When I first entered residency in 1957, psychotherapy was the very core of psychiatry, and my passion for exploring it was shared by almost all of my colleagues. But now, in the eight presentations I attended at this conference, there was only scant mention of psychotherapy.
I have read very little in psychiatry these past few years. I often pretend this is due to visual problems—I’ve had surgical procedures on both of my corneas, as well as bilateral cataract operations—but that’s a lame excuse. I could have kept abreast by reading professional material on the large font on my Kindle. The truth—slightly embarrassing to admit—is that I am no longer interested. When I start to feel guilty about this, I comfort myself by saying that I have put in my time, and that, at eighty-five, I should be free to read whatever I wish. Then, I add, “Besides, I’m a writer and need to stay abreast of contemporary literary currents.”
When it was my turn to address the audience at the Stanford conference, I did not lecture, and had no slides to show—unlike the other speakers. In fact—and here follows a huge first-time confession—I have never made or used a slide in my life! Instead, a Stanford colleague and close friend, David Spiegel, skillfully and genially interviewed me about my career and evolution as a therapist. This is a comfortable format for me, and the time flowed so quickly that I was startled when the session ended. As the audience stood and applauded, I had the disquieting sense they were saying farewell.
Because there are few psychiatrists practicing at my age, I often ask myself: Why are you still seeing patients? It’s not for economic reasons; I have enough money to live comfortably. It’s that I love my work too much to let it go before I have to. I feel privileged at being invited into the intimate lives of so many people, and after so many decades, I think I may be getting good at it.
Perhaps, in part, this is a result of getting good at selecting my patients. For the past several years I’ve done time-limited therapy: I tell patients at our first session that I will see them for a maximum of one year. As I approached eighty, I began to wonder how long my mind and memory would remain intact. I didn’t want patients to become overly dependent on a man who might soon be retiring. Moreover, I’ve found that setting a termination date at the outset generally increases the efficiency of treatment and plunges patients more quickly into the work. (Otto Rank, one of Freud’s early disciples, made that same observation over a hundred years ago.) I am careful not to accept a patient if it appears unlikely that we can make considerable progress in a year, and I refer patients who are more severely ill and in need of psychotropic medication to other psychiatrists. (Because I’ve not kept abreast of new research, I stopped prescribing medication several years ago.)
Since I have helped so many people deal with aging, I thought I was well prepared for the losses looming ahead, but I find it far more daunting than I had imagined. The aching knees, the loss of balance, the early-morning back stiffness, the fatigue, the fading vision and hearing, the skin blemishes, all these catch my attention but are minor compared to the fading of memory.
On a recent Saturday, my wife and I went out for a walk and lunch in San Francisco, and upon returning to our apartment I realized that I had neglected to take my keys with me. We had to wait outside for a couple of hours before the return of a neighbor who had a duplicate set. That evening we attended a play, The Unheard of World, by Fabrice Melquiot, about an imaginative vision of the afterlife. It was produced by my son Ben and staged by FoolsFURY, his dramatic group. Marilyn and I had agreed to discuss the play with the audience after the performance, she from a literary perspective and I from a philosophical and psychiatric one. Although my remarks seemed satisfactory to the audience, I realized, in the middle of my presentation, that I had forgotten an important and interesting point I had wished to discuss. I kept speaking on automatic pilot while frantically burrowing in my mind for the lost idea. After ten more minutes or so, it suddenly popped into awareness and I made my point. I doubt if the audience knew of the frantic internal chase for my lost material, but during those ten minutes, as I was speaking to the audience, I heard a phrase circling in my mind, “That’s it—the time has come. I’ve got to stop giving public talks. Remember Rollo.” I was referring to a scene I described earlier about Rollo May at an advanced age giving an address in which he repeated the same anecdote three different times. I had vowed never to put an audience through the spectacle of my senility.
The following day, I returned a rental car to the agency (my car had been in the shop). It was after hours, and the agency was closed. I followed the posted instructions: I locked the car and deposited the keys in the locked drop box. But only a few minutes later I discovered that I had left my bag containing my wallet, keys, money, and credit cards in the car. I finally had to call AAA to come and open the car to retrieve my bag.
Though this was an unusually bad siege of crumbling memory, milder lapses happen almost every day now. Who is that man smiling and approaching me? I know him, I’m certain, but his name, oh, his name? And what was the name of that restaurant Marilyn and I used to go to near the beach at Half Moon Bay? The name of that short funny comedian in the movie Throw Momma from the Train? On what street is the San Francisco Museum of Modern Art? What is the name of that odd form of therapy that rests on nine different personality types? And the name of the psychiatrist I used to know who originated transactional analysis? I recognize familiar faces, but the names evaporate—some return, and some disappear immediately after each reminder.
