~ 4 ~

Thank You, Molly

A few months ago I attended an outdoor funeral service for Molly, my long-term bookkeeper and Jane-of-all-trades who had worked for me for decades and had been both a godsend and a major thorn in my side. I’d first employed her in 1980 to collect my mail and pay my bills while I was on a year’s sabbatical, living and writing in Asia and Europe. When I returned, Molly soon grew dissatisfied with her bit role and little by little began to insinuate herself into all my domestic matters. Soon she was managing all our financial and household affairs, paying bills, taking care of correspondence, and filing papers, manuscripts, and contracts. She discharged my gardener and installed her own gardening team and, later, her own team of painters, and cleaners, and handymen—though, if the job were small, she insisted on doing it herself.

There was no stopping her. One day I came home to find several trucks in our driveway and Molly at the base of a huge oak, calling to a man a hundred feet above, telling him which branches to saw off. I was surprised that she was not up in the tree herself. She insisted that she had discussed this project with me, but I was certain she had not. That was the final straw, and I fired her on the spot and fired her again on at least three other occasions, but she would have none of it. Whenever I objected to her fees, she reminded me, quite correctly, of the many tortured evenings my wife and I had spent paying bills and balancing our checkbooks until she had come along, and then suggested I work two more hours each month to pay her salary. She insisted she was indispensable, and my firings and objections were never issued wholeheartedly because I knew she was right. I was greatly grieved at her death from pancreatic cancer, and I knew I was never to find her replacement.

Molly’s funeral was held on a glorious sunny afternoon in her son’s large backyard. I was surprised to see several Stanford colleagues there. I’d had no idea they’d been her clients too, but I recalled she honored a rigorous confidentiality code, steadfastly refusing to reveal the identities of any of her customers. At the end of the memorial service, I immediately rose to leave in order to pick up some friends at the airport, but just as I opened the gate to the street, I heard my name called and turned to see a stately older man wearing a stunning broad-brimmed panama hat approaching me, escorted by an exceedingly lovely woman. Seeing that I did not immediately recognize him, he introduced himself, “I’m Alvin Cross, and this is my wife, Monica. I saw you for therapy half a lifetime ago.”

I hate these awkward situations. Facial recognition has never been my strong suit, and as I’ve aged, it has progressively deteriorated. At the same time I felt it would be hurtful for this former patient to learn I didn’t remember him, so I stalled for time, waiting and hoping for memories of him to coast into my mind. “Alvin, good to see you. And good to meet you, Monica.”

“Irv Yalom,” she said, “it’s such a pleasure to meet you. I’ve heard so much about you from Al. I think I owe our meeting and our marriage and our two wonderful children to you.”

“That is quite wonderful to hear. Sorry to be so slow on recall, Alvin, but in a few minutes I’ll remember everything about our time together—that’s how it works at my age.”

“I was then, still am, a radiologist at Stanford and came to see you shortly after my brother died,” said Alvin, trying to stimulate my memory.

“Ah, yes, yes,” I lied, “it’s coming back to me. I’d really love a long talk and update on your post-therapy life, but I’m rushing to pick up friends at the airport. Could we meet for coffee and have a chat later this week?”

“Love to.”

“You still at Stanford?”

“Yes.” He took his card from his wallet and handed it to me.

“Thanks, I’ll phone you tomorrow,” I said, as I rushed off, mortified at my memory lapse.

Later that evening I went to my storage room to find my notes on Alvin. As I rifled through my files of patient records, I thought of all the deep, often uplifting, sometimes tragic, stories found in these records. Each one brought to mind the compelling two-person drama I had engaged in, and it was hard to tear myself away from reliving these old forgotten encounters. I found Alvin Cross’s file in my 1982 section, and though I saw him for only twelve hours, it was a thick file. In those precomputer days I had the luxury of a personal secretary, and I dictated long detailed notes of each session. I opened Alvin’s file and started to read. Within a few minutes, presto: everything rematerialized in my mind.

Alvin Cross, a radiologist at Stanford Hospital, phoned and requested a consultation for some personal problems. Many Stanford doctors whom I see for therapy make a point of coming very punctually or even a couple of minutes late, entering my office at the Stanford Hospital furtively because they are queasy about being seen visiting a psychiatrist. But not Dr. Cross, who sat leisurely reading a magazine in the clinic waiting room. When I approached and introduced myself, he shook my hand with a firm grip, strode into my office in a calm and confident manner, and sat tall in his chair.

I began as I usually do in first sessions, by sharing whatever information I have. “All I know about you, Dr. Cross, comes from our phone conversation. You’re a physician at Stanford Hospital, you heard my recent presentation at medical grand rounds about my psychotherapy work with patients dying from breast cancer, and you thought I might be able to be of help.”

“Yes, that’s right. You gave a refreshing and unusual talk. I’ve attended grand rounds for years, and this is the first one I’ve heard about human feelings and with no slides, data, or pathology reports.”

