~ 6 ~

Show Some Class for Your Kids

Because I could not stop for Death,

He kindly stopped for me.

These opening lines of an Emily Dickinson poem came to mind when a phone call informed me that Astrid had died from a ruptured aneurism. Astrid, dead? Impossible. An unstoppable life force, Astrid had shaken off one crisis and tragedy after another and kept on walking. Such boundless, crackling energy. And now forever quiescent? No, I couldn’t steady that thought in my mind.

Astrid was a therapist for whom I had served as both a supervisor and a therapist for more than ten years, and we had grown close. When an email from her family announced a ‘life celebration’ for Astrid to be held two weeks later at a local community center, I immediately accepted. On the designated day I dressed in a suit and tie—very rare for me as a committed Californian—and showed up promptly at noon. Along with two hundred other guests, I was greeted with champagne and hors d’oeuvres. No flowers. Nothing black. No tears or long faces. No suits and not a necktie in sight, aside from mine. Soon a small child, probably one of Astrid’s grandchildren, walked through the crowd with a megaphone in hand and announced, “Please take your seats. Ceremony to begin.”

We then viewed a polished, forty-minute video celebrating Astrid’s life. It took us seamlessly through images of her life. First, as an infant in her father’s arms, she yanked off his spectacles and waved them gleefully. Then, in rapid succession, we saw Astrid’s first steps toward her mother’s outstretched arms, Astrid playing pin the tail on the donkey, Astrid as an adolescent surfing at sunset beach in Hawaii, Astrid at her graduation from Vassar, Astrid as a bride at her most recent marriage celebration (she had married three times), several shots of Astrid pregnant and radiantly smiling, Astrid playing Frisbee with her children, and then the heartbreaking finale that brought tears to my eyes: Astrid gaily waltzing with her six-year-old grandson the evening before her sudden death. When the film ended, we sat silently in darkness. I was sorry when the lights came on because no one knew what to do. One brave, self-confident soul clapped, and soon most of the audience joined in. I found myself longing for a traditional religious ritual, a very rare state of mind for me. I missed the cozy familiar cadence and orderly sequence of events led by clergy and rabbis. What is one supposed to do at a funeral manqué that commences with champagne and hors d’oeuvres and has no place for weeping?

After some hurried discussion among themselves, her three children and five of her grandchildren strode in a cluster to the microphone, and each in turn, showing remarkable poise, shared remembrances of Astrid. Each was well prepared and well spoken, but I was most fascinated by an eight-year-old granddaughter who described how Grandma Astrid used to invite them to play by creeping silently up behind them and shaking a box of jigsaw puzzle or Scrabble pieces.

Since this was a life celebration and not a funeral, I was not surprised that there was no mention of her fourth child, Julian, who had been killed by a lightning bolt on a golf course when he was sixteen. But Astrid and I had devoted more than a full year of therapy to dealing with his death.

Next, many of Astrid’s friends spontaneously rose to take the microphone and share their memories. After two hours, quiet reigned for a few moments, and I expected someone to signal the end of the event. Instead, to my surprise, Astrid’s third and last husband, Wally, rose to address the celebrant-mourners. I was astonished at his composure; I tried to imagine speaking at such an occasion only weeks after my wife’s death and knew I would not be up to it. I would not be able to raise my head to the world. I examined Wally closely. For years I had heard Astrid’s version of him and was now faced with the odd task of superimposing the flesh-and-blood Wally on the image of him Astrid had given me. Every single time I have encountered a patient’s spouse, I have been surprised. Almost without fail I exclaim to myself, Can this possibly be the same person I’ve heard about for so many hours?

To my surprise, Wally was a stately man and much taller, more handsome, and more graceful than I had expected. And far more present. Astrid had often portrayed him as absent, as a man who, even into his seventies, was wedded to his hedge fund and to his office that he always entered at six am to prepare for the opening bell of the stock market. Absent on weekends also, either sailing or fixing his twenty-seven-foot sloop. Astrid told me she had never set foot on it. I remembered our chuckling together when she told me she got seasick whenever she saw a boat, and I responded that I get seasick even looking at a picture of a boat.

“Thank you all for coming to say goodbye to our Astrid,” Wally began. “I know there are a lot of her shrink colleagues here, and as you all know, she never tired of teaching. So I’m sure she’d have appreciated my passing on to you a bit of her legacy, her top secret weapon against anxiety: egg salad sandwiches!”

