Guilt

“I feel so awful, I can’t believe that I had to disappoint my parents. I can’t believe I couldn’t handle college, that I had to come home. My parents have always been there for me, always wanted the best for and all I do is screw up.”

This is my first session with Tiffany, a slender, attractive young woman with blue eyes and long blonde hair. Her mother, sounding concerned, had called to make the appointment, saying that Tiffany was having difficulty at Duke and needed to come home.

“I hate myself!” Tiffany continues.

“Wow! That’s pretty strong. Can you say why you hate yourself?”

“All I’ve done is give my parents problems my whole life, even before I was born. My mother had to be in bed for two months before she had me! She’s a physician – so’s my father – she can’t just take two months off. But she had to because of me.”

“That hardly sounds like your fault, Tiffany. I assume it was some medical condition your mother had.”

“She never had that problem with my brother. My brother never gives them problems. He’s graduating from Yale and going on to medical school. Of course!”

Clearly hearing her sense of competition and failure in relationship to her brother, I decide, for the moment, to focus more on her current situation. “Can you tell me what was going on for you at college?”     

“All those science courses! I can’t handle them. I’m just not smart enough. I started crying at every little thing. And I think I pretty much stopped eating. And then I couldn’t even get myself out of bed to go to class. Especially Chemistry class.  I don’t understand it. It makes me feel stupider than I already feel.”

“Are there classes that you enjoy, that you do well in?”

“Oh yes,” she says, brightening. “I love anthropology and I’m…hmm…I’m a pretty good writer.”

“So you take science courses because…?”

“What do you mean? I have to take science courses to get into medical school.”

“And do you want to go to medical school?”

“I’ve always known I’d go to medical school.”

“That’s not the same thing as wanting to go.”

“Yes, I want to go to medical school. I put my parents through a lot when I was a kid. I got rheumatic fever and ended up in the hospital for quite a while. I could tell how scared they were.”

“You must have been pretty scared too.”

“I was, particularly when I was alone. But the doctors and nurses were great. And I kind of enjoyed watching all the machines and monitors. That’s the kind of doctor I want to be, a pediatrician, to help kids like me.”

“And do your parents want you to be a doctor?”

“Definitely. It’s like a given.”

“So what if it wasn’t a given? What if you could decide to do anything you wanted to do?”

“I’d go on archeological digs and write about them or even write made-up stuff about the digs, like mysteries. But that’s not at all practical. No way to make a living.”  

“Have you ever wondered, Tiffany, why you feel so guilty in relation to your parents?”

“I told you why, I’ve always given them problems.  Besides rheumatic fever I was a sickly kid. And I broke my arm doing gymnastics. They always had to worry about me.”

“It seems that a lot of the things you feel guilty about you had absolutely no control over, like your mother needing bed rest or your having rheumatic fever or breaking your arm.”

“I was fooling around on the bar, that’s how I broke my arm.”

“You sound determined to have things be your fault. Do you think, Tiffany, if you felt things weren’t your fault, you’d end up feeling powerless and scared?”

“I don’t know. I’m not sure I know what you mean.”

Too soon for that interpretation I tell myself. I decide to pursue a different path. “Do you ever feel angry at all the pressure you’re under?”

“Angry? I don’t think so. I feel mad at myself for not being able to keep up and, like I said, worrying my parents.”

“So, now that you’re home, do you think you’re going to be able to relax and take it easy for the rest of the semester?”

“Oh no. My parents are going to get me a chemistry tutor so I can go back to school more prepared.”

At this point I find myself feeling angry at Tiffany’s parents and wonder if I’m feeling Tiffany’s unacknowledged  anger. That could explain the tremendous guilt she feels – guilt for the anger she doesn’t even know she has. But those interpretations are also premature.  

“Our time is almost up for today. But I hope I’ll be able to get to know you more and I hope you’ll tell me more about your wishes and your dreams, even if they aren’t always practical.”

“I wish you could make me smarter.”

“I don’t know if I can do that, but perhaps I can help you to be more accepting of yourself.”

Anger: Expressed and Repressed (Part II)

“You know, I’ve been thinking,” Jacquelyn begins. “I’ve been thinking I should take a break from therapy for a while.”

Internally, I scream, ‘What!? I thought you said you were going to think about your anger?’ To Jacquelyn I say, “And why is that?”

