I found recovery the most difficult phase for me. I was done with the bone marrow transplant, and I was ready to return to normal. However, there was a period of cell repair: regrowing blood cells, hair cells, gut cells, skin, enzymes, a complete starting over. When cell counts returned to near normal, Sue and I were able to leave Duke and return home. I was ready to return to my normal life. It took a few months. Gradually I regained my strength. I extended my daily walks to a mile, then two miles. Dorothy Douglas accompanied me and kept me informed about Johnson City's Sister Cities exchange program with Rabinsk, Russia, which she organized. My own organizational abilities were shot. It was all I could do to sort out the medical bills and answer the essential mail. I was instructed to take two naps a day under the covers. The first one came before breakfast. Sue went off to work. I was left to look after the house and preside over the impeachment hearings.
I was home about a week when I developed my first infection. It left me flatter than a pancake, the worst I felt through the whole experience, nearly lifeless. I had less energy than a wet dishrag. It was the only time I didn't mind being in the hospital. I didn't care where I was but the hospital seemed like a good place to get better. I now had 5200 white blood cells, which should have been enough to fight an infection, but each of them was a rookie; none of them knew what to do.
The second infection a few weeks later was a milestone. I had gone to grand rounds to hear one of my colleagues present. A cold was going around. Everyone had it. I caught it. It was one of those absolutely miserable colds progressing over four or five days from sore throat to stuffed head to cough. I called the oncologists to see if I should take one of the high-powered and expensive antibiotics I had become so accustomed to. They said, sorry, I was just like anyone else at this point, just treat it symptomatically. I suffered gladly, thrilled that at last I had an immune system that could handle a simple cold.
During this period it struck me that recovery from cancer was much like recovery from alcoholism; once you had it, you were always in recovery (or remission), never really cured. In the old medical model, if you thought of an illness as merely physiological, you would say you were cured when there were no longer any physiological changes in the body. With cancer you look for all the detectable signs, but you can never be sure there isn't some renegade cell somewhere ready to go on a rampage. None of us can be sure, of course.
With alcoholism as much as than anything else in medicine, the spiritual dimension is an important part of the treatment. Even though we now know enough about alcoholism to realize that there is a physiological component (addiction propensity) and not just moral weakness, we think of the illness as a bio-psycho-social as well as spiritual disorder. Cancer is really no different.
I like the analogy for cancer. It, like alcoholism, is a real illness involving biological, psychological, social, and spiritual components. Biology alone does not explain the totality of the illness experience. As with alcoholism, spiritual aspects of healing are important, as is the technology. As with alcoholism, we need to understand more about not only the biology of the illness, but how to integrate the various components that affect the balance of health and illness.
Alcoholism and other addictions are complex illnesses. They involve cravings which are mediated by neurotransmitters in the brain. Neurotransmitters are affected by the thoughts people have and the experiences that influence these thoughts, both in the present and remotely through memory. We have come to appreciate that addictions like other forms of mental (i.e. mind-body) illnesses, are "no fault" biological illnesses. It doesn't help to blame the victim. At the same time, it does help to help people assume responsibility for their behavior and the consequences of their actions. We can say this about alcoholism and addictions.
We can also say this about cancers. Empirically, it has been demonstrated that people who attend support groups do better than those who do not. Such population studies do not say what will happen to any given individual but suggest factors that are worth considering. People who attend church do better. Why? Intercessory prayer has been demonstrated to improve success rates in cardiac surgery even if the people having the surgery do not know they are being prayed for. It is easier for me to understand this if the people know and respond to the good will of their friends. Penny Smith tells the story of the Monday she felt like she would live. For days she barely had enough energy to raise her eyelids. One Monday morning her husband, Stephen, asked her how she felt. She looked surprised and said she felt better. She felt like she was going to make it. Stephen smiled and told her that her church had an extended prayer meeting for her the night before.
As I was struggling with my recovery, Paige Kirby returned from a trip to Maine. She and her friends had visited my mother who produced a Thanksgiving of leftovers. Knowing that they might visit, she had baked an apple pie, which awaited them on the sideboard. Paige and her friends climbed Mt. Washington in nearby New Hampshire. They raved about the experience.
Mount Washington is the mountain I climbed most in my youth, more even than Mount Katahdin. In recent years North Carolina's Grandfather Mountain has become a favorite. But again and again Washington was a worthy challenge. It is the highest mountain in New England and deserves respect. People have died of exposure even in the summer. It is the point of convergence of a number of weather systems, from Canada, from the Atlantic, from the South. Weather can change rapidly. The highest winds and coldest temperatures in North America have been recorded at the weather station atop the mountain. I climbed it from the East and West, North and South. Up the Lion's head, down the Amanoosic Ravine, across the whole Presidential Range from Mt. Madison or from Mt. Adams. There is a cog railroad with a steam engine, which has been in operation since the nineteenth century. There is even an auto road to the top. Once Russell, Charlie, Bobby Gray, and I hitched the travel trailer to my father's old jeep station wagon and camped at Dolly Copp in Pinkham Notch. We drove the jeep to the top of Mt. Washington. (Where was Steve? Probably away at prep school already. We were fifteen that summer. I would be the next to go off to school.) Legend has it that I skied Tuckerman's Ravine Headwall the day before Sue and I were married. That story is true. I did.