I cringed. Oh no. Don’t do this, Wally. Dear Astrid dead only ten days and you inflict a Jay Leno imitation on us.

“When Astrid was a child,” Wally continued unabashed, “and upset about anything—school, argument with friends, boyfriend trouble, you name it—her mother always soothed her with an egg salad sandwich. Just chopped eggs, mayo, celery, and a bit of pimento on toasted white bread. No lettuce. Astrid called it her Valium and claimed it had four and a half times the potency of chicken soup. Whenever I came home late in the evening and walked from the garage through the kitchen, I always took a look at the sink, and if I spotted eggshells there, I braced myself for the worst.”

I looked around. Smiling faces! Everyone except me was engaged by Wally’s attempts at humor. For a moment I felt very alone, as though I were the only one who seemed to be taking this seriously. Then I reminded myself that I was not the outsider—I was the insider, the one who really knew Astrid.

Throughout the event, I had vacillated in my feelings. At first, as the speakers described their special contact and their stories about Astrid, I had felt smug about my privileged place in her life. After all, wasn’t I the one who had the inside truth, the one who knew the real Astrid, the authentic Astrid? But as time passed and I listened to speaker after speaker, I wavered. Perhaps my belief in a privileged place in her life was illusory. Yes, she and I had shared that special hour each week for so many years. And I had access to the real stuff—special knowledge of her fears and passions and inner conversations and fantasies and dreams. But was that more real, more true, more privileged than knowing what made her smile? Which folks she liked most? What she liked to eat, her favorite movies, books, shops, yoga poses, music, clouds, magazines, games, snacks, and TV series? The in-jokes with husband and friends, the sexual secrets known only to lovers? I especially wondered if I knew her better than that grandchild who had heard her footsteps as she crept up behind the sofa shaking pieces of a Scrabble game or jigsaw puzzle? Yes, I think it was that grandchild who put me in my place, who made it clear that, though I knew some parts, there was so much of Astrid I never knew.

I had first met Astrid over ten years earlier, when she asked me to supervise her work with several patients. She was fifty, and though she had been in practice for many years, she always sought to sharpen her skills. She was a delightful student: savvy, empathic, intelligent. For the next two years we met for an hour every other week. The supervision was a pleasure. Rarely had I known a student with such wonderful clinical instincts. But toward the end of our second year, things changed between us when she began to discuss her work with one of her patients, a young man named Roy who was a disorganized alcoholic with whom she became uncharacteristically over-involved. She gave him her home phone and took calls from him at all hours of the day or night; obsessed about him frequently during the day, even while seeing other patients; and allowed him to run up a large bill of several thousand dollars that he would obviously never pay. Once Astrid started discussing Roy, she moved from being student to patient. When it is evident that the student has strong and irrational feelings toward a patient (“countertransference” in the professional jargon), the supervision often must change form.

There was no mystery about the source of her powerful feelings toward Roy: Astrid had a brother, Martin, six years older than she. He had been her savior during and after their mother’s death from breast cancer, when Astrid was an adolescent. Martin had protected Astrid from their abusive father, and she remembered the car ride home from their mother’s funeral when he put his arm around her, leaned over, and whispered in her ear, “For the rest of your life, Astrid, count on me. I’ll be there for you.” Martin kept his word until he enlisted in the Marines and served in the 1991 Persian Gulf War, from which he returned with Gulf War Syndrome and multi-drug addiction. Though she did her best to be there for him, she was no match for heroin and could not protect him from a fatal overdose in 2005. Astrid never forgave herself for not saving Martin. Her over-involvement with young Roy was only the latest embodiment of her reliving her attempt to save her brother.

Two years after Martin’s death, the lightning bolt that struck her sixteen-year-old son once more shattered the illusion that she could protect either others or herself. Grief after the death of a child is the harshest grief of all. It is, in the words of Yeats, “tragedy wrought to its uttermost,” and often there is no outlet beyond tears. Astrid’s tears flowed without cease during our twice-weekly sessions throughout the next year. Gradually she rebounded, once in a while even displaying her infectious joie de vivre, and we moved back to a once-weekly schedule, then to a format where we moved back and forth between supervision and therapy. Finally Astrid regained so much of her tranquility that I raised the question of termination, but we never really ended: she took solace in my presence and called every few weeks for a supervisory session.

