Writer, M.D.

by Leah Kaminsky

  There have been many bloody nights since that one. So that bloodiness has not interrupted my sense of surgery’s beauty. And so that I know that the ugliness of that night was not about gore. Nor was it about misdiagnosis, which I have since learned is quite common in cases of leaking aneurysm, and is sometimes unavoidable.

  What was awful that night was that, in the name of saving Mr. Cooke’s life, in the rush toward an operation that offered the only hope of survival, this man was denied his last minutes of liberty. The short time he had left was taken from him, minutes he would probably have spent holding his wife’s hand as I had seen him do so easily when I had been talking to them earlier that night. Instead, he was rushed off, to meet a terrified end in a strange and brutal place at the hands of people who—though they aimed to be saviors—became his executioners.

  I still see the beauty of surgery all around me when I’m at work. In clear diagnosis. In methodical procedure. In the rudimentary environment of the operating theater. In the rigorous magic performed by surgeons on patients, whose diseases are often cured by going under the knife.

  But even the most righteous surgery can be ugly. Even the most necessary operation, in the best hands, can fail. And in the process of acting in patients’ best surgical interests, we may sometimes make the final moments of their life more terrible than they would ever have been, had we left them alone to say their farewells uninterfered with, more wholly and with more grace.

  Do Not Go Gentle

  IRVIN YALOM

  I didn’t know how to respond. Never before had a patient asked me to be the keeper of love letters. Dave presented his reasons straightforwardly. Sixty-nine-year-old men have been known to die suddenly. In that event, his wife would find the letters and be pained by reading them. There was no one else he could ask to keep them, no friend he had dared tell of this affair. His lover, Soraya? Thirty years dead. She had died while giving birth. Not his child, Dave was quick to add. God knows what had happened to his letters to her!

  “What do you want me to do with them?” I asked.

  “Nothing. Do nothing at all. Just keep them.”

  “When was the last time you read them?”

  “I haven’t read them for at least twenty years.”

  “They seem like such a hot potato,” I ventured. “Why keep them at all?”

  Dave looked at me incredulously. I think a shiver of doubt went through him. Was I really that stupid? Had he made a mistake in thinking I was sensitive enough to help him? After a few seconds, he said, “I’ll never destroy those letters.”

  These words had an edge to them, the first signs of strain in the relationship we had been forming over the past six months. My comment had been a blunder, and I retreated to a more conciliatory, open-ended line of questioning. “Dave, tell me some more about the letters and what they mean to you.”

  Dave began to talk about Soraya, and in a few minutes the tension had gone and his self-assured, easy jauntiness returned. He had met her while he was managing a branch of an American company in Beirut. She was the most beautiful woman he had ever conquered. Conquer was his word. Dave always surprised me with such statements, part ingenuousness, part cynicism. How could he say conquer? Was he even less self-aware than I had thought? Or was it possible that he was far ahead of me, and mocked himself—and me, too—with subtle irony?

  He had loved Soraya—or, at least, she was the only one of his lovers (and they had been legion) to whom he had ever said “I love you.” He and Soraya had a deliciously clandestine affair for four years. (Not delicious and clandestine but deliciously clandestine, for secrecy—and I shall say more about this shortly—was the axis of Dave’s personality around which all else rotated. He was aroused by, compelled by, secrecy, and often courted it at great personal expense. Many relationships, especially those with his two ex-wives and his current wife, had been twisted and torn by his unwillingness to be open or straight about anything.)

  After four years, Dave’s company transferred him to another part of the world, and for the next six years until her death Dave and Soraya saw each other only four times. But they corresponded almost daily. He had kept Soraya’s letters (numbering in the hundreds) well hidden. Sometimes he put them in a file cabinet in quirky categories (under G for guilty, or D for depression—that is, to be read when deeply depressed).

  Once, for three years, he had stored them in a safe-deposit box. I wondered, but did not ask, about the relationship between his wife and the key to that safe-deposit box. Knowing his penchant for secrecy and intrigue, I could imagine what would happen: he would accidentally let his wife see the key, and then devise an obviously false cover story to churn her curiosity; then, as she grew anxious and inquisitive, he would proceed to despise her for snooping and for constricting him by her unseemly suspiciousness. Dave had frequently enacted that type of scenario.

  “Now I’m getting more and more nervous about Soraya’s letters, and I wondered if you’d keep them. It’s just that simple.”

  We both looked at his large briefcase bulging with words of love from Soraya—the long-dead, dear Soraya whose brain and mind had vanished, whose scattered DNA molecules had drained back into the basin of earth, and who, for thirty years, had not thought of Dave or anything else.

  I wondered whether Dave could step back and become witness to himself. To see how ludicrous, how pathetic, how idolatrous he was—an old man, stumbling toward death, comforted only by a clutch of letters, a marching banner proclaiming that he had loved and been loved once, thirty years before. Would it help Dave to see that image? Could I help him assume the “witness to himself” posture without his feeling that I was demeaning both him and the letters?

