to myself at the words ‘my inpatient ward’; in every sense, it was so obviously Miss Markum’s ward. Ah, the eternal doctor-nurse struggles! Quickly brushing the past from my mind, I sat silently with Justine for a few moments as she swiveled her head slowly, observing objects in my office. Her glance paused at my bookshelf along one wall.
“I see some familiar titles here, Dr. Yalom . . . ”
“How would you feel if we went by first names? Irv and Justine?” I almost always say this to patients but rarely so quickly. Perhaps I needed to sweep Miss Markum from my mind.
“Well, all right, but it feels a bit strange—you an eminent professor of psychiatry and I a head nurse.”
“Thank you for not saying ‘venerable’ professor.”
She smiled, very briefly. “I’ll try but may forget. I’m old school about titles.” She glanced again at my bookcase. “I’ve read several of your books. They were important for me.”
“Were those books behind your decision to contact me?”
“Yes, in part. The other part is that our patient, Astrid, spoke so much of how helpful you had been with her. She spoke of you a good bit.”
Our patient, I liked that. It might help us bond. “I knew our patient for quite a long time. A good woman. A good therapist, too. But tell me, was there something in these books that particularly spoke to you?”
“Maybe in the book that Astrid gave me, Staring at the Sun: Overcoming the Terror of Death. My copy is heavily underlined. I’ve read it more than once. I’m a surgical nurse and spend all of my time with cri
tically ill oncology and transplant patients. I deal with death every single day at work. Also I liked your novel The Schopenhauer Cure. That main character who is dealing with malignant melanoma—I can’t get him out of my mind.”
“I have a hunch, more than a hunch, that you’re already addressing this, but let me ask more directly: Tell me, why have you contacted me? What are you dealing with now?”
Justine exhaled loudly, let her arms hang loosely, and leaned back in her seat. “What am I not dealing with? There’s a lot going on.” She paused. Her anxiety was palpable.
“Try to dive in, Justine. You’re safe here.”
She seemed startled. Perhaps she still wasn’t used to my addressing her as Justine. She looked directly at me. I imagined that few people had ever told her she was safe.
“OK,” she inhaled deeply, “here goes. I’ll start with the heaviest thing. About a month ago I had a mole removed from my foot, and the path report said it was a malignant melanoma. So you can imagine my interest in your Schopenhauer Cure character. Julius, right? I’ve read the section describing his death repeatedly and cried every time.”
“I’m so sorry to hear about the melanoma, Justine. Tell me just what your doc said.”
“It was not good, but it could have been worse. The lesion was slightly ulcerated and fairly deep, about four millimeters, but the first lymphatic drainage site, the sentinel node, was clear. You know what I’m talking about? The inguinal nodes? When I talk to psychiatrists I’m never clear about how much of their medicine they remember.”
“I admit I’ve got yawning abysses in my knowledge of much current medicine. But I’ve worked extensively with oncology patients, so I’m following you so far.”
“Good. Well, the lack of node involvement is, of course, encouraging, but the depth of the lesion is not good news. I’m not as bad off as Julius, but I’ve a good chance of recurrence. The pathologist says perhaps nearly fifty percent. So I’ve been trying to live with that now.”
We sat in silence for a few moments. My heart went out to her. A fifty percent chance of recurrence! And if it did recur, she and I both knew there was no effective treatment available. I tried to imagine being in her shoes and felt myself starting to sweat. “That’s so hard, Justine. But often it helps to have someone to share it with.”
“Wait, there’s more.”
“Right. I’ve tagged your earlier statement: ‘What am I not dealing with?’ What else is happening in your life?”
“My work fills most of my life space, and work is painful. Take Astrid, for example. I took care of her for weeks, got to know her well, really well, and now she’s dead. We worked so hard. She was so sick, so close to death; her bilirubin and prothrombin time were through the roof; her jaundice was as bad as I’ve ever seen in a patient; and miraculously a liver transplant became available, and we saved her and brought her back to health. And now, a few months later, suddenly—just like that—she’s dead. And she’s only one of many, many patients. It’s the tale of most of my patients, my cystic fibrosis lung transplants, my advanced ovarian or cervical or pancreatic cancer patients. I get close to them, work my butt off to save them, and for what? Generally they die soon. I’m just their escort through the valley of death. My great dilemma is that if I keep my distance, I’m a bad nurse not doing my job. Yet if I do my job, I get scorched.”
“Sounds familiar, Justine. So very familiar. Let me share something with you. The other day, when you first tapped me on the shoulder at Astrid’s memorial, I wasn’t too responsive because I was lost in a reverie with those same thoughts, those exact thoughts, running through my mind. So much work, my work, Astrid’s work, your work, and then, in an instant, she’s gone. It’s hard to get my mind around it.”
“I was hesitant about tapping your shoulder last week. I had a feeling I was interrupting something.”
“I’m glad you took the chance. But let’s keep going. Is there more going on in the rest of your life we should talk about?”