“I don’t know. I’ve been doing this for over a year, seems like it’s time for a vacation.”

“Does your desire for a vacation seem connected to last week’s session when you realized you were angry at your mother for not protecting you as a child?” I ask.

“I didn’t say that.”

“Not exactly, but you did want the woman in the TV show who reminded you of your mother to be killed by the serial killer.”

“I didn’t say that either.”

Disappointed that Jacquelyn has moved so far away from her more open, insightful stance of last week, I ask, “What’s your sense of what’s going on between us right now?”

“Nothing special.”

Feeling increasingly exasperated, I ask, “Can you say what you think is going on between us even if it’s not anything special.”

“You’re mad at me. You’re mad at me because I want to stop therapy.”

“I am annoyed with you, Jacquelyn, because I felt so hopeful last week, hopeful that we’d made a breakthrough, that you experienced your anger at your mother and that although you were scared of the repercussions, you went away wanting to think about it.”

“It was too scary.”

“I do understand that, Jacquelyn,” I say, thinking that perhaps she’s put one toe back in the water.

“But why were you angry at me if you understood?”

Hmm, I think to myself, I wonder if Jacquelyn wanted me to feel angry so that I could feel what she feels – angry but thwarted in its expression. I decide to keep that thought to myself. “I can understand and still be angry. Anger is a feeling. We can’t control what we feel, although we can control what we say or what we do.”

“So you don’t feel scared when you feel angry?”

“No, I don’t feel scared when I feel angry. Except some times.”

“Like when?”

Although repeatedly answering a patient’s questions is unusual for me, I feel that in Jacquelyn’s case it is a helpful form of modeling, perhaps making her own anger less frightening. “Well, I guess like in that TV show you talked about last week, I’d probably be scared if I got angry at the serial killer because I’d be afraid if my anger showed he might immediately kill me.”

“That’s it!” Jacquelyn says staring at me, her eyes wide open. A second later she’s sobbing, pulling at her hair.

“It’s ok, Jacquelyn,” I say quietly. “There’s no serial killer here and your father is long dead.”

She continues crying, but seems calmer. Through her tears she haltingly says, “I never even knew I was afraid he’d kill me. Like he could read my mind. Like he’d know I hated him. I was always so scared, so scared, so scared,” she says cradling her body in her arms and rocking in the chair.

“I’m so sorry, Jacquelyn. I’m so sorry that you had to go through all that. You were only a powerless, dependent little girl. You were so scared.”

I can see Jacquelyn bristle. She stops crying and lifts her head. I went too far.

“I’m sorry, Jacquelyn,” I say, “I know it’s very hard for you to be aware of how powerless you were as a child. It makes you feel all the more frightened.  It’s more than you can bear.  

“Maybe it is time to take a break from therapy.”

I look at Jacquelyn tenderly. “No, it isn’t,” I say. “I know I went too far. You were back there being that little girl and I so terrified you that you had to come back to your adult self, had to go back into a defensive mode. Will you forgive me?”

She is again crying. “I don’t think in my entire life anyone asked me to forgive them. I used to dream about that. I used to dream that one day both my mother and father would take me aside and apologize for all the bad things they’d done to me. But of course that was ridiculous. Except it’s kind of like you made my dream come true, even though you didn’t do anything nearly as bad as they did.” Pause. “Yes, I’ll forgive you,” she says crossing both her hands on her lap and staring directly at me.

You're Back

“I’m really glad you’re back,” Christine says, her eyes filling with tears. “I know you were only gone a week, but it’s been a hard week. I thought I was more prepared, more ready to deal with my parents this time, but I don’t know, I guess it was the holidays. It was awful. I felt sorry for my girls. They were so looking forward to Nana and Poppy coming for Christmas and it was such a disaster. My parents never stopped fighting, my mother never stopped telling me what I was doing wrong, most particularly as a mother and, of course, as someone who couldn’t keep my husband from straying and my father just got more and more depressed.”

“I’m sorry, Christine. It does sound awful and so disappointing.”

“Yes, that’s exactly right, terribly disappointing. I guess I thought since we’d been working so much on my parents these days, I’d be able to handle them differently or be less affected by them or something.”

“So it sounds as though you’re saying that you’re disappointed in me too, in our work together.”

