MARCH 22, 2015
WHAT DOES IT MEAN to die well? Can talk therapy help? These are the questions posed by Creatures of a Day, psychiatrist Irvin Yalom’s poignant and bracing collection of stories based on his therapeutic work. Yalom, a published novelist with decades of clinical experience, offers vivid and generous descriptions of patients brought face-to-face with their mortality. They struggle with fear of the inevitable and regret for the unchangeable, and find comfort, or don’t. The result is a book by turns frustrating and inspirational. Yalom’s therapeutic answers to the most difficult questions are often unsatisfying, but to hear the questions asked so honestly is an inspiration in itself.
Yalom is a professor emeritus of psychiatry at Stanford, the author of well-received philosophical novels (When Nietzsche Wept, The Schopenhauer Cure), and one of the leading American exponents of a form of therapy known as existential psychiatry. Existential psychiatrists believe that psychological disorder is neither the result of chemical imbalance nor of unconscious drives, but of patients’ inability to come to terms with the existential givens of human life: mortality, freedom, solitude, meaninglessness — the big ones. The result is a form of therapy in refreshing contrast to mainstream psychiatry. Rather than regarding patients’ thoughts and feelings as delusive symptoms of an underlying biochemical cause, Yalom treats them as serious (if dysfunctional) attempts to answer the most serious questions a person can ask.
Most of the patients described in the book are middle-aged or older. (Yalom is 83 himself.) A few are very sick, but most are simply coming to recognize that they have more past behind them than future to look forward to. They are afraid, but even more, they are regretful: unsure of how their lives turned out this way. And many of them have a great deal to regret. We meet a writer in his 70s who has been trying unsuccessfully to write the same novel for 50 years, a woman in a “good enough” marriage who still longs for the love of her life she hasn’t seen in decades, and a mother permanently estranged from her only son. They are introduced with their various problems — what might be diagnosed as minor depressions or anxiety disorders — but Yalom has no interest in diagnosing them; he doesn’t even really seem to consider them ill. To be sad and frightened at the end of life is natural. His goal is simply to talk it through, to help his patients decide how best to live with their feelings.
And what a talent he has for talking it through! Watching “Irv,” as his patients call him, convince patients to unpack their baggage is the chief pleasure of this book. He is overtly kind, sympathetic, and generous, but subtly merciless. And mercilessness is requisite. Faced with mortality, his patients, like most of us, would rather discuss almost anything else. After all, what’s the point of lingering over what you can’t change? More than that, isn’t it dangerous? One senses and shares the patients’ fear: if they were ever to really stare these things in the face, wouldn’t the grief and terror overwhelm them? They know very well that they’re old, sad, regretful, and guilty. It’s by suppressing all this that they get through the day, and they want help getting through the day.
But Yalom won’t let them off so easily. He’s quietly insistent, and not afraid to play the trump card of his own mortality (I’m a very old man; I will die before you), and eventually it all comes out. Often the patients surprise themselves. The past that weighed them down appears in a new light. But even when it doesn’t, we sense the tremendous relief of no longer avoiding it. In a culture that likes to imagine death as a contingent result of poor lifestyle decisions, and youth and old age as states of mind, it’s a relief to face the fact that death is inevitable, the past irrecoverable. It’s a relief to know one can acknowledge that and still get through the day. Yalom discovers in his patients a courage they did not know they had, and it helps them.
Still the question lingers: What are we to do with our mortality? Is it possible to “accept” it? Yalom’s advice here is far less satisfying. When it comes to death and aging, the profound lingers uncomfortably close to the banal. As Yalom frequently tells his patients, “You must give up the hope for a better past” — a nice turn of phrase, but a clichéd sentiment: live each day to the fullest, don’t let your regrets keep you from appreciating what you have … It’s not that this is bad advice (clichés are clichés for a reason), just that it’s so often impossible to take. Humans are future-facing creatures. We spend our whole lives hoping for one thing or another. When the future begins to close in and becomes too short a space to accommodate our hopes, we begin to hope backward — to regret. By attributing psychological disorder to a dysfunctional relationship with things like mortality, the existential psychiatrist posits a functional, healthy relationship to these things — but Creatures of a Day has little new to say about what that might look like. One wonders whether Yalom’s therapy works by reminding his patients of the last things only to make it easier for them to forget: having had it all out in therapy, patients can go back to ignoring it most of the time, to living day-to-day.
Not that Yalom pretends to have all the answers. On the contrary, he’s fascinated by the help his patients find in chance encounters and throwaway questions, both in therapy and elsewhere. One of the most thought-provoking attitudes toward death in Creatures has nothing to do with therapy, or even acceptance. One of his patients, Astrid, is hospitalized with a near-fatal illness. Afterward, she describes a moment of grace on what might have been her deathbed:
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. […] Somehow it just got me outside of myself.