  To my mind, “good” therapy (which I equate with deep, or penetrating, therapy, not with efficient or even, I am pained to say, helpful therapy) conducted with a “good” patient is at bottom a truth-seeking venture. My quarry when I was a novitiate was the truth of the past, to trace all of a life’s coordinates and, thereby, to locate and to explain a person’s current life, pathology, motivation, and actions.

  I used to be so sure. What arrogance! And now what kind of truth was I stalking? I think my quarry is illusion. I war against magic. I believe that, though illusion often cheers and comforts, it ultimately and invariably weakens and constricts the spirit.

  But there is timing and judgment. Never take away anything if you have nothing better to offer. Beware of stripping a patient who can’t bear the chill of reality. And don’t exhaust yourself by jousting with religious magic: you’re no match for it. The thirst for religion is too strong, its roots too deep, its cultural reinforcement too powerful.

  Yet I am not without faith, my Hail Mary being the Socratic incantation “The unexamined life is not worth living.” But that was not Dave’s faith. So I curbed my curiosity. Dave scarcely wondered about the ultimate meaning of his clutch of letters and now, tight and brittle, he would not be receptive to such an inquiry. Nor would it be helpful—now or probably ever.

  Besides, my questions had a hollow ring. I saw much of myself in Dave, and there are limits to my hypocrisy. I, too, had my sack of letters from a long-lost love. I, too, had them cutely hidden away (in my system, under B for Bleak House, my favorite Dickens novel, to be read when life was at its bleakest). I, too, had never reread the letters. Whenever I tried, they brought pain, not comfort. They had lain there untouched for fifteen years, and I, too, could not destroy them.

  Were I my own patient (or my own therapist), I would say, “Imagine the letters gone, destroyed, or lost. What would you feel? Plunge into that feeling, explore it.” But I could not. Often I thought of burning them, but that thought always evoked an inexpressible ache. My great interest in Dave, my surge of curiosity and fascination, I knew whence it came: I was asking Dave to do my work for me. Or our work for us.

  From the outset, I had felt drawn to Dave. At our first session six months before, I had asked him, after a few pleasantries, “What ails?”r />
  He responded, “I can’t get it up anymore!”

  I was astonished. I remember looking at him—his tall, lean, athletic body, his full head of glistening black hair, and his lively elfish eyes belying his sixty-nine years—and thinking, “Chapeaux!” (“Hats off!”). My father had done his first coronary at forty-eight. I hoped that when I was sixty-nine I’d be sufficiently alive and vital to worry about “getting it up.”

  Dave and I both had a proclivity to sexualize much in our environment. I contained it better than he, and had long since learned to prevent it from dominating my life. I also did not share Dave’s passion for secrecy, and have many friends, including my wife, with whom I share everything.

  Back to the letters. What should I do? Should I keep Dave’s letters? Well, why not? After all, was it not an auspicious sign that he was willing to trust me? He had never been able to confide much in anyone, and certainly not in a male. Although impotence had been his explicit reason for choosing to see me, I felt that the real task of therapy was to improve the way he related to others. A trusting, confiding relationship is a prerequisite for any therapy and, in Dave’s, might be instrumental in changing his pathological need for secrecy. Keeping the letters would forge a bond of trust between us.

  Perhaps the letters might give me additional leverage. I had never felt that Dave was securely lodged in therapy. We had worked well with his impotence. My tactic had been to focus on the marital discord, and to suggest that impotence was to be expected in a relationship with so much anger and mutual suspicion. Dave, who had been recently married (for the fourth time), described his current marriage in the same way he described his previous marriages: he felt he was in prison, and his wife was a prison guard who listened to his phone conversations and read his mail and personal papers. I had helped him realize that, to the extent that he was in prison, it was a prison of his own construction. Of course his wife tried to obtain information. Of course she was curious about his actions and correspondence. But it was he who had whetted her curiosity by refusing to share even innocent crumbs of information about his life.

  Dave had responded well to this approach, and made impressive attempts to share with his wife more of his life and internal experience. His action broke the vicious circle, his wife softened, his own anger diminished, and his sexual performance improved.

  I had turned, now, in treatment, to a consideration of unconscious motivation. What payoff did Dave get from a belief that he was imprisoned by a woman? What fueled his passion for secrecy? What had prevented him from forming even one intimate, nonsexualized relationship with either man or woman? What had happened to his cravings for closeness? Could these cravings, even now at sixty-nine, be excavated, reanimated, and realized?

  But these seemed more my project than Dave’s. I suspected that, in part, he agreed to examine unconscious motivations simply to humor me. He liked to talk to me, but I believe that the primary attraction was the opportunity to reminisce, to keep alive the halcyon days of sexual triumph. My connection with him felt tentative. I always felt that if I probed too far, ranged too close to his anxiety, he would simply disappear—fail to show up for his next appointment, and I would never be able to contact him again.

  If I kept the letters, they could act as a guyline: he couldn’t simply float away and disappear. At the very least, he would have to be up front about terminating: he’d have to face me and request the letters back.

  Besides, I felt I had to accept the letters. Dave was so hypersensitive. How could I reject the letters without his feeling I was rejecting him? He was also highly judgmental. A mistake would be fatal: he rarely gave people a second chance.