Justine slowly nodded. “The rest of my life . . . that’s the problem. There is not enough of the rest. My life is too small. My husband and I split up over twenty years ago.” She took a deep breath. “Now the hardest part. I have one child . . . had one child . . . a heroin addict. He’s in San Quentin doing ten years for deadly assault, dealing, and burglary.”
“When you said ‘had one child,’ I first thought you were saying he was dead.”
“That’s precisely what I meant. He is dead to me. I pray I never see him again. I’ve written him off. Completely. I have no children. I’m all alone.”
“A lot of pain there.”
“There would be pain if I let myself think about it, but as I say, I’ve written him off. The pain’s been unbearable all these years. He violated me in every way, and in the end he stole everything he could from me, and then some.”
“Have you sought any help for any of these things, your feelings about your work, your melanoma, your husband, your son?”
Justine shook her head. “Never. I’m a tough bitch. That’s my reputation, and I guess I get off on it. I can take care of myself. Even now with you, let it be noted that I’m not asking for much. Two, maybe three, sessions—just enough to regain my bearings. Besides, I’m still in such credit card debt from my son’s stealing I don’t think I can afford much more. And if the melanoma wakes up and decides to march, who knows how long I can keep working.” She stopped and looked directly at me. “Are you all right with that, really short-term? I want you to level with me. Astrid told me you were not a bullshitter.”
“I’m okay with short-term. Let’s plan on three sessions, today and two more. If you find you need more in the future, we can renegotiate. And I’ll be honest, there’s something about short-term that feels comfortable. Your term ‘scorched’ hits home for me: I was scorched by Astrid’s death. Yes, short-term sounds fine to me. I think of it as scorch-free.”
“Wow. She’s right—you’re no bullshitter. I’m not used to that. The shrinks on the ward are always weaseling.”
“I will assiduously avoid weaseling. Now let me ask you a question you may not have expected. How are things going for you so far in this session? We’re just starting out, I know, but you’ve laid out a lot of your personal life already, and I have a hunch that’s uncommon for you.”
“Very uncommon. But you’re making it minimally painful. I do open myself up to two good friends, Connie and Jackie, friends from college days. We live in different parts of the country, but we stay in contact by Skype or phone at least once a week. Connie’s folks have a great vacation home on Lake Michigan, and we have a reunion every summer.”
“And they’re close confidants?”
Justine nodded, “Yep, they know almost everything. Even about my son. They’re my only confidants.”
“Aside from me?”
“Right. But I haven’t told them about the melanoma. That I’ve only shared with you.”
“Because?”
“I think you know. Cancer is just too heavy. Unless they’re close family, people run the other way.”
“Would they run? Connie and Jackie?”
“Hmm, not sure. Probably not.”
“Then you don’t tell them because? . . .”
“Hey, give a girl a break.”
“I’m pushing too hard? Sorry.”
“No, no. Don’t stop. It’s probably good for me. I’m the tough bitch who always does the pushing. It’s educational for me to be on the other side. What’s more, you’re pushing in the right spot. You’ve got a pretty good nose because my reunion with Connie and Jackie is coming up next month, and the last couple of weeks I’ve been mulling about telling them. In fact, tell you the truth: my going back and forth about telling them or not is probably the major reason for contacting you.”
“Let’s dig into it a bit. What do you most fear about telling
them?”
“Pity, I guess—pity and withdrawal. My contact with them is the place I feel most real, and I don’t want to jeopardize it. I worry about losing them. When I was a kid in New York, my grandmother scraped up the money to send me to camp every summer in the Adirondacks. Most of us went for two months but some for only one month. I remember that toward the end of the first month I withdrew from the ones who were leaving early and spent my time with the ones staying. Not much future in relating to the dying.”
“You’ve taken a chance and told me about the melanoma. Any questions you have for me?”
Justine looked directly at me, incredulously. “Whoa, that’s a new twist. I didn’t think that shrinks answer questions.” She thought for a few moments and then said, “Yeah, I do have one, if you’re up to it. Do you pity me?”
“I’m honestly not trying to duck your question, but that word, ‘pity,’ throws me. You have to be more clear about what you mean by ‘pity.’”
“Why do I think you are ducking my question? Here, let me put it differently. Exactly what did you feel about me when I told you of the melanoma?”
“Sorrow, compassion, concern—those were my first feelings about you. Then I imagined myself being informed that I had a melanoma, and I felt fear—I could almost feel myself begin to sweat. My problem with your word ‘pity’ was that it has the connotation of someone ‘other’ or even ‘lesser’ than me. I pity a starving dog or an injured kitten. But, Justine, you’re not ‘other.’ You’re not different from me. You’re facing what all of us must sooner or later confront. I have no specific malady, but my hoary age forces me to think about the end of my life all the time. My hunch is that your good friends are going to respond in a similar fashion. Already I personally cannot imagine deserting you, and I cannot imagine them deserting you.”