The nurse’s demand helps Astrid immensely, and it’s not hard to see why. Her point is that Astrid’s death, even if it is nothing but horror to her, can still be worth something as a gift to her children. Implied is the suggestion that perhaps in dying we have an obligation to our fellow mortals: in meeting the shared fate with courage, we help them do the same.
Yalom’s own advice to his patients, though much kinder than the nurse’s, is rarely as original or as helpful. For example, an instance from the same chapter: he later meets the tough-assed nurse herself, a woman named Justine, at Astrid’s funeral, and she enters therapy with him. Justine turns out to be a somewhat tragic figure: middle-aged, divorced years ago, her only family an estranged son who has been in prison for years, recently diagnosed with cancer. She is understandably depressed. She feels guilty about whatever she must have done to deserve such a harsh lot in life and angry at the fate that dealt her these cards. Yalom’s therapeutic response is to talk her down from these feelings, to remind her that she is a good person, after all:
“Imagine,” I continued, “right here in my office, a row of people you’ve helped, maybe even transformed. […] I can imagine […] a very long line winding out of the office and down the street. Right?”
“Yes,” Justine said softly, “I can see them […], and yes, it does stretch far — all the way into the distance — as far as I can see.”
Is it wrong to wonder just how far the line would have to stretch to make up for a child you no longer speak to? Or question whether this sort of self-affirmation, this balancing act in which the good more or less outweighs the bad, at least in your therapist’s opinion, is what it means to come to terms with death? It’s easy to understand Yalom’s impulse here — Justine is in pain. He wants to console her, to cheer her up. But cheering up is what friends are for, and what we do for ourselves: “Yes, but it’s not all bad, you have so much to be grateful for.” Good therapy (Yalom’s own therapy, at its best) has a different function. Its job is to let the patient face bad feelings with open eyes, not to help her turn away from them. Justine’s reaction — “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” — gets at just this. She has been asked to be consoled when she isn’t quite finished being inconsolable. She didn’t want to be comforted, at least not yet. But the therapy session ends with a lukewarm call to positive thinking, and the opportunity is lost.
Of course, half the pleasure of case studies is second-guessing the therapist, and it is to Yalom’s great credit that he is honest enough to confess to the reader his uncertainty at every step, and to provide abundant material for second-guessing. But reading these records, one has the suspicion all too often that he’s turning back at the limit. That for him the goal of therapy is acceptance, and when feelings are unacceptable they are ignored. One sometimes longs for the icy realism of Freud, for instance, who had no truck with acceptance. The Freudian unconscious cannot renounce anything. It never accepts, it never gives up. Freud’s account of the goal of therapy — “to transform your hysterical misery into ordinary unhappiness” — promises no consolation, but in exchange, it demands no acceptance: the patient is free to be full of grief, full of rage.
Then again, there’s something more human than this in Yalom’s struggle to help his patients come to terms. Psychoanalysis has often been compared to the confessional, but if the psychoanalyst is a priest, he has no grace to offer: psychoanalysis is all sin and no redemption. And the modern mainstream replacement, the biologizing psychiatrist, podiatrist of the soul, is sometimes scarcely more convincing. There are forms of sadness that can’t be pinned to chemical imbalance and disorders that don’t fit neatly on insurance forms. Yalom’s struggle to find another way has its fascinations. When he gets in over his head, he prescribes his patients the Stoic Roman emperor Marcus Aurelius — good advice in almost any situation. Creatures of a Day takes its title from Aurelius’s Meditations:
All of us are creatures of a day; the rememberer and the remembered alike. All is ephemeral — both memory and the object of memory. The time is at hand when you will have forgotten everything; and the time is at hand when all will have forgotten you. Always reflect that soon you will be no one, and nowhere.
Always reflect. Not only when death seems nearest, but also when it seems furthest away. This austere wisdom is as close as Yalom comes to providing an answer to the questions he raises: remember what you’ve always known and spent your whole life forgetting, remember that you, like any human, were always already going to die; fold your contingent fears of a diagnosis or an accident back into the universal fact of mortality from which they come. It’s strange to hear the words of the Stoic emperor from a San Francisco therapist, but quite fitting: the Stoics were the shrinks of their day, after all, the people you went to when you were at your wits’ end. It’s a very long way from ancient Rome to 21st-century California, of course — nothing could be further from our therapeutic culture than the Stoic demand that we treat not only honor and wealth but love and personal fulfillment with equal and absolute indifference — but Creatures of a Day suggests that maybe it’s time to start walking that road. Montaigne’s paradoxical paraphrase of Cicero — “To study philosophy is to learn how to die” — might serve as Yalom’s motto. You’ll die anyway, of course, whether you learn how to or not, but it is possible to die less frightened, less surprised, with greater wisdom, and a quieter soul. It’s a tall order but a powerful promise, and Yalom is wise to give Marcus Aurelius the last word:
Pass, then, through this little space of time in harmony with nature and end thy journey in contentment, just as an olive falls off when it is ripe, blessing nature who produced it, and thanking the tree on which it grew.