“No. I don’t think so. I was disappointed that you weren’t here to bounce things off of, to maybe give me some ideas of how to handle things differently.”

Although Christine’s denial doesn’t convince me, I let it go for the moment. “For example,” I say. “Can you give me an idea of what you thought you could have handled differently?”

“There are so many things. How I could have gotten them to stop fighting. How I could have stopped my mother from being so critical of me. How I could have stopped her from being critical of my girls.”

“All right, let’s look at those three things which don’t all strike me as the same. Could you have gotten them to stop fighting? If I’m not mistaken you’ve been trying unsuccessfully your whole life to get them to stop fighting.”

Christine looks startled. “Oh, right. One of the things I need to give up on. I forgot. I can’t keep hoping for what will never be. I need to accept my powerlessness. I knew you should have been here. But why did I forget? I feel ashamed of myself. Why couldn’t I hold onto that?”

“Seems like you said a lot there, Christine. First, I think you are angry with me for not being here. Then I think you got uncomfortable with your anger and felt ashamed instead. And, I agree we should look at why it’s easier for you to hold onto your feelings of hopelessness and powerlessness when I’m here.”

“I do feel ashamed of myself. We’ve talked and talked about my needing to give up hope with my parents and I just can’t seem to do it.”

“Well, it’s very painful. It means you can never have the parents you want or wanted either now or in the past. It involves mourning for what never was and never can be.”

“I know. I guess that’s why it’s harder to do when you’re not here. If you’re not here and I don’t have my parents – and I sure don’t have my ex any more – I feel all alone. Except for the girls of course, but that’s different.”

“That’s a great insight, Christine.”

“Thanks. But what about the other two things I mentioned, why did you feel they were different?”

“The second one might not be all that different, getting your mother not to be critical of you, but I guess I wondered what it is that you felt when your mother’s so critical.”

“I do feel angry, but I try to pretend it doesn’t bother me and just ignore her.”

“Because?”

“Confronting her only makes it worse.”

“And when she attacks your girls?”

“I guess I do about the same thing.”

I am annoyed by Christine’s passivity. I feel she is leaving her daughters unprotected, just as I felt unprotected by my mother in relation to my explosive father. I tread lightly. “I wonder what message you give your girls when you don’t stick up for them.”

“But I thought I’m supposed to give up hope of ever changing her,” she says plaintively.

“This could just be me, Christine, but I think there’s a difference between accepting there’s no way you’re ever going to change your mother and still giving your girls the message that it’s not okay with you for her to attack them, or you for that matter.”

“That’s confusing.”

“It’s like saying, you know you’re not going to change her behavior but you’re still going to let her – and your girls – know her behavior isn’t acceptable.”

“It scares me.”

“What scares you?”

“I guess her anger.”

“I get that. And perhaps your anger as well.”

“I don’t like all this talk about my anger.”

“I believe you.”

Until Death Do Us Part

Bob Samuels looks as though he would once have been a handsome man. Now his disheveled white hair, creased brown pants and too small plaid shirt, along with his sad eyes and almost shuffling gait, gives him the appearance of a man who has grown old before his time.

“I read your book,” he begins. “I thought maybe you could help me. You know about loss. But I worry that you don’t know about regret. You don’t mention it much.”

I immediately flash on some of the regrets I have regarding my husband’s treatment of prostate cancer and heart disease: Should we have chosen surgery rather than radiation? Why did no doctor ever tell us about the possible false negatives from chemical stress tests? Yes, I have regrets, but they don’t plague me. I accept that no one is infallible; no one can anticipate or control everything. I say nothing and wait for Mr. Samuels to continue.

“My wife died of ovarian cancer five years ago. She was diagnosed five years before that. In the beginning she put up a valiant fight, although I always wanted her to pursue more alternative treatments in addition to the chemo. I don’t mean anything way out there. Stuff like nutrition. I thought she should become a vegan, try juicing, stuff like that. But she couldn’t deal with it. And then in the end, when the cancer came back again and then again, she called it quits. Said she had enough. She stopped all treatment and just died. I wanted us to go to Europe and try some of the experimental treatments that aren’t available in the States. But she said she couldn’t, said she was done.”