Then, a year ago, Astrid left a phone message on a weekend evening telling me that she had fallen from her bicycle earlier in the day, suffering only minor injury, but that now her bruises were growing in size at an alarming rate and she was feeling a bit confused. She couldn’t reach her internist and asked me whether she should go to the emergency room. I called back and told her that these problems definitely warranted a trip to the ER.

Not hearing back from her during the next few days, I left a couple of phone messages inquiring about the ER visit and received a call from her son, who told me his mother was unable to take calls: she was critically ill in the intensive care unit with a diagnosis of autoimmune liver disease. I knew nothing about this disease. It had not been described when I attended medical school fifty years ago, but a quick search of the medical literature informed me that this was a serious, often lethal ailment for which a liver transplant offered the best chance of survival. Two weeks later I received a call from her son informing me that his mother’s condition had deteriorated precipitously; she had severe jaundice and was in acute liver failure. A few days later he called back with great news: the hospital had miraculously located a liver, she had had the transplant, and she was now in serious but stable condition.

Three weeks later I had a brief phone discussion with Astrid, who told me she was getting stronger and was shortly to be released. I visited her at home for a couple of sessions, and soon Astrid was strong enough to travel to my office. “To hell and back,” she told me. “The most awful, frightening, anguished time in my life—and as you know, I’ve had quite a few. For days in the hospital I couldn’t stop trembling, couldn’t stop weeping. I was certain I was going to die. I couldn’t talk to you . . . couldn’t talk to anyone. And then, suddenly, I turned a corner.”

“How did you do it? Was there a specific turning point?”

“Very specific. A conversation with a nurse—a tough-assed, no-nonsense head nurse who had a good heart. It was just before my children were coming to visit. I had been in extremis for days. I was absolutely terrified of dying; I could not stop shivering and sobbing. And then, just before my family entered my room, she leaned over and whispered in my ear, ‘Show some class for your kids.’ That changed everything.”

“Tell me how.”

“I’m not sure how. But it was damned powerful. Somehow it just got me outside of myself. Up to then I just couldn’t stop being terrified. I was so close to death so many times. I couldn’t talk. Couldn’t cope, couldn’t even pick up the phone to have a session with you. All I did was cry. That statement, ‘Show some class for your kids,’ jolted me back to thinking of someone other than myself and let me see that I could still do something for my family, that I could set an example for them. That nurse was something. Tough love.”

Astrid was discharged from the hospital, gradually resumed her previous life, and soon began seeing her patients again. But her reprieve from death was short. One day a few months later, she slumped forward in her hairdresser’s chair and died instantly of a ruptured aneurism in her brain. All this passed through my mind as I walked out of the community center with the other celebrants. All that drama, that hard life, that valiant effort: working through her grief for her mother, liberating herself from her father, surviving her brother’s death and, most of all, her son’s death. She had worked through so many knotty situations with her own patients and in her own therapy work with me. She had survived her liver disease by virtue of a liver transplant from a young man killed in a motorcycle accident. And, then, all of this remarkable drama extinguished in an instant by a single small artery exploding in her brain. Everything gone in one moment: her extraordinary universe of self; that lush, layered trove of sense data; her teeming memories of a lifetime; all that pain, that courage, that struggle and transcendence; that army of transplant surgeons and nurses; all that terror, that wailing, those gutsy recoveries. And for what? For what?

I had left the celebration and was approaching my car about a half block away when a light tap on my shoulder yanked me out of my morose reverie. I turned to see an unfamiliar face: a dour, fiftyish woman with stringy yellow hair, dressed in a plain, frumpy black suit. She hesitated, obviously apprehensive about speaking. “Excuse me, but are you Irvin Yalom?”

I nodded, and she continued, “I thought I recognized you from the photo on the cover of your book.”

Wishing to linger in my reverie with Astrid, I felt reluctant to enter into conversation. So I simply smiled and nodded.

“Astrid gave me a copy of your book. I’m Justine Casey. I was one of Astrid’s nurses on the surgery ward, and . . . um, I . . . I wonder if you’re still taking patients?”

Still taking patients? For many years, at least ten or fifteen, maybe more, no one has ever simply asked me if I were taking patients. It’s invariably “Are you still taking patients?” One of the endless, unnecessary, and, by now, slightly irritating reminders of my getting on in years. I told her I’d be glad to see her, gave her my card, and asked her to call me for a consultation. As I watched her stride away, I wondered if this was the nurse Astrid had spoken of. Was it she who had whispered in Astrid’s ear, “Show some class for your kids”?

