“I didn’t know if I wanted to start seeing you again – I still don’t know – but I thought it would be best for me to at least meet with you a few times before I decide to throw in the towel and give up medicine.”
Across from me sits Don, a young, African-American internist. Those of you who read my book, might remember him as the first patient who asked me about all my medical emergencies during the time my husband was ill and dying. I answered honestly, which I came to see as both a help and a detriment to his treatment. In some ways it made it more difficult for him to talk about himself without feeling excessively guilty, but it also allowed us to focus more directly on the burden of guilt he carried with him.
“That would be a huge decision for you, Don” I say. “You worked so hard to put yourself through medical school. And I’m sure you still have lots of loans.”
“Funny. I thought were going to say my mother sacrificed so much for me to become a doctor.”
I smile at him.
“I know,” he says smiling back, “You’d never say that. That’s my voice. My mother did do everything she could when my father left us, but I know she did it because she needed me to succeed for her as well as for me.”
“Why are you considering leaving medicine?” I ask.
“Too much pressure. Dealing with constant staff changes and the never ending dramas and bickering. And the paper work. I don’t think the government and insurance companies could possibly come up with a more complicated record keeping system if they tried! And there are so many patients I can’t help. They’re just way too sick by the time they come to me. Or they’re non-compliant – not taking their meds, or smoking, or not losing weight.”
“How do you feel when they’re non-compliant?”
“Angry. Sometimes angry at them for throwing away their lives; sometimes angry at me for not being able to reach them.”
“That sounds familiar, Don, that harsh, judgmental voice that gets turned on either yourself or others.”
“True.”
I suddenly find myself thinking of 2008, the time Don left treatment with me - from my perspective - both prematurely and precipitously. It was the year after my husband’s death, a terribly sad, painful time for me. I decide to follow my association. “Do you ever feel sad for these patients, Don?”
“Sad? I don’t know. More angry that they won’t take care of themselves.”
“This might seem like an unrelated question, Don, but I wonder in retrospect if you have any thoughts about why you left treatment with me when you did?”
“I don’t know,” he says shrugging. “I guess because I felt we’d hit a dead end, going over the same stuff – my critical voice, my unrelenting guilt. It didn’t seem we were getting anywhere.”
“How did you feel about me then? How did you feel about my loss, my sadness?”
Don looks downward. He shakes his head. “I tried not to think about it. I didn’t know how you were coping, working, listening to me go on and on about trivia.”
“So, in the second part of what you just said, you’re again feeling guilty and beating up on yourself, as in how could you be talking about yourself when I was dealing with such a major loss. But initially, it sounded as though something else was going on for you, as in maybe you felt sad and that sadness made you uncomfortable.”
“I don’t like feeling sad. Sadness feels hopeless, like there’s nothing that can be done.”
“Well, sometimes that’s true. Sometimes there is nothing that can be done other than feeling the sadness.”
“I hate that. It makes me feel powerless. There’s nothing worse than feeling powerless.”
“But sometimes we are powerless, Don. You were powerless as a child to keep your father from leaving. We also all die, age. Even a doctor can’t cure everyone. I wonder if that’s a problem for you as a doctor: you have to face your own limitations, your own powerlessness. As awful as it is to feel guilty, guilt often feels preferable to powerlessness. So you’d rather be angry at yourself or your staff or the insurance companies than to feel your sadness about only being able to do so much. It brings back all the powerless feelings you had as a child too, which makes those feelings all the more difficult.”
“So you think I should come back into treatment?”
“Yes, I do. It’s time to deal with the pain of that which you can’t control.”
Mr. Marty Stein sits across from me. With his slight, stooped frame, bald head, and sad, drooping eyes he looks all of his 89 years. Shifting in the chair and sighing audibly he begins.
“Rose said I had to come. She said she can’t stand it anymore that I don’t talk. I’m happy with her. I don’t know what more she wants. We’ve been going out for over five years. I’m too old for this. Who ever heard of an 89 year old man seeing a … you’re a psychologist, right?”
“No one is too old for therapy,” I say nodding, “But it doesn’t sound as though you want to be here.”
“Right,” he says. “I’m not going to change now. I was married for over fifty years and my wife complained of the same thing. I didn’t change then and I’m not going to change now.”
“You sound almost proud of your reluctance to change,” I offer tentatively.
“No, just resigned. What’s the expression, ‘You can’t teach an old dog new tricks.’ But I told Rose I’d come, so here I am.”
“Can you tell me about yourself, about your background, your childhood?”
Another sigh. “My mother died when I was three. My father couldn’t take care of me – or didn’t want to – so I spent my childhood in an orphanage, two orphanages actually. The first one was in Brooklyn. It was boys and girls. Then when I was 10 they sent me to upstate New York, Syracuse, where it was just boys. It was run by rabbis, very strict. But it was okay. We got fed. And then when I got to be 18 I had to leave, so I joined the army. That was OK too. It was good actually. I grew up and learned to be responsible and even got to see some of the world. And they taught me to be a mechanic so I got to make a decent living when I got out. All in all it was a pretty good life. I have no complaints. The bad parts, I just put them away. No point in dwelling on the negative.”
As Mr. Stein relates his story, deadpan with no affect, I feel an increasing heaviness in my body and an enveloping cloud of sadness overtaking me. “You certainly had a very sad, deprived childhood,” I say gingerly.
“It wasn’t so bad. As I said, they fed me, they didn’t abuse me and in Syracuse we had lots of empty space to run around. Besides, I did all right. Took care of my wife and three kids. No complaints. I just put the bad stuff away.”
“Did you see your father over the years?” I ask, aware that I am reluctant to probe too deeply into this man’s psyche. Over his long life, he’s built up a stalwart defense that has worked for him, protecting himself from the pain of his early life.
“He’d come and visit sometimes. But he could never be counted on. He wasn’t reliable. I don’t even know how many wives he had. And he stole money from me. While I was in the army I sent him money to hold for me and he gambled it away.”
“That must have made you very angry.”
“I guess. At the time. But I just started working again and built up my little nest egg. As I said, no point dwelling on the negative.”
“And your mother? Do you remember her?”
“Nah. I was only two or three when she died. I didn’t know anything more than the orphanage. When that’s all you know, it’s okay. As I said, my life turned out pretty good.”
What next, I ask myself. If this man was 30 or even 20 years younger, I’d be far more eager to explore his defenses, to try and get to the pain that must reside underneath. Is my reluctance to attempt to plumb his depths ageism? Perhaps. But he has the same reluctance. Except he’s here.
“Mr. Stein, you say that Rose insisted that you come. What would happen if you didn’t? Why did you agree? Is there anything you’d like to get out of coming here?”
“She’s a good person. I don’t think she’d stop seeing me, but maybe she would. I don’t think so, though. But I’d like to make her happy. Maybe you could help me work on things to talk to her about.”
“How about what you were telling me about today? Your background. Your experiences.”
“You think she’d be interested in that old stuff?”
“Yes, I suspect she would. So maybe that’s one thing we could do. You could tell me things about yourself, as kind of practice for telling Rose.”
“I guess.”
We are both still reluctant participants, perhaps fearful of exposing too much pain on the one hand, or dealing with the deadness of meaningless conversation on the other.