I think about my husband’s words when he too decided to stop treatment: “It’s enough already.” He had fought for years to stay alive. But he reached his limit. Although I was grief stricken, I understood his decision.

“Sounds like you’re angry at your wife for giving up,” I say to Bob.

He startles. “No, no,” he says. “I could never be angry at her. I’m angry at myself for not being able to convince her, for not being able to make a good enough argument. I’m inadequate. I couldn’t make her see.”

“You couldn’t make her see what?” 

“That there was a chance. That there were still things we could do.”

I believe that Bob is angry at his wife for letting go. I also believe that he can’t let himself feel that anger, that he blames himself rather than her. And he can’t tolerate the helplessness we must all deal with in the face of death. But these interpretations are all too premature.

“It sounds as though you miss your wife tremendously,” I say instead.

He sobs. Reaching for the tissues he tries to control of himself. “I’m sorry,” he says, his voice breaking.

“There’s nothing to apologize for,” I reply.

“It’s five years. I shouldn’t be like this anymore. But I keep tormenting myself. What if I’d done X? What if I’d say Y? What if I was enough of a husband for her that she wanted to stay?”  

“You think if she loved you enough she would have fought harder?” I ask, wondering if his wife’s decision to stop treatment felt like a narcissistic injury to him.

He cocks his head and puts a finger to his lips, pondering my question. “I think I always loved my wife more than she loved me. I mean, she did love me, but I adored her. She was the only woman who really ever mattered to me. So do I think if she loved me more she would have continued to fight? Maybe I do. I don’t like to hear myself say that. It sounds so selfish, so much about me.”

“You know Bob, in the end, none of us can defeat death, no matter how much we might love or how much we might want to stay.”

“I know.”

“I wonder if you do. I mean I’m sure you know intellectually that we all die, but I wonder if on a gut level you feel that if only we do enough, if only we try harder, somehow we’ll be able to continue on.”

“I don’t know.”

“Bob, my sense is that we jumped right into this very painful, difficult topic because you’ve obviously been struggling with these feelings for quite some time. But I wonder if we could go back a bit so I can get some sense of you, of your life, of who you are.”

He takes a deep breath. “Where would you like me to start?”

“Wherever you’d like.”    

Never Again

“I appreciate your seeing me again so quickly,” Marv says. 

“Of course,” I reply. Marv and I terminated about three years ago, but he called earlier this week saying he’d fallen into another depression and needed to see me. 

“Have you been following the news?” he asks.

“What specifically are you referring to?” I reply.

“Hungary,” he says, passing his hand over his eyes. “Putting them in a train and taking them to a ‘processing center.’ I can’t understand. How is it possible? How can it be happening again?”

I know exactly what he’s referring to and, truth be told, I felt very much like Marv when I first heard the story. Syrian refugees in Budapest with tickets to Germany boarded a train believing they were going to their destination. Instead they were taken against their will to a rural area in Hungary. It was a story that immediately brought to mind images of the Jews during World War II crammed into trains, taken to “labor camps,” taken to their deaths. What happened to “never again?” Still, these refugees’ story had a happy ending. They weren’t gassed. They were allowed to leave Hungary and were joyously welcomed into Germany. But I don’t have Marv’s history. I didn’t lose most of my relatives to the Nazi atrocity.

“Yes, Marv, it’s horrible. I understand the images it must bring forth for you.”

He begins to cry. “I’m glad you get it. My wife doesn’t. She thinks it shouldn’t affect me.”

“And how do you feel about that?”

“Alone. Depressed.  She says it all turned out fine, so why am I depressed. Yes, these people were saved. Some of the Jews were saved too. But millions were killed. And now thousands of refugees are dying on boats, in trucks, for God sakes. Besides, that’s not the point. It’s that most human beings are brutes. We never learn. We just go around brutalizing each other. What’s the point? What’s the point of anything? I give up.” 

That’s what Marv does. He gives up. He surrenders. He surrenders to the world, to his wife and, in the past, to his tyrannical father. Giving up is not something I sit with easily. I want to shake Marv into action, into assertion. “Do you ever feel like brutalizing anyone, Marv?”

“No, never.”

“Never? Not the Hungarian government or your wife or your father?”

“Never. My father was the brutal one, taking his rage out on me and my brothers. I know he lost his whole family in the war – parents, aunts, uncles, everyone – but that shouldn’t excuse him. It should have made him appreciate us more.”