When Justine entered my office a few days later, I was struck by how ungenerous nature had been to her. Her proportions were off. Her tight pinched face was too small for her large head, and her roundness was incongruous with her ramrod, head-nurse carriage. She brought to my mind the icy, forbidding Miss Markum, the head nurse on my inpatient ward when I was a resident at Johns Hopkins over a half century ago. I smiled to myself at the words ‘my inpatient ward’; in every sense, it was so obviously Miss Markum’s ward. Ah, the eternal doctor-nurse struggles! Quickly brushing the past from my mind, I sat silently with Justine for a few moments as she swiveled her head slowly, observing objects in my office. Her glance paused at my bookshelf along one wall.

“I see some familiar titles here, Dr. Yalom . . . ”

“How would you feel if we went by first names? Irv and Justine?” I almost always say this to patients but rarely so quickly. Perhaps I needed to sweep Miss Markum from my mind.

“Well, all right, but it feels a bit strange—you an eminent professor of psychiatry and I a head nurse.”

“Thank you for not saying ‘venerable’ professor.”

She smiled, very briefly. “I’ll try but may forget. I’m old school about titles.” She glanced again at my bookcase. “I’ve read several of your books. They were important for me.”

“Were those books behind your decision to contact me?”

“Yes, in part. The other part is that our patient, Astrid, spoke so much of how helpful you had been with her. She spoke of you a good bit.”

Our patient, I liked that. It might help us bond. “I knew our patient for quite a long time. A good woman. A good therapist, too. But tell me, was there something in these books that particularly spoke to you?”

“Maybe in the book that Astrid gave me, Staring at the Sun: Overcoming the Terror of Death. My copy is heavily underlined. I’ve read it more than once. I’m a surgical nurse and spend all of my time with critically ill oncology and transplant patients. I deal with death every single day at work. Also I liked your novel The Schopenhauer Cure. That main character who is dealing with malignant melanoma—I can’t get him out of my mind.”

“I have a hunch, more than a hunch, that you’re already addressing this, but let me ask more directly: Tell me, why have you contacted me? What are you dealing with now?”

Justine exhaled loudly, let her arms hang loosely, and leaned back in her seat. “What am I not dealing with? There’s a lot going on.” She paused. Her anxiety was palpable.

“Try to dive in, Justine. You’re safe here.”

She seemed startled. Perhaps she still wasn’t used to my addressing her as Justine. She looked directly at me. I imagined that few people had ever told her she was safe.

“OK,” she inhaled deeply, “here goes. I’ll start with the heaviest thing. About a month ago I had a mole removed from my foot, and the path report said it was a malignant melanoma. So you can imagine my interest in your Schopenhauer Cure character. Julius, right? I’ve read the section describing his death repeatedly and cried every time.”

“I’m so sorry to hear about the melanoma, Justine. Tell me just what your doc said.”

“It was not good, but it could have been worse. The lesion was slightly ulcerated and fairly deep, about four millimeters, but the first lymphatic drainage site, the sentinel node, was clear. You know what I’m talking about? The inguinal nodes? When I talk to psychiatrists I’m never clear about how much of their medicine they remember.”

“I admit I’ve got yawning abysses in my knowledge of much current medicine. But I’ve worked extensively with oncology patients, so I’m following you so far.”

“Good. Well, the lack of node involvement is, of course, encouraging, but the depth of the lesion is not good news. I’m not as bad off as Julius, but I’ve a good chance of recurrence. The pathologist says perhaps nearly fifty percent. So I’ve been trying to live with that now.”

We sat in silence for a few moments. My heart went out to her. A fifty percent chance of recurrence! And if it did recur, she and I both knew there was no effective treatment available. I tried to imagine being in her shoes and felt myself starting to sweat. “That’s so hard, Justine. But often it helps to have someone to share it with.”

“Wait, there’s more.”

“Right. I’ve tagged your earlier statement: ‘What am I not dealing with?’ What else is happening in your life?”

“My work fills most of my life space, and work is painful. Take Astrid, for example. I took care of her for weeks, got to know her well, really well, and now she’s dead. We worked so hard. She was so sick, so close to death; her bilirubin and prothrombin time were through the roof; her jaundice was as bad as I’ve ever seen in a patient; and miraculously a liver transplant became available, and we saved her and brought her back to health. And now, a few months later, suddenly—just like that—she’s dead. And she’s only one of many, many patients. It’s the tale of most of my patients, my cystic fibrosis lung transplants, my advanced ovarian or cervical or pancreatic cancer patients. I get close to them, work my butt off to save them, and for what? Generally they die soon. I’m just their escort through the valley of death. My great dilemma is that if I keep my distance, I’m a bad nurse not doing my job. Yet if I do my job, I get scorched.”

