“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?”