“Let me ask you this, Marv, did you ever feel like hitting him back?”

“I don’t think so. Eddie, my oldest brother, he’d talk about wanting to kill my father. I figured he was only talking, but it still scared me.” 

“So what did you feel when your father was beating you?”

“Scared.”

“Scared and powerless and like the little vulnerable boy you were.”

“Yeah. Sounds about right.”

“I wonder though, Marv, if you also felt enraged underneath. Felt a rage that you certainly couldn’t express and couldn’t even let yourself know about.”

“I don’t know. It’s all in the past. Doesn’t matter much anyway.”

Now I’m aware of feeling angry, angry at Marv’s immediate surrender. I suspect my anger stems both from my own intolerance of passivity, as well as Marv’s projection of his angry feelings into me. I say: 

“You know, Marv, it’s interesting that as soon as I started talking about your rage, you withdrew, gave yourself over to defeat rather than engaging with me in trying to find your anger, which I bet would help you feel less depressed.”

“How would that help the refugees?”

“Your depression won’t help the refugees either.” Oops, I think. I just acted out my frustration.

He sighs, even more dejected. “You’re right. It won’t.”

“Marv, I wish you could fight with me. I wish you could tell me that my last remark was uncalled for. I’m not your father. You can fight with me. You can put me in my place. And I don’t know what you could do for the refugees. But if you decided it was important enough to you, you could do something. It wouldn’t solve the crisis. It wouldn’t save the world. But it might help. And it might help you to feel more powerful. You don’t have to be either the brutalizing father or the scared, little boy. There’s a huge middle ground in between.”

Marv stares as me. “You got mad at me.”

“Yes, I got mad at you. But my anger won’t destroy you or me or our relationship. And your anger isn’t deadly either. In fact, I’m sure it’s far less destructive than your depression.”

Taking a Break

“I know we only have a few minutes left in our session,” Martha says interrupting her complaints about her work and her marriage, “But I wanted to tell you I’m planning on taking a break from therapy.”

Feeling immediately angry at this sudden pronouncement with almost no time to discuss it, I ask, “What led you to that decision?”

“I’ve been thinking about it for a while. We just don’t seem to be getting anywhere. I come in every week and complain about either Mitchell or my boss, my boss or Mitchell. It doesn’t change anything.”

I happen to concur with Martha’s assessment, but my sense is that my attempts to engage Martha in greater self-reflection, as opposed to her litany of complaints, has been mostly unsuccessful. 

“Martha, could you at least come for one more session to talk about what you think hasn’t worked and why, as well as giving us a chance to say good-bye should you decide to end.”

“I’m not ending. Just taking a break. Besides, I’m on vacation the next two weeks.”

Another surprise. Martha obviously had planned her leave-taking for a while, even neglecting to mention her upcoming vacation.

Aware we have no time left this hour I say, “Well, what if you come in three weeks from today so that we have a chance to talk and in the meantime maybe we can both think about why you chose to tell me about your break at the very end of a session right before you were going on vacation?”

Martha sighs. “I guess. This seemed like a natural break point, but if you want me to come in once more I guess I can do that.”
“Thank you. I’ll see you in three weeks and have a good vacation.”

I am definitely annoyed, feeling dismissed and discarded. I have no idea whether Martha will show for her session in three weeks and whether or not she’ll continue. I feel obliged to keep Martha’s time available even though she’s made no commitment to the continuation of our relationship. 

Martha does show in three weeks. She is, however, uncharacteristically late, leaving me again off-balance and unsure of her intentions.

“Well, I’m here,” she says. “What do you want to talk about?”

“Maybe we should start by talking about your anger at me,” I suggest.

“I’m not angry at you. I just don’t think we’re getting anywhere.”

“You tell me the last few minutes of an hour that you’re leaving, you’re late to this session and you seem annoyed about being here.”

She shrugs.

Here I am again, angry. My anger. Her anger. My anger. Her anger. Maybe that’s what’s going on.

“You know, Martha, I think what you’ve been trying to do – unconsciously of course – is help me to feel your level of anger, dissatisfaction, and powerlessness, whether those feelings are directed towards me, your husband, or your boss. Things aren’t going the way you want them to in any aspect of your life and you feel powerless to change them.”