My first impression of Alvin Cross was of a dignified, attractive man in his thirties, with angular features, slight graying at his temples, and a self-assured way of speaking. He and I were dressed the same, each wearing white hospital coats with our names sewed in dark blue cursive letters on our left upper pocket.

“So tell me, what did I say at grand rounds that made you think I could be of help?”

“It seemed you had tender feelings for your patients,” he began. “And I was jolted by your description of an oncologist dispassionately giving your patient the results of her radiological scans. Of her terror at learning that her cancer had metastasized and her clinging tightly to her husband—her terror at being given a death sentence.”

“Yes, I remember. But tell me the relevance of that for you and me today.”

“Well, I’m the guy who writes those death sentences. I’ve been writing those kind of reports for a long time, for five years, yet your talk brought the job home to me in a different way.”

“Made it more personal?”

“Exactly. In our radiology viewing rooms, we don’t encounter the whole patient. We look for areas of calcifications or increased sizes of nodes. We look for oddities that we can show students—organs displaced by masses, decalcified bone in myeloma, distended bowel, an extra spleen. It’s always about parts, body parts. It’s never about whole people in whole bodies. But now I think about how patients feel and how their faces will look when doctors read them my x-ray reports, and I get a bit shaken up.”

“Is this a recent change? Since my talk?”

“Oh, yes, very recent and, in part, due to your talk. Otherwise I couldn’t have functioned in my work all these years. I know you wouldn’t want your x-rays read by someone who is freaking out about how you’re going to feel about his report.”

“For sure. Our fields are so different, aren’t they? I strive to be close; you strive to stay distant.” He nodded, and I continued, “But you said, your changes were ‘in part’ due to my talk. Any hunch about what else was responsible?”

“More than a hunch. It was my brother’s death a couple months ago. A few weeks before he died, he asked me to look at his films. Lung cancer. Heavy smoker.”

“Tell me about you and your brother.” As a psychiatric resident, I’d been taught to conduct a highly systematic interview starting with the presenting complaint and then following a protocol—a history of the present illness followed by an exploration of the patient’s family, education, social life, sexual development, and vocational history—and then moving on to the intricacies of the psychiatric examination. But I had no intention of following any schema; it had been decades since I proceeded so systematically. Like all seasoned therapists, I work far more intuitively in my pursuit of information. I’ve come to trust my intuition so much I suspect I’m no longer a good teacher for neophytes, who require methodical guidelines in their early years.

“When my brother, Jason, called to ask me to consult on his films,” Dr. Cross said, “it was the first time I had heard his voice in over fifteen years. We had had a falling out.” He sighed and looked up at me, his lips quivering. I was surprised to see that. It was my first glimpse of vulnerability.

“Tell me about it,” I spoke more gently now.

“Jason is two years younger—was two years younger—and I guess I was a tough act to follow. I was the good kid, always at the top of the class. Without fail, every time poor Jason entered a new school, he’d be greeted by a chorus of teachers talking about me and saying they hoped he would be the student that I was. Ultimately he chose not to compete, to opt out. In high school he rarely cracked a book and got heavily into drugs. Maybe he couldn’t compete. I don’t think he was all that bright.

“At the end of his senior year, he became involved with a girl who ended up defining his future. She was a fellow druggie, good-looking in a cheap way but intellectually limited: her life aspiration was to be a manicurist. They soon got engaged, and one evening he brought her home for dinner. That was a disaster of biblical proportion. I can still see the scene: the two of them, unwashed and unkempt, smooching the whole time, just flaunting it in everyone’s face. My parents and grandparents were shocked and disgusted. Frankly, I was too.

“Everyone in the family detested his girlfriend, but no one said anything because they knew Jason would do the exact opposite. So my parents gave me the job of warning him about her. They also made me promise I wouldn’t mention their having asked me to intervene. I had a big-brother talk with Jason and laid it all out. I told him that marriage was a momentous decision, that the time would come when he’d want more—a lot more—in a wife, that she’d drag him down. The next morning we woke up to find he had gone, along with all the money and silver in the house. He never spoke to any of us again.”

“The family put you on the spot. Talk about a damned-if-you-do and damned-if-you-don’t situation. Are there other siblings?”

“No, just the two of us. In retrospect, I think that maybe I could’ve been a better big brother and I should have tried harder to contact Jason years ago.”

“Let’s tag that and come back to it. First, tell me what happened to your brother after he split.”

“He simply vanished. From that time on, all we ever had were a few stray scraps of information that drifted in from his acquaintances. He was doing construction work, then stone masonry. I heard he got reasonably good at it and ended up building fireplaces and stone walls. Continued heavy drug use. And then out of the blue, a couple of months ago, came the phone call. ‘Alvin, this is Jason. I’ve got lung cancer. Would you look at my x-rays? My doctor said it would be OK for you to see them.’

“Of course, I agreed and got his doctor’s name and promised to contact him that very day. I found out Jason was living in North Carolina, and I asked if I could visit him. After a pause, a pause long enough that I thought he’d hung up, he agreed.”

I looked at Dr. Cross’s face. He looked so taut and so sad that I wondered if this was too much, too soon. We’d hardly said hello before we had plunged into deep and very dark water. I gave him a breathing spell by reflecting on what had happened up to that point between us.