“Sounds familiar, Justine. So very familiar. Let me share something with you. The other day, when you first tapped me on the shoulder at Astrid’s memorial, I wasn’t too responsive because I was lost in a reverie with those same thoughts, those exact thoughts, running through my mind. So much work, my work, Astrid’s work, your work, and then, in an instant, she’s gone. It’s hard to get my mind around it.”

“I was hesitant about tapping your shoulder last week. I had a feeling I was interrupting something.”

“I’m glad you took the chance. But let’s keep going. Is there more going on in the rest of your life we should talk about?”

Justine slowly nodded. “The rest of my life . . . that’s the problem. There is not enough of the rest. My life is too small. My husband and I split up over twenty years ago.” She took a deep breath. “Now the hardest part. I have one child . . . had one child . . . a heroin addict. He’s in San Quentin doing ten years for deadly assault, dealing, and burglary.”

“When you said ‘had one child,’ I first thought you were saying he was dead.”

“That’s precisely what I meant. He is dead to me. I pray I never see him again. I’ve written him off. Completely. I have no children. I’m all alone.”

“A lot of pain there.”

“There would be pain if I let myself think about it, but as I say, I’ve written him off. The pain’s been unbearable all these years. He violated me in every way, and in the end he stole everything he could from me, and then some.”

“Have you sought any help for any of these things, your feelings about your work, your melanoma, your husband, your son?”

Justine shook her head. “Never. I’m a tough bitch. That’s my reputation, and I guess I get off on it. I can take care of myself. Even now with you, let it be noted that I’m not asking for much. Two, maybe three, sessions—just enough to regain my bearings. Besides, I’m still in such credit card debt from my son’s stealing I don’t think I can afford much more. And if the melanoma wakes up and decides to march, who knows how long I can keep working.” She stopped and looked directly at me. “Are you all right with that, really short-term? I want you to level with me. Astrid told me you were not a bullshitter.”

“I’m okay with short-term. Let’s plan on three sessions, today and two more. If you find you need more in the future, we can renegotiate. And I’ll be honest, there’s something about short-term that feels comfortable. Your term ‘scorched’ hits home for me: I was scorched by Astrid’s death. Yes, short-term sounds fine to me. I think of it as scorch-free.”

“Wow. She’s right—you’re no bullshitter. I’m not used to that. The shrinks on the ward are always weaseling.”

“I will assiduously avoid weaseling. Now let me ask you a question you may not have expected. How are things going for you so far in this session? We’re just starting out, I know, but you’ve laid out a lot of your personal life already, and I have a hunch that’s uncommon for you.”

“Very uncommon. But you’re making it minimally painful. I do open myself up to two good friends, Connie and Jackie, friends from college days. We live in different parts of the country, but we stay in contact by Skype or phone at least once a week. Connie’s folks have a great vacation home on Lake Michigan, and we have a reunion every summer.”

“And they’re close confidants?”

Justine nodded, “Yep, they know almost everything. Even about my son. They’re my only confidants.”

“Aside from me?”

“Right. But I haven’t told them about the melanoma. That I’ve only shared with you.”

“Because?”

“I think you know. Cancer is just too heavy. Unless they’re close family, people run the other way.”

“Would they run? Connie and Jackie?”

“Hmm, not sure. Probably not.”

“Then you don’t tell them because? . . .”

“Hey, give a girl a break.”

“I’m pushing too hard? Sorry.”

“No, no. Don’t stop. It’s probably good for me. I’m the tough bitch who always does the pushing. It’s educational for me to be on the other side. What’s more, you’re pushing in the right spot. You’ve got a pretty good nose because my reunion with Connie and Jackie is coming up next month, and the last couple of weeks I’ve been mulling about telling them. In fact, tell you the truth: my going back and forth about telling them or not is probably the major reason for contacting you.”

“Let’s dig into it a bit. What do you most fear about telling them?”

“Pity, I guess—pity and withdrawal. My contact with them is the place I feel most real, and I don’t want to jeopardize it. I worry about losing them. When I was a kid in New York, my grandmother scraped up the money to send me to camp every summer in the Adirondacks. Most of us went for two months but some for only one month. I remember that toward the end of the first month I withdrew from the ones who were leaving early and spent my time with the ones staying. Not much future in relating to the dying.”