Yesterday I had lunch with a friend, Van Harvey, a few years older than I (yes, there are still a few of those around). He suggested I read a novel called The Glass Room by Simon Mawer, and I suggested he try Winter by Christopher Nicholson. A few hours later our emails crossed, each asking the other: “What was the name of that novel you recommended?” Of course, I should carry a notepad. But remembering to bring the notepad—ah, there’s the rub.
Lost keys, eyeglasses, iPhones, phone numbers, and the location of parked cars—this is my daily fare. But losing both my apartment and automobile keys was extreme and probably related to the insomnia I had experienced the night before. I am certain I know the cause of the insomnia. That evening I had seen a French film, Amour, that depicts the ordeal of an aging loving husband who helps his ailing wife die. The couple resembled Marilyn and me, and the film haunted me all night long. Amour is a superb film, but take my advice: see it before you reach your eighties.
I’ve worried for a long time that my aging memory may force me to give up seeing patients, so, to forestall retirement, I make heavy use of a computer dictating program: after each session I never fail to dictate a one- or two-page summary of each hour, and I take great care always to read the summary just before I see the patient again. For that reason I always schedule at least twenty minutes between patients. Moreover, for the past few years, I see no more than three patients a day. When a patient from the deep past emails me, I often draw a blank at first, but reading a few sentences of my old notes usually opens up the spigot for the entire story.
But there is one bright side to memory loss: forgetting plotlines of many books enables me to obtain pleasure in rereading them. I find fewer and fewer contemporary novels that I enjoy, and so I turn back to my “favorites” lined up in my bookcase: A Hundred Years of Solitude, Grendel, Great Expectations, The Adventures of Maqroll, Bleak House, Midnight’s Children, Aunt Julia and the Scriptwriter, Daniel Deronda, Silas Marner, and The Way of All Flesh, many of which I can read as though for the first time.
In Staring at the Sun, I describe the concept of “rippling” as a way to assuage anxiety about death. Each of us creates, often without our knowledge, concentric circles of influence that may affect others for years to come, even for generations. The effect we have on others is passed on much as the ripples of a pond go on and on, until they are no longer visible but still continue at a nano level. As John Whitehorn and Jerry Frank have rippled into me, I believe
I have rippled into my students and readers and patients, and especially into my four children and seven grandchildren. I still remember my tears of joy when my daughter, Eve, phoned to tell me she had gotten into medical school, and last year my tears flowed again when I learned that her daughter, Alana, had been accepted into Tulane University School of Medicine. And this past Christmas, I sat down with Adrian, my three-year-old grandson, for our first game of chess.
THE AUTHOR GIVING HIS GRANDSON, AGE THREE, A FIRST CHESS LESSON, 2016.
A conundrum: When shall I retire? I am often called upon to help patients deal with that very decision. Not long ago, I worked with Howard, a successful, highly intelligent hedge fund manager in his mid-eighties, whose wife insisted he seek therapy because he couldn’t stop working long hours glued to his computer screen. Living on the West Coast, he had to rise at 4:30 a.m. to monitor the stock market, and he stayed at the screen all day. Even though he had worked for years to perfect a computer program to do his work, he felt he owed it to his investors never to stray far from the monitor. His three partners, two younger brothers and a lifelong friend, rarely missed their daily nine holes of golf, and Howard felt that he had to work for all of them. He knew that he and his wife and three daughters had far more money than they could spend, but he couldn’t stop. It was his duty, he said. He couldn’t entirely trust the computer program he’d designed to make trades. Yes, he agreed he was addicted to watching the rise and fall of the ticker tape, yet he knew no other way to live. And moreover, he winked at me, it’s a blast to win big on the market.
“Imagine your life without work, Howard. What would it be like?”
“I admit I am terrified about stopping.”
“Try to imagine this life without work.”
“I know where you’re heading. I admit it makes no sense. I admit I’m scared to stop. What would I do all day long? There’s only so much traveling and sightseeing possible. All the interesting sites—you name them—I’ve seen them all.”
I pushed him harder: “I wonder if you feel that work keeps you alive, that without work you’d drift into the final stages of life—senility and death. Can we together find some way to disentangle life and work?”
He listened intently and nodded. “I will think about these issues.”
I doubted that he would.