“My plan, as I told you on the phone, is that we meet today in consultation and see if starting therapy might be a good idea. Have you been in therapy before?”

He shook his head. “No, I’m a therapy virgin.”

“Well, tell me, Dr. Cross—”

“If you don’t mind, I’m fine with Alvin.”

“Okay. And I’m Irv. So tell me, Alvin, what’s it been like so far talking to me? Seems we’ve moved quickly into some heavy feelings. Perhaps too quickly?”

He shook his head. “Not at all.”

“Are we on track? Is this what you hoped to discuss?”

“My reaction to Jason’s death is exactly what I wanted to discuss. I’m just surprised—pleasantly surprised—that we’re there already.”

“Any questions for me so far?” I asked, wanting to establish the norm of free interchange.

He seemed puzzled, then shook his head, and said, “No. Most of all what I want to do is to tell you this story. I need to get this out in the open.”

“Please, go on.”

“So after Jason’s call, I hopped on a plane to North Carolina and went to see him. In Raleigh I first stopped at his doctor’s office and reviewed the films. Jason’s tumor was deadly. It had infiltrated his left lung and metastasized to his ribs, spine, and brain. There was no hope.

“I drove an hour on the highway and then three miles down a North Carolina dirt road to a run-down house, little more than a shack really, although it contained an impressive stone fireplace he’d built for himself. I was shocked by his appearance. His cancer had already done much of its work and turned my younger brother into an old man. Jason was emaciated. His body was stooped, and his face was pallid and weary. And he smoked marijuana without stop. When I complained the fumes were getting to me, he switched to tobacco. ‘Not a good idea with lung cancer,’ I almost said, but held my tongue. Having looked at the films, I knew my words would be pointless. So there I sat, watching my cancer-riddled kid brother chain-smoke. I caught his glance a couple of times as he lit up. I’m certain I saw a look of defiance. I’ll never forget that scene.”

“Reminds me a bit of that dilemma you faced years before when you so disapproved of his choice of a mate. Damned if you spoke, damned if you didn’t.”

“I had the same thought. Continuing to smoke was crazy, but it would have been crazy for me to tell him so. And, for sure, telling him what I thought about his fiancée was the wrong choice back then, even though my prediction about the relationship proved accurate. I’m ashamed to say it, but I had a flash of satisfaction when he told me his wife had disappeared a few years earlier with their young daughter and all the money they had hidden in the house. He hadn’t heard from her since. I have a hunch they’d been growing and peddling grass.”

“So what happened next between the two of you?”

“I had one last shot at being a good big brother. I did my best. I asked what he’d been told about his condition. His doc had been straight with him—told him that treatment could do little and that statistics indicated he might expect only a few months of life. With a heavy heart, I confirmed the doctor’s diagnosis and bleak prognosis. I offered some medical advice about his pain management. I told him he wasn’t alone, that I’d be there for him. I wanted to hug him, but the time gap was too wide to bridge. I offered money but was uneasy about it since he’d just use it for drugs. Still, I left him three hundred dollars on the kitchen table before I left. Perhaps he appreciated it, but he never acknowledged it. I didn’t know what else I could do. He wouldn’t consider coming to California, an offer I made only halfheartedly. Nor would he consider chemo or any other treatment that might have slowed the cancer a bit or made him more comfortable. ‘It won’t make any difference, and I don’t give a shit,’ he said. I tried my best to talk about our family and our past life together, but he said he wanted to forget all that. Perhaps, Irv, you might have known what else to say. I just hit a dead end. When I left, we agreed to stay in touch, but he had no phone. He said he’d use a neighbor’s phone to call me.”

“Did he?”

“Never did. And I couldn’t reach him. Heard from a North Carolina hospital a few weeks ago that he died. I went back East to bury him in our family plot.”

“What was that like for you?”

“Lonely. Only an elderly aunt and uncle were there, and a couple of cousins who barely knew him. My parents were killed ten years ago in a head-on car crash. At Jason’s funeral, I kept thinking, over and over, that it was better my folks were dead and didn’t have to see this. What a sad, wasted life.”

“And it was then that your feelings changed about your work?”

“Yes, pretty soon after that. I just felt dread about going to work and viewing the films and writing reports informing patients they’re going to die. Everything at work, especially chest films, reminded me of Jason.”

I turned inward for a moment. It seemed pretty straightforward. A well-functioning man is traumatized by his brother’s death, flooded with death anxiety, and traumatized repeatedly by reminders of death in his everyday work. I was pretty sure I understood what was going on and knew exactly how to help him. As our hour drew to a close, I told him that I thought I could help and suggested we meet weekly. He seemed relieved, as though he had just passed an audition.

The following session I obtained some background information. His father had been a family doctor in a rural Virginia area, and his mother worked by his side as a nurse in their home office. Alvin had taken a straight premed path at the University of Virginia and then went to medical school in New York and radiology residency in California. He was single; he’d had many relationships with women but none of any duration. Moreover, he had not been out with a woman since Jason’s phone call.