“You’ve taken a chance and told me about the melanoma. Any questions you have for me?”

Justine looked directly at me, incredulously. “Whoa, that’s a new twist. I didn’t think that shrinks answer questions.” She thought for a few moments and then said, “Yeah, I do have one, if you’re up to it. Do you pity me?”

“I’m honestly not trying to duck your question, but that word, ‘pity,’ throws me. You have to be more clear about what you mean by ‘pity.’”

“Why do I think you are ducking my question? Here, let me put it differently. Exactly what did you feel about me when I told you of the melanoma?”

“Sorrow, compassion, concern—those were my first feelings about you. Then I imagined myself being informed that I had a melanoma, and I felt fear—I could almost feel myself begin to sweat. My problem with your word ‘pity’ was that it has the connotation of someone ‘other’ or even ‘lesser’ than me. I pity a starving dog or an injured kitten. But, Justine, you’re not ‘other.’ You’re not different from me. You’re facing what all of us must sooner or later confront. I have no specific malady, but my hoary age forces me to think about the end of my life all the time. My hunch is that your good friends are going to respond in a similar fashion. Already I personally cannot imagine deserting you, and I cannot imagine them deserting you.”

In our second meeting Justine thanked me for my advice. She did tell her two friends about her melanoma, and they responded generously and lovingly. She seemed warmer, thanked me with a fleeting smile, and then turned to the topic of her son. For the rest of the session she related the nightmarish tale of her only child.

“Perhaps I should never have married. I never expected to. I was born clunky and awkward. I was never attractive, had no innate feminine guile and no female mentors. My mother died of cervical cancer when I was nine. I had no siblings and a mostly absent father, a gruff uneducated man, a truck driver who was only home weekends. My paternal grandma, an immigrant from Yugoslavia, raised me. She was an unhappy woman who barely spoke English. Men didn’t look at me, and though I had some one-night stands, I never had a good relationship with a man. I probably never would have married if I hadn’t gotten pregnant and, with the help of my grandmother, forced the father to marry me. That was about five years after nursing school. Marriage was a mistake: he was a brutish, alcoholic lout who was so abusive to James and me that one day when he was at work I packed my suitcases and left with James, then age three, and moved several hundred miles away to Chicago, where I had been offered a job at Michael Reese Hospital. I never looked back. I never contacted my husband again. I doubt if he searched very hard for us. He probably was relieved we were gone.”

“Keep going. Tell me about you and James.”

“I did my best for him. I was a nurse forty hours a week and a mother the rest of my time. I had no other life. Zero. And James was a problem every step of the way: problems sleeping, walking, speaking, playing with other children. And major disciplinary problems all the way through his life. I’ve read a lot now, and I think he was born a sociopath, something deep, inbuilt, genetic, unchangeable about him. Also major learning problems. He just couldn’t concentrate, never learned to read well, always in special schools. I suspect today he’d also be diagnosed as severe attention deficit disorder.

Justine went on for much of the hour telling me in detail about James’s medical and psychological problems and all the treatments attempted. “We tried lots of meds, including Ritalin, anticonvulsants, and even antipsychotics. Nothing helped. I spent all my money on medical and psychological help. All in vain.

“When he entered adolescence, he hit the recreational drugs big-time and used anything he could find. I sent him to detox centers, rehab ranches, and wilderness retreats. He ran away from each of them. He fought everything. Then, around sixteen or seventeen, he met the hard drugs, especially heroin, and he was gone for good. He stole everything he could from me, including thousands of dollars from my credit cards. He robbed my neighbors and friends, and I finally threw him out and disowned him. The next and last I heard was that he was in San Quentin. That’s the story. And I am exhausted telling it.” Justine leaned back in her chair and wiped her eyes with a tissue.

After a few moments, she looked up and added, “I’ve been imagining this whole week telling you this story. I rehearsed this conversation with you, and I imagined your response.”

“Which was? . . .”

“I imagined you inquiring about positive memories as a young child, about putting him to bed at night, about warm feelings I had about him or the good times we shared. And my answer to you is that I cannot remember a single one. I mean it. Not a single one.”

“You’re right. You nailed it: that is what I would have asked. And your answer is very heavy, very dark. I’m saddened by what you’ve told me. Saddened for James but even more saddened for you. Tell me, have you shared all of this with Connie and Jackie?”