“That’s exactly right!” Martha says brightening.

“But I wonder if you’re really as powerless as you feel,” I continue. “Or if you don’t know how to ask for what you want or don’t know how to make it happen. For example, I want you to stay in treatment. I do understand that simply complaining about what’s not working in your life isn’t helpful; that we have to figure out ways in which you can get what you need here as well as in other parts of your life.”

“But how am I supposed to know what I need? You’re the doctor, you’re supposed to know.”

“There’s an awful lot in what you just said, Martha. First, there’s a request to be taken care of and anger at not being taken care of. But there’s also a lot of passivity in your statement which only increases your feelings of powerlessness and makes you less likely to get what you want.”

“But I don’t know what I want! I just know I’m not getting it.”

“That’s a great insight, Martha. And it makes a lot of sense. When you were a kid, no one cared what you wanted. They were too busy with what they wanted. You don’t know what you want. But you do know you feel dissatisfied. And when you’re dissatisfied you complain or leave. I’d say we know what we need to work on, assuming you’re willing to stay and work on it.”

“I was sure I was going to take a break. But, yeah, I’m willing to give it another try.”

“Good,” I say smiling. 

Why Can’t I Leave?

“I’m such a mess,” Janette says. “And a coward. I hate myself. He does it again and again and I do nothing. I couldn’t believe it when I asked him last week where our tax returns were and he said he asked our accountant for an extension. My stomach dropped through the floor. He tried playing innocent, like he just didn’t have the time to get all the paperwork together and our tax guy was swamped anyway, etc., etc. But I knew better. I was so mad I started hitting him with my fists. He kept trying to worm out of it, but he knew I knew.

“So then he got all apologetic. Sorry! As if that could fix everything! I’m so mad. He goes to his Gamblers Anonymous meetings, he has a sponsor – supposedly anyway – but he keeps betting on those damn games and losing more and more of our money. It’s our money I remind him, but I’m just talking to myself. I know, he’s an addict, but that’s not an explanation. Besides, it doesn’t matter anymore why he does what he does, the problem is that I stay.”

I remain silent. Janette and I have been here many times and she indeed knows the problem.

She sighs. “I know, I’m reliving my childhood, my father an alcoholic, my mother a gambler. You would have thought I’d know better, but here I am, stuck in it all over again. I do hate myself. I’m furious at Joe, but I despise myself for my inability to get out. I know, I should feel more compassion for myself – that’s what you always say – but how can I feel compassionate when I’m so stupid.”

I feel Janette’s frustration, as well as my own, not so much at her inability to leave her husband, but at her unmerciless attacks on herself. “I doubt it’s that you’re stupid, Janette, but rather that you can’t give up hope. When you started this session you said you couldn’t believe it when you realized Joe had been gambling again. I think you couldn’t believe it because you keep hoping Joe will change, just as you hoped that your mother would change and your father would change.”

“Well,” Janette, asks defiantly, “Isn’t that proof that I’m stupid. If you keep hitting your head on the same brick wall, hoping that it will stop hurting, you must be stupid.”  

Janette’s response intrigues me. “That’s an interesting response, you didn’t say hoping the wall would break, you said hoping it would stop hurting.”

“So, what’s that supposed to mean?”

“I’m not sure, but can you talk about your anger at me?”

“I’m just mad. Mad at me. Mad at Joe. Mad at you. We’ve been going round and round on this for a long time, and I’m still here.”

I wonder whether the “here” means with me or with Joe, but I ask, “How does it feel to feel mad at me?”

“Pointless. Just as it feels with Joe. You’re not going to change.”

“How would you like me to change?”

“Tell me how to get out of this damn marriage.”

The response that goes through my head – hire an attorney, file for divorce and don’t go back – shows me I’m more annoyed than I realize. “And if I can’t tell you how to get out of your damn marriage, what do you feel?”

“Angry.”

“I believe that you’re angry, but I wonder if you also feel scared and powerless?”

“I’m scared that he’s going to go through all our money. But I’m not powerless. All I have to do is be brave enough to leave.”   

“What about when you were a child, Janette, when your father was drinking and your mother had gambled away your school lunch money?”