I asked him for a detailed history of a recent, typical twenty-­four-hour period, starting at bedtime. The exercise proved particularly illuminating with Alvin because I learned how little intimacy his life contained. Though he was busily involved with students and colleagues during his working day, he had little other human contact. He spent weekends alone, generally kayaking, and almost all of his meals were solitary ­affairs: breakfast and lunch at the hospital cafeteria and take-out food for dinners at home or a fast meal at some restaurant with counter seating, generally a sushi or oyster bar. His colleagues had long ago given up trying to fix him up with women and had come to view him as a committed bachelor. Some faculty wives had tried to turn him into a family uncle by inviting him for holiday or celebratory family dinners. He had no close male friends or confidants, and although he had a steady stream of dates—most (in that pre-Internet time) stemming from newspaper personal ads—the relationships always fizzled out after a date or two. Naturally, I inquired into the quick endings, but he never gave me a clear answer, and even more odd, he appeared curiously uncurious about the matter. I tagged that also for future exploration.

His sleep was generally good, usually seven to eight hours per night. Though he rarely remembered dreams, he recalled a recurrent nightmare that had visited him several times over the last month.

“I’m in the bathroom. I’m looking into the mirror, and suddenly I see a big black bird swooping into the room. I don’t know where it’s come from or how it’s gotten inside. The house lights begin to dim, and then they go off completely. It’s pitch black. I’m frightened and run through other rooms, but I hear and feel the flapping wings following me. That’s when I wake up frightened, heart pounding, and, strangely, with an electric erection.” He grinned at the lilt of his alliteration.

I grinned in return. “Electric erection?”

“It was buzzing, throbbing.”

“What hunches do you have about this dream, Alvin? Just let your thoughts run free for a couple minutes. In other words, try to think out loud.”

“Pretty obvious. The dream is about death . . . black bird . . . Poe’s raven, birds of prey, vultures eating roadkill. . . . I hate vultures and buzzards, and I used to take Jason out with our 22s to pick them off. . . . I remember those shooting expeditions very clearly. We did a lot of those. And then the lights in the house dimming . . . I know what that is: it’s life fading out. I’m scared to death of death.”

“How much do you think about it?”

“Since Jason died, it’s on my mind almost every day. Before that, almost never. I remember an eruption of death thoughts and fears when my parents were killed. I was already at Stanford then. I remember the call from my aunt like it was yesterday. I was watching a Warriors-Lakers basketball game on TV.”

“How awful, losing both your parents so suddenly.”

“It was such a jolt, so sudden, so unexpected. I lived the first two or three weeks stumbling about in a heavy fog. Too much of a shock for tears. And yet, it’s strange, after a while I got over it and reentered my life easier than I’m doing now with Jason’s death.”

“Any ideas why?”

“I think it’s because I have no regrets about me and my folks. We all loved one another. They were proud of me, and I was a good son. They lived a full, worthwhile life, were beloved in the community, had a great marriage, and were spared the ravages of old age. I felt clean about them and me. No regrets . . . ”

“You paused at ‘No regrets.’”

“You don’t miss much. Well, I guess there is one regret. I regret that my parents didn’t live long enough to see me married and to see their grandkids.”

“That’s the first mention I’ve heard about marriage or children. Is that in the cards for you?”

“I always thought so. Not making much progress though.”

I tagged that comment, too, for later discussion and pursued the more pressing issue of his grief. “I’m not surprised that your grief over Jason’s death has been tougher than grief for your parents. It seems paradoxical, but often we grieve the loss of those with whom we had fulfilled relationships more easily than those with whom so much was unsatisfying, those with whom there was so much unfinished business. After his death, your relationship with Jason was flash-frozen in an unfinished state, never to be resolved. But I want to urge you not to be so hard on yourself. Jason had his own devils pursuing him, and your not having been a good older brother isn’t necessarily all about you.”

“You mean that Jason played his role in it?”

“That’s sure part of it. Being a good older brother requires some cooperation from the younger brother. I’m glad, though, you had that last chance with Jason. Sounds like you really stretched out toward him.”

Alvin nodded. “I did all I could. It was tough, reaching out to him with no response. And I felt so alone at his funeral.”

“Was there no one you could grieve with?”

“Just a couple of cousins on my paternal side, but I was never close to them. My mother’s parents had both died young, and I barely remember my aunts and uncles.”

As I dictated my notes after that session, I reviewed the issues I had tagged for later discussion: the death terror manifest in Alvin’s nightmare, his expectation of marriage, his self-­imposed isolation from both women and men, and his lack of curiosity about that. And that odd “electric erection” at the end of the black bird nightmare.

In the next session, Alvin spoke more of his grief over his parents’ death. He recalled the shock when he realized that he had become an orphan. For a while, the thought of moving back to Virginia and taking over his father’s practice soothed him, but he soon gave up that plan.