“Everything. They’ve been aboard from the very beginning, when James was born, and followed every step of the way. But it’s a different experience here today telling the entire story all at once. I’ve never done that with anyone. I’m wiped out.”

“I feel uneasy asking you more, but it’s best to get it all out—like excavating an abscess. Tell me, what are you experiencing right now, here with me?”

“Shame. It’s like your coming into my home and seeing nothing but filth and rags.” She paused briefly and then asked, “Do you have children?”

“Four. I know what it is to be a parent, and I’m able to get in touch with how unbearably painful this is for you. But still, don’t stop. I want you to keep expressing it all.”

“I must have been a ghastly mother, but believe me I tried—I did everything in my power. But it is shame. It . . . James . . . that creature in San Quentin . . . however you put it, he is a part of me. He’s wrapped in a banner for all to see, saying, ‘Made by Justine Casey.’”

“Do you think that others think that?”

Justine sobbed and nodded, “Yes, anybody who knows my story.”

“I know your story, and I don’t think that. Try to keep talking. What other questions are there for me?”

“Am I ghastly? Am I a horror of a mother? Am I James? Is he me?”

“None of the above. I want you to know I’m on your side, Justine. I’m here to help you. Not once, not for an instant, did such thoughts enter my mind. What I am thinking about a lot now is how relentlessly harsh you are on yourself. We’ve got to stop today, but I’d like to focus some of our final session on the topic of being kinder to yourself.”

A week later Justine arrived at my office with a folded sheet of paper in her hand. “I had a dream last night, and I know from reading your work that you pay attention to dreams. This one woke me up about four am. I think it had something to do with you.”

“Let’s go over it.”

She unfolded the paper. “This is just a fragment—I couldn’t remember most of it . . . I’m walking along a path and climb through a window into a large, dark room. Somehow that path reminds me of the path to your office, but it’s night and I can’t see much. Then once I enter the room, I hide behind a very small chair and wait. I’m holding a weapon in my hand. Suddenly I notice that the chair is gone. Someone has removed it, and I am totally visible, totally unprotected. I am scared shitless. That’s when I woke up drenched with sweat.”

“You have hunches about this dream?”

“I’ve no clue about how to even start. How do we proceed?”

“Since we have only this last session, we don’t have time to explore it in depth, but generally I’d ask you to think about certain parts of the dream and just free-associate. That is, just ruminate out loud; let your thoughts run free. But given our shortage of time, let me pitch in first. What strikes me about the dream is the location. You say it resembles the path to my office. Moreover, it was dreamt the night before our appointment. Any thoughts about that?”

“It was your path. I could hear the crackly pebbles just like your walkway. But the window and the very large room: they’re not familiar. A big room, maybe a movie set? I don’t know where that comes from.”

“And then you try to hide but behind a very small chair, which doesn’t seem to give you much protection. And then that soon disappears. So you’re in my office, and suddenly your hiding place is gone. What’s that make you think of?”

“I see where you’re going. I’m here in this office, maybe it was your office, and my cover is yanked away, and I can’t hide, and I get very scared.”

“You say your cover was yanked, but you yanked it by your decision to come.”

“It was tougher than I thought. I couldn’t or didn’t hide from you and was bare-breasted.”

“Bare-breasted?”

“I didn’t mean that . . . ” Justine blushed. “What I meant was I got everything off my chest.”

Strange slip and probably loaded with meaning, but there was no time to explore it in this last session. I tagged it and put it into storage, in case Justine opted to return for longer therapy, and responded, “Another aspect of the dream is that it is night, you are entering surreptitiously by going through a window, and you hide inside. I wonder if that refers to the unusual way you contacted me. Meeting at Astrid’s memorial and making an appointment there is somehow not the same as coming into my office through my front door. And then you make sure it will be for a very few sessions.”

“Yes, that’s right on: I see your point.”

“But I keep thinking about that pistol you’re carrying. What hunches do you have about that?”

“I never said anything about a pistol. I said I had a weapon.”

“Tell me: Do you still see the dream in your mind’s eye?”

Justine closed her eyes and seemed to drift off, “Right, it’s there. I can see it, but it’s a little faded, but I can see that I’m carrying a weapon, and it’s definitely not a pistol. I’m carrying something large, huge. It’s a bazooka—no, no, it’s an atomic bomb.” She opened her eyes and shook her head.

“Lot of feeling there. Stay with it; keep going. What about that huge weapon?”