I know what my psychoanalytic colleagues would say about this. They would say it was counterphobic behavior. They would not be entirely wrong. I also know that behavioral geneticists would recognize such adventurousness as a correlate of what they call the novelty-seeking gene. My Aunt Mary alluded to this in noting a similarity between my adventurousness and the spirit of my Grandfather Randall. My Grandmother Dyer had the same gene. She loved to travel. Once she invited herself on a transcontinental automobile trip the day before departure when she found out that her sidekick was going. I could see adventurousness in myself not only with physical challenges, but also in taking on difficult administrative situations.
Paige and friends climbed down Tuckerman's Ravine Headwall with packs. They reported that it was nearly vertical. The most recent death on Mt. Washington occurred when a climber with a pack had bent over to pick up his sunglasses and fallen to his death. As the story of their Mt. Washington adventure was told, a bit of ancient history got thrown in. "Dr. Dyer skied this the day before his wedding, you know," Paige said at dinner one night.
Wait a minute. The legend was getting out of hand. I wanted to make sure my friends realized that the headwall, a glacial cirque or head of the glacier, was not so steep when the bowl was filled with snow. It was steep, and a fall to the boulders below could have meant death. But I determined that the prudent course was not wide traverses down the snow fan, where the turns would be taken above the boulders. Instead I felt that the safest course would be skiing straight down the fall line with quick checks to the snowy outrun. If there were a fall, which there wasn't, it would not be fatal. I was addicted to adventure, but not to danger.
For me the path to extreme skiing had been not one of reckless abandon, but years of progressive challenges leading to mastery of the skills necessary. As a youngster skiing on Maine's big Sugarloaf, I recall the progression of trails, each bearing the name of some remnant of Maine's logging industry: Peavey, Cant Dog, Tote Road, Narrow Gauge, Upper Narrow Gauge, Sluice. A Peavey is a cant dog, named for the man who invented it. It was in important tool for lumberjacks on rivers such as the Androscoggin, Kennebec, Penobscot, and Allagash, the routes to the paper mills. A cant dog is a pole about eight feet long, with a sharp metal spike and a hook on the working end. It is designed to poke and/or roll the logs that are jammed to keep the logs moving downstream. I have never used one myself, but I have sometimes felt that as an administrator it was my job to break up logjams and to keep things moving. It is dangerous work, stressful work, but necessary work. It is also rewarding work.
For me the lure of the Maine outdoors was inculcated at early age. One might think that the way to survive a Maine winter would be to stay indoors as much as possible. In my experience, just the opposite was the case. I couldn't have been more than four or five when my father first took me into the North Woods to see the lumbering operations. I remember wading through the tracks he made in waist-deep snow (my waist) popping up and down like a playful puppy. The old jeep traversed the snowy track with ease in the valley between the piles of snow plowed beside the road, banked so high on both sides that you couldn't see over it. Uncle Aubrey, after his experiences with heavy equipment in World War II, established himself as a contractor. He had a road grader, a back hoe, and some dump trucks, which were also used as snow plows. My favorite was the one he always called "the Ten Wheelah." It was huge. This particular winter he had a contract loading logs, trees actually, onto flatbeds. That was the operation my father and I went to inspect.
We went to a place called The Forks, where two branches of the upper Kennebec River came together. The way Maine people drop their r's, it sounded like an animal. Sue was bewildered the first time she visited our home, and my mother asked her to put the fox on the table. "Why would she want me to do that?" thought Sue. But Sue is quick, and in a second realized that "silverware" was what was called for. Silverware was only a slightly more accurate descriptor. It wasn't really silver, but it looked silver and was called silver.
Not far from The Forks is a place called the Sluice, a steep bank, where logs are slid from the forest into the river. The ski trail at Sugarloaf called the Sluice, like its namesake, goes straight down the side of the mountain. Logging was a most impressive operation. I was impressed not only with the magnitude of the undertaking, but also with the logistics of a multi-national force (French-Canadian and Mainer) working together to get these trees onto flatbeds or into the river. Winter was prime logging time because the ground was frozen, and the heavy equipment wouldn't sink into the mud. Everything was magnified to the eyes of a small boy, but those really were big trucks, big logs, big men, and big tasks. My ambitions to attempt big things in the world were nurtured on outings like that into the Maine woods.