Her eyes fill with tears. “Why’d you have to bring that up?” She pauses. “Yeah, I was powerless then and I hated it. But if I started “sniveling” – that’s what my father called it – he’d just start screaming at me for being such a baby.”

“So that’s what you’re doing, Janette, you’re screaming at yourself just like your father screamed at you. And you keep hoping, not only that Joe and your parents will change, but that you can endure their repeated disappointments without feeling any pain. It’s an impossible task. But if you can acknowledge your own powerlessness and mourn both the husband and the parents you never had, you’ll be more able to make the break.”

“Doesn’t sound easy.”

“No, it’s not. Definitely not easy.”

Indecision

“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.” 

Counting the Years

Slim, youthful-looking Marjorie is trying to break her habit of reading obituaries. 

“I’ve read them for more years than I can remember. And now that I’ll be turning 65 in a couple of weeks – I hate saying that but unfortunately it’s all too true - I keep focusing on how old people are when they die, trying to figure out how much time I have left. I remember when I turned 50. I knew that more than half my life was over. Maybe that’s when I started counting the years. There are lots of people who die in their 80s or even older, but there are people who die in their 70s too. That could mean I have less than ten years to live! That scares me, really scares me. I tell myself I should just stop reading those damn obituaries, but I’m not sure I can.”

“What are you afraid would happen if you stopped?” I ask.

“Nothing. Nothing would happen.”

Silence.

“I guess it’s like then I wouldn’t know,” she says.

“Wouldn’t know?” I echo.

“Wouldn’t know who died. Or when. Or how old they were. Or what they died of.”

“And that would mean what to you, Marjorie?”

She knits her brow and sighs in exasperation. “I just wouldn’t know,” she says emphatically. “I don’t like not knowing.”

“’I don’t like not knowing.’ That’s an interesting statement. Does not knowing makes you feel powerless, out of control? After all, what we can least know is when and how we’re going to die.”

“Just listening to you say that scared me. It’s like my heart fluttered. I always wanted to know.”

“And if you didn’t?”

“You know the first thing that popped into my head? My mother would die. I know that’s ridiculous, but that’s how I felt as a kid. My mother was sickly, although it wasn’t ever clear what was wrong with her. It was all hush, hush. Don’t upset your mother; don’t bother your mother; be good to your mother. From as early as I can remember I was scared that something would happen to her, that she’d die and it would be my fault. I think she had some kind of neurological disease. By the time I was in high school she was in a wheelchair. She died while I was away at college.”

“So your fears about dying started very early and your not knowing felt dangerous. You didn’t know what was wrong with your mother so you couldn’t protect her.” I suspect Marjorie was also angry with her mother for needing caretaking rather than providing it, but I leave that thought unsaid.  

“So you think that’s when my fears about death started?”

“I think that’s when your fears about being out of control started, including your fears about death.” Here again I say nothing about my thought that Marjorie was also fearful of being out of control of her own anger.

“I was thinking about the office next door to you,” she says. “I think it’s a doctor’s office. They’re lots of patients in walkers and wheelchairs, lots of them with aides. I don’t like it.”

I don’t like it either, I think. Recently I too have been dismayed by having the inevitability of the aging process impinge daily on my working space. I’ve also been surprised by my feelings. Both my husband – 21 years my senior - and my mother deteriorated greatly in the last years of their lives. Although it greatly pained me to watch that deterioration, it didn’t affect me in the same way. It felt as though the aging process was about them, not me. But six years have gone by. Although I don’t count the years I have left, I am increasingly aware that I am no longer young. But unlike Marjorie’s experience, my mother lived until almost 99 with a positive, rosy disposition until the end. I may not like the daily reminder, but it isn’t as frightening as it is for my patient. 

“I suspect it makes you anxious,” I say.

“Yes it does,” she replies. “But that must be true for everyone.”

“Well,” I say, “No one likes the idea of being old and infirm and helpless, but it carries extra meaning for you. It reminds you of the helplessness of both your mother and yourself. After all, you were the child. You were in need of caretaking too. You didn’t have a mother who could take care of you and that left you feeling all the more alone and scared.”

“And you think that’s why I’m afraid of dying?” Marjorie asks skeptically. 

“I think that’s one of the reasons you’re afraid of getting old and of dying. But there’s never just one reason for anything. We have to keep exploring and trying to understand.”