“Living my father’s life in Virginia would be like burying myself. I opted to remain in California, but my grief ravaged my sleep. It was terrible for weeks. As soon as I turned off the lights, my heart would start to race, and I’d know there would be no sleep that night. This went on night after night.”

“You tried sedatives, of course?”

“I tried everything—even went back to old ones like Seconal, chloral hydrate, Doriden—you name it. Nothing worked.”

“How did you resolve it? How long did it take?”

“Eventually . . . ” He hesitated for a long time, and his speech became very measured, “Eventually I developed the habit of masturbating in bed. That, uh . . . that was the only thing that worked, and ever since then, I’ve masturbated every single night. That became my sleeping pill.”

Alvin flushed and seemed so uncomfortable that I offered him some breathing room by turning back to the process, to what was happening between the two of us. “I can see how uncomfortable it is for you to speak of this.”

“‘Uncomfortable’ is putting it lightly. I’d say cosmic embarrassment. I’ve never spoken of this to anyone.”

“And I want you to know I feel moved by your trust in me. But please, I think it’s important to dissect your embarrassment a bit more. You know, embarrassment is never a solitary event. It always requires at least one other person—in this case, me. I think it emanates from your expectation of how I’d receive your disclosure and how I’d feel about you.”

Alvin nodded.

“Can you elaborate on that nod?”

“It’s not easy. I thought you’d think I was bizarre—an infant sucking his thumb at night, a creep defiling his family. Yes, a creep: that fits best. And you’d be repelled. And you’d say, ‘No wonder you’re not going out with women; you’re jerking off every night.’”

“None of that, Alvin. Didn’t enter my mind. That’s not at all where I was. I wasn’t judging. I was entirely caught up in trying to understand. My mind was buzzing with ideas. I was thinking of how your heart raced when you turned out the lights at night after your parents’ death, and my thoughts went to the connection between sleep and death. I know that many have commented that sleep, losing consciousness, is a little foretaste of death. Did you know that, in Greek mythology, Thanatos and Hypnos—death and sleep—are twin brothers?”

Alvin was listening intently. “No, I didn’t know that. Interesting.”

“And,” I continued, “your comment about being an orphan is so important. I’ve heard many others who have lost their parents say that. And I know I had the very same thought when my mother died, ten years after my father. When parents die, we always feel vulnerable because we’re dealing not only with loss but also with confronting our own death. When we become orphans, there is no one between us and the grave. So I’m not surprised that the death of your whole family has left you feeling exposed and frightened by death and more vulnerable to death anxiety.”

“You’re saying a whole lot here. You think that, after I turned out the light, my heart began racing because I was experiencing death anxiety?”

“Yes, I do. Remember the light dimming in your black bird nightmare? The presence of darkness sets the stage for awareness of one’s own death. And let me say some things that have been on my mind about another part of the puzzle—about your sexual arousal.” I knew I was saying much too much at one time here, but after I got started, I couldn’t stop. “I think of sex as the vital antagonist to death—isn’t the orgasm the primal spark of life? I know of many instances in which sexual feelings arise in order to neutralize fears of death. That protective process, I think, produced the ‘electric erection’ at the end of your nightmare and explains your use of masturbation as a way of soothing yourself to ward off death anxiety so you can fall asleep.”

“These are all new thoughts to me, Irv. A little too much to take in at one time.”

“And I don’t expect you to. It’s important we go over this again and again. In my field this is what we mean by ‘working it through.’”

Over the next sessions, I continued to address, in a candid manner, his concerns about death. I did a detailed death anamnesis, in which he related all of his early memories of death. I asked him, for example, when he first apprehended the idea of death.

He thought for a minute or two. “I was about five or six, I guess, when our collie, Max, was hit by a car. I remember crying and running into my father’s office, in the front room of our house. My father grabbed his black bag, rushed outside, and leaned down to examine Max, who was lying by the curb. My father shook his head and said there was nothing he could do. That was when I got it. I got that death couldn’t be fixed. Not even by my father, who could fix almost anything.

“Another time, a few years later, maybe seventh grade, my teacher, Mrs. Thurston, told us that Ralph, a boy in my class—my age, a kid like me—had died of polio. Still, today, I see Ralph’s face clearly, his large ears, bristle-brush hair always standing at attention, bright brown eyes full of wonder. But here’s the curious thing: I wasn’t that close to Ralph. I never saw him outside of school. He lived far away, and his mother drove him to school. But I walked, with several other classmates. And I played with those kids all the time. Yet it is Ralph’s face I see. I can’t see the others.”

“Interesting,” I said. “I suspect that Ralph’s face remains so clearly etched in your memory because it’s linked to some strong subterranean thoughts about death.”

Alvin nodded. “Hard to argue with that. I’m sure that is so. In Sunday school, the grown-ups talked of heaven, and I remember asking Dad about it. He dismissed the thought. He called it a fairy tale. He was a materialist—like most physicians, I think. His view was that when the brain goes, the mind goes, and along with it all awareness and perception, everything. Death is simply ‘lights out.’ You agree?”

I nodded. “I’m with your dad on that: I can’t imagine a disembodied consciousness.”