  Yet I was uncomfortable with Dave’s request. I began to think of good reasons not to accept his letters. I would be making a pact with his shadow—an alliance with pathology. There was something conspiratorial about the request. We’d be relating together as two bad little boys. Could I build a solid therapeutic relationship on such insubstantial foundations?

  My idea that keeping the letters would make it harder for Dave to terminate therapy was, I realized quickly, nonsense. I dismissed this angle as being just that—an angle, one of my dumb, harebrained, manipulative ploys that always backfire. Angles or gimmicks were not going to help Dave relate to others directly and authentically: I had to model straightforward, honest behavior.

  Besides, if he wanted to stop therapy, he’d find a way to get the letters back. I recall a patient I saw twenty years ago whose therapy was pockmarked with duplicity. She was a multiple personality whose two personae (whom I shall call Blush and Brazen) waged a deceitful war against each other. The person I treated was Blush, a constricted, prudish young thing, while Brazen, whom I rarely encountered, referred to herself as a “sexual supermarket” and dated the king of California pornography. Blush often “awoke” surprised to find that Brazen had emptied her bank account and bought sexy gowns, red lace underwear, and airline tickets for jaunts to Tijuana and Las Vegas. One day, Blush was alarmed to find an around-the-world airline ticket on her dresser, and thought that she could prevent the trip by locking up all of Brazen’s sexy clothing in my office. Somewhat bemused and willing to try anything once, I agreed and stored her clothes under my desk. A week later, I arrived at work one morning to find my door broken open, my office rifled, and the clothes gone. Gone was also my patient. I never saw Blush (or Brazen) again.

  Suppose Dave did die on me? However good his health, he was sixty-nine. People do die at sixty-nine. What would I do with the letters then? Besides, where in the hell would I store them? Those letters must weigh ten pounds. I imagined, for a moment, interring them together with mine. They might, if discovered, provide me some cover.

  But the really major problem with keeping the letters had to do with group therapy. Several weeks before, I had suggested to Dave that he enter a therapy group, and over the past three sessions we had discussed this at great length. His penchant for concealment, his sexualization of all transactions with women, his fear and distrust of all men—all of these traits, it seemed to me, were excellent issues to work on in group therapy. Reluctantly, he had agreed to begin my therapy group, and our session that day was to be our last individual meeting.

  Dave’s request for me to keep the letters had to be seen in this context. First, it was entirely possible that the imminent transfer to the group was the factor behind his request. No doubt he regretted losing his exclusive relationship with me and resented the idea of sharing me with the group members. Asking me to keep the letters might, thus, be a way of perpetuating our special, and private, relationship.

  I tried very, very delicately to express that idea, in order not to provoke Dave’s exquisite sensitivity. I was careful not to demean the letters by suggesting he was using them as a means to an end. I was also careful to avoid sounding as though I were minutely scrutinizing our relationship: this was a time to nurture its growth.

  Dave, being a person who needed extensive time in therapy simply to learn how to use it, scoffed at my interpretation instead of considering whether there was any truth in it. He insisted that he had asked me to keep the letters at this time for one reason only: his wife was now doing a major housecleaning and working her way steadily and surely toward his study, where the letters lay hidden.

  I didn’t buy his reply, but the moment called for patience, not confrontation. I let it go. I was even more concerned that keeping the letters might ultimately sabotage his work in the therapy group. Group therapy for Dave was, I knew, a high-gain but high-risk venture, and I wanted to facilitate his entry into it.

  The benefits might be great. The group could offer Dave a safe community in which he could identify his interpersonal problems and experiment with new behavior. For example, he might reveal more of himself, get closer to other men, relate to women as human beings rather than as sexual parts. Dave unconsciously believed that each of these acts would result in some calamitous event: the group was the ideal arena to disconfirm the
se assumptions.

  Of the many risks, I feared one particular scenario. I imagined that Dave would not only refuse to share important (or trivial) information about himself, but do so in a coy or provocative way. The other group members would proceed to request and then demand more. Dave would respond by sharing less. The group would be angered, and accuse him of playing games with them. Dave would feel hurt and trapped. His suspicions and fears of the group members would be confirmed, and he would drop out of the group, more isolated and discouraged than when he began.

  It seemed to me that, if I were to keep the letters, I would be colluding, in a countertherapeutic way, with his penchant for secrecy. Even before starting the group, he would have entered into a conspiracy with me that excluded the other members.

  Weighing all these considerations, I finally chose my response.

  “I understand why the letters are important to you, Dave, and I also feel good that I’m the one you’re willing to entrust with them. However, it’s my experience that group therapy works best if everyone in the group, and that includes the group leader, is as open as possible. I really want the group to be helpful to you, and I think it best that we do it this way: I’ll be glad to store the letters in a safe, locked place for as long as you wish, provided that you agree to tell the group about our bargain.”

  Dave looked startled. He hadn’t anticipated this. Would he take the leap? He cogitated for a couple of minutes: “I don’t know. I’ll have to think about it. I’ll get back to you.” He left my office, his briefcase and homeless letters in tow.