Most of the lessons of childhood were lessons of self-sufficiency, lessons of independence, lessons of how to get by in the world outside. The things my father and my uncles taught me were of this nature. How to pitch a baseball (or a snowball). How to swim. How to use a hammer. How to build a soap box derby racer and a kayak. How to make a fist. How to load hay bales. How to solve quadratic equations. How to respect women. It is said that my grandfather Randall once horsewhipped a man. There is no doubt the man deserved it. It is less clear what he did. Perhaps he made a disparaging comment about a woman. Perhaps that woman was my grandmother, who carried eight pregnancies to term in thirteen years. Coleman, Mary, Nellie (who did not survive the first year), Audrey, Charles, Avis (my mother), Caroline, and Erma were all born between October 1911 and March 1924.
In comparison to my father and uncles, my mother, my grandmothers, and my aunts were solicitous. They were caring. They took care of me and us, my sister and cousins, everyone. Food. Attention. Concern. Worry. Scoldings. Advice. Whatever we needed. I never left Aunt Mary's driveway (often with a carful of friends to or from a ski trip) without her saying, "Drive carefully." I couldn't forget.
The lessons of the Maine woods, the rivers and lakes, the farm, and growing up in a small town were all lessons about self-sufficiency. They were lessons about becoming independent and taking care of yourself. If you could take care of yourself, you could also take care of others. Dependency was a state you left behind. Certainly, you left it behind when you went off to college, maybe even earlier if you went away to high school. Choosing medicine as a profession meant taking care of others. To do it well required taking care of oneself also. Many doctors get themselves into emotional difficulty by ignoring their own needs while they take care of others. Cancer takes you back a step further. Not only must you take care of yourself. You must let others take care of you. You must regress.
The way we talk about dependency, it sounds like addiction, pathology. There is something wrong with dependency. Someone might say they are dealing with their dependency in a twelve-step program. It would be unusual to hear someone say they were dealing with dependency issues in psychotherapy, especially in the managed-care era. In psychiatry we have a different take on dependency. Dependency is a feeling that needs to be recognized. The relationship between the feeling and the behaviors that stem from it need to be recognized and understood so that satisfying decisions about dependency can be made. Men in particular are likely to lack access to regression and consequently not get their dependency needs met. Men typically have difficulty even acknowledging and articulating their feelings and consequently have difficulty getting their emotional needs met. Men are likely to be alexathymic, without words for feelings. I was raised as a typical male. I have learned a great deal about myself from psychotherapy and psychoanalysis, and those lessons were important when confronted with a complex illness like cancer.
The Japanese do have a vocabulary for dealing with dependency. They have a concept, amae, which deals with the passive longings to be taken care of. In Japan amae is not shunned in adulthood, but is part of hospitality as well as familial interactions. Japanese psychiatrist Takeo Doi noticed the contrast in the way American culture and Japanese culture deal with dependency issues. He wrote about this in a book, The Anatomy of Dependence, which is taken as a key analysis of Japanese behavior. I find Doi's analysis informative not only of Japanese character, but offering a useful description for a phenomenon which has no real vocabulary in Western thought. The Japanese word amae describes the condition of passive love, for which European languages do not have an equivalent. Amae is the yearning to be taken care of. It is the experience of the infant at the breast. It may also be the experience of the patient in time of illness or suffering.
During my first trip to Japan, I had an experience of amae, which I did not understand until sometime later. I met with Dr. Doi at the National Institute of Mental Health in Tokyo, where he served as director. Later I was to give a lecture at one of the Tokyo universities. There was a conflict in scheduling which would have prevented me from accompanying Sue, Will and Cliff on a tour to Lake Hakone. No problem, it was explained. I could give the lecture in Tokyo then take the bullet train to catch up with my family at the first night's hotel.
After my lecture, I needed instructions to get to Tokyo station. I knew that all trains led to Tokyo station, so if I could get to any train, I could find my way from there. A professor and a law student accompanied me on the bus to the train, got on the train with me, accompanied me all the way to Tokyo station, helped me buy my ticket, got me onto the train and did not take their leave until they had found a seat for me. What extraordinary courtesy to show a guest, I thought.
It was not until a couple of years later that I fully appreciated the cultural significance of this event. Back in Oxford, I was introduced to Dr. Junichi Suzuki, a psychiatrist and associate of Dr. Doi. After hearing about my experience, he asked simply, "Did you enjoy the regression?"
Nothing in my New England experience prepared me for this interpretation. Schooled as I was in Western notions of autonomy, independence, and Emersonian self-reliance, it never occurred to me to "enjoy the regression." I realized that I had missed an opportunity to amaeru, that is, to behave self-indulgently. I did recall a feeling of helpless dependence on my translator that could best be described as amae, though at the time "gratitude" was as close as I could come to describing the feeling.
So now as a cancer patient, I again had an opportunity to amaeru. I can tell you survival depended on it. I can tell you that I enjoyed having the love and support of family and friends. I can tell you that I realized that in order for the doctor to be a good patient, he would have to let go of being in charge, and do as he was told. I did that, and I was complimented by my doctors for not trying to do their job. I understood that. I wish I could tell you that I enjoyed the regression, but in fact, this was the part of the whole experience that was the most difficult for me.