We sat in silence for a while. It was a good moment. I felt close to Alvin. “What did your dad’s answer mean to you? Did it diminish your anxiety about death?”

“No, it offered no solace. The idea of everything ending, or at least ending for me, was something I just couldn’t get my mind around.”

Alvin and I worked through these issues for several sessions. We reviewed them from different angles, we considered additional confirmatory memories, we explored some new, relevant dreams, and we solidified our gains. Gradually, however, therapy began to slow down. I always think therapy is working well when patients take risks each session, but Alvin took no further risks, and we broke no new ground. Soon, right on schedule, Alvin began to question what we were doing.

“I’m puzzled about your approach. I’m losing sight of exactly where we’re going. Are we trying to help eliminate my death anxiety? After all, don’t we all dread death? Don’t you?”

“Of course I do. The fear of death is hardwired into all of us. It enables us to survive. Those who were wired without that trait were winnowed out eons ago. So, no, I’m not aiming at removing fear, but for you, Alvin, that fear has morphed into something greater, into a terror that haunts you in your recurring nightmares and intrudes into your daily work. Am I right?”

“Well, not exactly. I’m noticing that I am changing a bit. Maybe I’m better. No more nightmares; I’m OK at work now; I rarely think of Jason anymore. So what next? I wonder if we’re about finished?”

That question arises often in therapy when symptoms diminish and patients regain their previous equilibrium. Is it really time to stop? Is it enough simply to remove the symptoms? Or should we reach for more? Should we not try to alter the patient’s underlying character and lifestyle that have given birth to these symptoms? I tried to be tactful as I gently guided Alvin toward further exploration: “Ultimately, Alvin, the decision as to whether you’re finished and ready to stop rests with you. But I think we shouldn’t fail to take a closer look at what’s helped you to improve. If we can identify the helpful factors, you may be able to call upon them in the future.”

“What’s helped? Tough question. For sure, something about talking to you has helped. But how? I’d be only guessing. Maybe just getting things out, revealing some things for the first time. For sure, knowing you were genuinely interested helped me. I haven’t had that feeling with anyone since my dad died.”

“Yes, I sensed that. And I felt that you took some real risks and made good use of our time together.” So far, so good, I thought, and then attempted to go further. “But now I think we’re ready to do more. I think it’s important to explore why you’ve arranged your life in the way you have. You have good social skills, you seem comfortable in your skin, and you say you benefit from the intimacy with me. So my question is, why have you backed away from the possibility of intimacy with others? What’s the payoff in living in such isolation?”

Alvin obviously did not appreciate my inquiry and shook his head as I spoke. “Look, there’s a continuum from private to public. Some folks are extroverts by nature, and some simply prefer to remain private. I guess I’m just at the ‘private’ end of the continuum. I like being alone.”

There it was. In therapy lingo, resistance had made its entry. I persevered, though I knew he was digging in his heels. “Yet just a few minutes ago you talked about how comforting it was for you to speak intimately to me and to experience my interest in you.”

“That’s true, but I don’t need it all the time.”

The hour came to an end, and as we stopped, Alvin said, “I don’t think we’re getting anywhere.”

As I thought about our session, I marveled at how quickly things had changed. Until this session, Alvin and I had been allies in every way, yet now, suddenly, we seemed to be on opposing sides. No, as I thought more about what had happened, I knew that Alvin’s deep resistance wasn’t a complete surprise; I’d had a foreshadowing of it earlier when my exploration of his relationships with women had always fizzled out so quickly. I remembered his refusal to engage that question, and I recalled puzzling at his lack of curiosity about himself. In fact, a prominent lack of curiosity is generally a road sign telling a therapist that a patient may be unwilling to explore more deeply. I knew this was not going to be easy.

The struggle continued through the next session. The strength of his refusal to look at his social withdrawal convinced me that there were powerful forces in play. I’d seen many isolated, withdrawn individuals before, but rarely anyone with such competent social skills and capacity for intimacy. I was baffled. There was something odd going on.

“Let me share something, Alvin. In one of our first meetings, when you told me about your twenty-four-hour schedule, I felt some sadness for you. There seems so little warmth or human touch in your life. That somehow doesn’t fit with the Alvin I know, not with your forthrightness or your capacity for intimacy. And it doesn’t fit with the type of home life you had growing up. I know there were problems with your brother; still, you describe your parents as caring and nurturing and modeling a loving relationship and partnership. Individuals with your kind of background don’t cut themselves off from others in adulthood.”

“I’ll grant there are changes I should make, and I will get around to them.”

I kept trying to chip away, “Yet time keeps flowing on. I recall your saying that, ten years ago, when your parents died, you felt regret that they’d never seen you married or known their grandchildren. What about those regrets? And what are your regrets for yourself? Are you living the life you’ve hoped to live?”

“As I say, I will get around to making changes. But it’s not front and center for me now. Remember why I came to you. I came because of my anxiety following my brother’s death. My social life has got nothing to do with that.”