“The dream says I am dangerous.”

“Say more about being dangerous.”

“Truth is, I am dangerous. Venomous. I’m full of anger. Bad, angry thoughts about everyone circle through my mind. That’s why I stay away from people. That’s why I’m so alone.”

We remained silent for a minute or two. The time had come. I hesitated while I formulated what I wanted and needed to say to her. “There’s something I’ve wanted to tell you. I’ve hesitated until now because of my discomfort about patient confidentiality. It’s something Astrid told me during our therapy, and usually I’d never repeat anything told to me by a patient. But this may be so important for you to hear that I can’t be silent. Moreover I’m certain Astrid would not have minded my sharing this.”

Justine’s eyes were riveted on me.

“Astrid told me about a time when she was at her worst, full of terror, certain she was dying, unable to control her sobbing. She was awaiting the arrival of her family when a nurse bent over and whispered in her ear, ‘Show some class for your kids.’”

I stopped and glanced at Justine. Her face, her whole body was deathly still, as though frozen in time.

“She gave me no name but only said it was a nurse who was tough but whom she highly respected. Was it you, Justine? Did you say that to her?”

“Yes, I said that to her.”

“Astrid told me that those words, your words, were ‘transformative.’ She called it the turning point in her ordeal. She said those were the most helpful words she had ever heard.”

“Why? How?”

“She said it immediately, miraculously, brought her out of herself, that it made her think of others, that it gave her a sense of meaning, that it told her that, even if she were dying, she still had something to offer her family—she could model how to face death. You gave her a priceless gift.”

Justine sat silently for a long time until she said, “Good God. This is the cruelest joke.” She looked away staring out of my office window, and she spoke as though in a trance. “The cruelest of jokes. You see, I didn’t whisper that into Astrid’s ears. I hissed it. Yes, hissed it. Astrid had everything—a room full of beautiful vases and flowers, a golf-ball-sized diamond ring . . . beautiful grandchildren, big family and friends gathered around her. I’d have given anything to have had her life—even with her disease. She held court in her powder blue cashmere robe for an endless stream of beautiful visitors and friends. Her husband told me about his goddamn yacht a hundred times, and her therapist and chum was the important Dr. Yalom with his signed books spread all around her bedside, and yet, despite all that, all she could do was whimper and sob, day after day. She was pitiful. I was spiteful, viciously envious, and totally exasperated by her.”

“And yet, despite all that, you were the one who brought such great comfort to her. ‘Transformative,’ she said. You changed her life. What do you do with that knowledge?”

Justine sat silently, slowly shaking her bowed head.

I glanced at the clock. “We’re running out of time, and I’m struggling to find closure. Despite all your self-accusations, the better part of you found the right words to say. In the end it is deeds not thoughts that really count. Let’s do a thought experiment, Justine.”

She raised her head to stare at me.

“Imagine,” I continued, “right here in my office, a row of people you’ve helped, maybe even transformed. The line starts here”—I pointed to a spot near my chair—“and imagine all the people who are grateful to you, people dead or alive. Can you see folks you remember? Please try hard.”

Justine silently nodded.

“I can imagine,” I suggested, “a very long line winding out of the office and down the street. Right?”

“Yes,” Justine said softly, “I can see them. A few of them back from Michael Reese Hospital days. I see both the living and the dead, the recovering and the moribund. I see Astrid standing there near the head of the line, and yes, it does stretch far—all the way into the distance—as far as I can see.” A long pause and then, “Thank you, this helps. But there’s a lot left. The anger isn’t quelled. The vicious thoughts are there on all sides, lying in wait.”

“Those thoughts are old, archaic, going back to your early rough, hapless days. And you’ve come by your anger honestly. Of course, much of your anger and guilt is still tethered to your son, who is disowned but, as we both know, not forgotten. All these feelings have to be exhumed, examined, and, finally, scattered. It will take time and a guide, but you can do it. I’m certain of it, and if you wish, I’m glad to be the guide.”

Justine sat there, tears flowing down her cheeks, no longer forbidding, no longer resembling Miss Markum from olden days but softer now, almost winsome, almost huggable. She raised her chin, “You mean that? What about your comment about being scorched?”

“Not doing what’s right is worse than being scorched. And what’s more, you’re worth it. Call me whenever you’re ready.”

Justine rose and collected her things, and I walked with her to the door. As she left, she turned back to me for a last look. I saw pain and sadness in her eyes and perhaps pride as well. I hoped she would call.