I am a novice at being eighty-five and, like Howard, struggle with being old. Sometimes I accept the idea that retirement should be a time of rest and peace, a time of contented reflection. Yet I also know there are unruly feelings from my very early life that continue to create turbulence and threaten to surface if I slow down. Earlier I cited lines from Dickens: “For, as I draw closer and closer to the end, I travel in a circle nearer and nearer to the beginning.” Those words haunt me. More and more, I sense some forces tugging me back to my beginnings. The other night, Marilyn and I attended the FoolsFURY Factory Festival in San Francisco—an event sponsored every two years by my son Ben’s company—in which twenty small theaters from around the country presented their work. Before the show we stopped for a quick bite at Wise Sons, a small Jewish deli that seems to have stepped right out of the 1940s Washington, DC, of my childhood. The walls of the deli are almost entirely covered with family pictures—groups of soulful, wide-eyed, frightened refugees arriving at Ellis Island from Eastern Europe. The photographs transfixed me: they resembled those of my own extended family. I saw a sad young boy, who could have been me, delivering his Bar Mitzvah speech. I saw a woman who I first thought was my mother. I felt a sudden—and novel—rush of tenderness for her and felt mortified and guilty for having criticized her in these pages. Like my mother, the woman in the photo seemed uneducated, frightened, hardworking, and just trying to survive and raise her family in a strange new culture. My life has been so rich, so privileged, so safe—largely because of the hard work and generosity of my mother. I sat there in this deli weeping as I looked into her eyes and the eyes of all those refugees. I’ve had a lifetime of exploring, analyzing, and reconstructing my past, but I’m realizing now there is a vale of tears and pain in me I may never be done with.
Since I took early retirement from Stanford in 1994 my daily schedule has remained the same: I write for three to four hours every morning, usually six or seven days weekly, and five times a week I see patients later in the day. I’ve lived for over fifty years in Palo Alto, and my office is a separate building fifty meters from my home. About thirty-five years ago I bought a flat on Russian Hill in San Francisco with a beautiful view of the city and bay, and I see patients there on Thursday and Friday afternoons. Marilyn joins me Friday evenings and we generally spend weekends in San Francisco, a city that I find endlessly interesting.
THE AUTHOR IN HIS PALO ALTO OFFICE, 2010.
I chide myself about my faux retirement. “How many eighty-five-year-old psychiatrists are working as hard as I do?” Am I, like my patient Howard, continuing to work in order to stave off senility and death? Such questions jolt me, but I have my arsenal of answers. “I still have a lot to offer. . . . My aging makes me more able to understand and comfort people my age. . . . I am a writer and intoxicated by the writing process, so why give it up?”
Yes, I confess: I have terrible qualms about arriving at this last paragraph. I’ve always had a stack of books waiting in the back of my mind to be written, but no longer. Once I finish this work, I feel certain there are no more books waiting for me. My friends and colleagues groan when they hear me say this. They’ve heard it many times before. But I fear this time is different.
I always ask my patients to explore regrets and urge them to aspire to a regret-free life. Looking back now, I have few regrets. I’ve had an extraordinary woman as my life partner. I have loving children and grandchildren. I’ve lived in a privileged part of the world with ideal weather, lovely parks, little poverty or crime, and Stanford, one of the world’s great universities. And I receive letters every day reminding me that I’ve been helpful to someone in a distant land. Hence, the words of Nietzsche’s Zarathustra speak to me:
“Was that life? Well then once again!”
ACKNOWLEDGMENTS
I am grateful to many who have assisted me in this venture. The members of Pegasus, my monthly group of Stanford doctors who write, critiqued several chapters. And special thanks to the founder of this group, Hans Steiner, and to my friend Randy Weingarten, a psychiatrist and poet, who proposed the chapter title “A Novice at Growing Old.” My thanks to my patients who have permitted me to describe incidents from therapy. In order to protect their confidentiality I have changed all names and deeply disguised all identifying details while attempting, at the same time, to convey certain truths of each encounter. My patients continually educate and inspire me. I was extremely fortunate to have Sam Douglas and Dan Gerstle as editors. Thanks to David Spiegel and, as always, to my literary agent Sandra Dijkstra and her associate, Andrea Cavallaro, who offered enthusiastic support from start to finish. Lifelong friends Julius Kaplan and Bea Glick helped jar my memory, as did my four children and seven grandchildren. And, most of all, to my beloved wife, Marilyn, who helped me recall events of long ago and served as my in-house editor-in-chief.
Irvin D. Yalom, Becoming Myself: A Psychiatrist's Memoir
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