I took the last arrow out of my quiver, “I don’t agree. There’s a strong connection between the two. Let me try to explain. I’ve observed again and again that the amount of death terror experienced is closely related to the amount of life unlived. And that’s the reason that I’m trying to focus on the quality of your life now.”

As though I had hit a resonant chord, Alvin sank into deep thought for a minute, but then he responded, “Perhaps at some later time. I’m doing OK at present and feel disinclined to pursue it now.”

Analyze the resistance, analyze the resistance—that’s my mantra when I encounter such an impasse. I persisted: “During our first several hours together I was so impressed with your willingness to examine your responses to your brother’s death, and by your courage in sharing intimate aspects of your life. I had a sense of our working well together. But in these last sessions, we’ve really hit a wall. You’re balking at going further, but I’m absolutely convinced that you know there’s more to do. It’s as though you no longer trust me.”

“No, that last part’s not true.”

“Then help me understand what’s happened. At what point do you feel things changed here?”

“It’s not you, Irv; it’s me. Look, there are just some things I’m not ready to discuss.”

“I know this feels like badgering, but indulge me a bit further. Let me make one last inquiry. I have a hunch that the blockage you’re feeling is related to your relationships with women. Earlier you described your relationships as just fizzling out. I’m wondering if that had to do with the sexual aspect of those relationships.”

“No, that’s not the issue.”

“Then what is the issue?” I knew I was out of line. I was almost battering my patient, but I couldn’t stop. My curiosity was aflame and had taken on a life of its own.

To my surprise, Alvin opened the door a crack. “I meet a lot of terrific women, and the same thing happens every time. We go out, have dinner, sex is great, we like one another, and then sooner or later, after a few dates, the women come to my house. And then it ends.”

“Why? What happens?”

“Once they see my house, I never see them again.”

“Why? What do they see?” I was still clueless and feeling oddly slow on the uptake.

“They get upset. Don’t like what they see. Don’t like the way I take care of my house.”

Alvin and I both looked at the clock. We had run over a few minutes. He wanted out of the office, and I had a patient waiting. I took a risk.

“I’m really glad you’re trusting me with this. I’m going to make an unusual proposal that I think might be tremendously important for your therapy. I’d like to hold our next session at your house. Can you make it a week from today at six pm?”

Alvin took a deep breath and tried to relax. “I’m not sure. I need to think about it. Let me sleep on it and phone you tomorrow.”

“Sure, call me here between seven and ten in the morning.” That was my writing time, which I ordinarily hold inviolate. But this was really important.

At one minute past seven the next morning, Alvin called: “Irv, I can’t handle this. I was up all night stewing. I just can’t deal with your visiting me at home, and I can’t deal with more sleepless nights waiting for next week. I want to stop therapy.”

A lot of things flashed through my mind. I’d been around long enough to know that many patients require repeated courses of therapy. They do some work, make some changes, and then terminate. After therapy stops, they consolidate their gains for months or years, and then, at some future point, they return for additional, often more comprehensive work. Any mature therapist would recognize that pattern and show restraint. But I wasn’t feeling particularly mature.

“Alvin, I feel certain that you’re upset by envisioning my response to your home. Perhaps you feel a lot of shame; perhaps you worry about my feelings toward you?”

“I can’t deny that’s part of it.”

“I have a sense your thought is divided. You’ve alluded to one part, the part overwhelmed by shame. But there is also the part that wants to change. That’s the part that decided to tell me about the nature of your problem, the part that really wants to live in a different way. And that’s the part of you I want to engage. You don’t have to wait a week. Let’s meet today. What’s your schedule this morning? I could come right now.”

“No, it’s too much for me.”

“Alvin, you’re turning down an opportunity to set your life on a different, more satisfying course, and I think you’re rejecting that option because of your fears of my judging you. But you’ve already learned those fears are unfounded. And, second, let me ask you to take a cosmic perspective: you’re allowing a fear of some fleeting feeling passing through my mind to influence the entire course of your one and only life. Does that make sense?”

“Okay, Irv, you’re wearing me down. But I can’t do it now. I’m just leaving for work, and I’m scheduled wall-to-wall today.”

“What time are you done?”

“About seven this evening.”

“How about I come over at seven thirty for a session?”

“Are you sure this is the right thing?”

“Trust me. I’m sure.”

Promptly at seven thirty, I arrived at his attractive small home in Sunnyvale, a few miles from my Palo Alto office. The front door was ajar, and scotch-taped to it was a note that read, “Come right in.” I rang the doorbell and entered. At the far end of the living room, in a large lounge chair, Alvin sat facing a window. I could see only the back of his head. He did not turn toward me.

I wanted to go to Alvin, but I wasn’t sure how to reach him. I could not see more than a few, very small sections of bare floor. The remainder of its surface was covered entirely by tall stacks of old telephone books—where had he gotten them all?—large art books, books of train schedules, stacks of yellowed newspapers, and piles of old science fiction books. I love science fiction and restrained myself from sitting down on a New York Times tumulus to start browsing. The only places I could see the hardwood floor were narrow, perhaps ten-inch-wide trails, one leading to the adjoining kitchen, another to Alvin’s chair, and a third to a large sofa covered with more dusty books and heaps of old x-ray films and medical charts.

The year was 1982, and hoarding had not yet appeared as a familiar topic in psychiatry or on daytime television. I had never before seen or imagined anything like the inside of Alvin’s home. Feeling too overcome to manage a foray into other rooms, I cautiously weaved my way over to the chair nearest Alvin and sat down, facing his back.

“Alvin,” I spoke loudly, the chairs being fifteen feet apart, “thank you for meeting with me here. It is important that you’ve allowed me to see your home, and I feel now, more than ever, that we need to continue to meet. I know how hard this is for you, and I appreciate your allowing me into your life and your home.”

Alvin nodded but remained silent.

I was at a loss for words. I knew that eventually we would attempt to understand the hoarding by working on its meaning and its genesis, but at this moment, it was imperative that we examine our relationship, now roiling with humiliation and anger.

“Alvin, I’m so sorry to put you through this, but there is no other way. We have to face this together. I know this is hard for you, but it’s a big step forward—a huge step—and we need to talk it through. I’m wondering if there’s a place where we can sit closer to talk.”

Alvin shook his head.

“Or perhaps we can stroll around the block?”

“Not now, Irv, this is all I can do today, and I want to stop.”

“Well then, tomorrow. Can you make it at this same time, seven thirty, tomorrow evening, in my office?”

Alvin nodded. “I’ll phone you first thing in the morning.”

I sat for a few more minutes in silence and then left.

The next morning, Alvin phoned. I was not surprised by his words, “Irv, I’m sorry, but I simply can’t make it. Don’t think I don’t appreciate what you’ve done, but I can’t meet again. At least not now.”

“Alvin, I know I’ve pushed you hard—too hard perhaps—but look at what we’ve done. We’re on the brink of something crucial.”

“Nope. Not now. We’re done. Perhaps I’ll call you in the future. For now I can deal with it on my own. I’ll start to organize my home.”

I closed Alvin’s folder. Since that visit to his house I had not seen him or heard from him until the previous day at Molly’s funeral. And what was he doing there anyway? What was his connection with Molly? I recall that for some time after our last visit I thought about Alvin and wondered about what had happened to him, and while walking through the corridors or sitting in the hospital cafeteria, I scanned my surroundings looking for him. I remember, also, following my last session with him, speaking at some length with an old and close friend, also a psychiatrist, to help me deal with my own dismay at having so badly bungled a case. But now, after our meeting at Molly’s memorial yesterday, I had to reconsider. Had I bungled it? Alvin looked great and had two children and a lovely wife, who told me that I was responsible for their marriage. How had that all come about? I must have been more effective than I thought. My curiosity once again was aflame.

***

We met for coffee at a small café near the hospital, taking a corner table for privacy.

“Sorry,” I began, “that I was a bit slow to recognize you. As I mentioned, aging has taken its toll on my facial recognition. But don’t think I haven’t thought about you, Alvin. I’ve often wondered about how you’ve fared, especially since I thought our work together ended prematurely, leaving you with problems still to work on. I’d love a follow-up. You know, I think I didn’t recognize you at first yesterday because I hadn’t expected to see you at Molly’s funeral. How did you know Molly?”

A look of surprise appeared on Alvin’s face. “Don’t you remember? A day or two after our last session you called and gave me her name and suggested I contact her to help me get my house back in order.”

“Oh, my, I had entirely forgotten that. And you did contact her?”

Alvin nodded vigorously. “Oh yes. You mean, she never mentioned me to you?”

“She wouldn’t. She had her honor code: she was tight-lipped as a clam about identifying her clients. But I referred you to her over thirty years ago. You still remember her from back then?”

“No, that’s not quite it. What happened is that I called Molly immediately, and she took over. I mean took over completely. In a few days my house was neater than it had ever been, and she has taken care of my house and my bills, my taxes, and all my affairs ever since. I was her client right up till her death. I’ve often told Monica how grateful I am to you. You turned my life around. You gave me so much. But, most of all, you gave me Molly. All these years, the past thirty years, she’s come to my house once a week without fail and taken care of everything until just a couple of months ago, when she grew too ill. She was the best thing that ever came my way—except, of course, for Monica and my two wonderful children.”

After our conversation, my mind swirled with thoughts about the impossibility of ever learning how psychotherapy works. We therapists strive so fervently for precision in our work and aspire to be fine-tuned empiricists, trying to offer precise fixes for the broken elements in our patients’ attachment history or DNA sequences. Yet the realities of our work do not fit that model, and often we find ourselves improvising as we and our patients stumble together on the journey toward recovery. I used to be unnerved by that, but now, in my golden years, I whistle softly to myself as I marvel at the complexities and unpredictability of human thought and behavior. Now, rather than being rattled by uncertainty, I realize that it is pure hubris to posit specificity. Now, the one thing I’ve come to know with certainty is that if I can create a genuine and caring environment, my patients will find the help they need, often in marvelous ways I could never have predicted or even imagined. Thank you, Molly.