Four Things That Matter Most: 10th Anniversary Edition
Introduction to the Tenth Anniversary Edition

Learning from Conversations with My Readers

There are few better ways to deepen one’s understanding of a subject than to teach it. As a practicing physician and professor at a medical school, I am continually learning. Questions from patients or doctors-to-be frequently illuminate a problem’s complexities, allowing me to see the whys, hows, and what-ifs through fresh eyes.

Similarly, in the 10 years since The Four Things That Matter Most was first published, readers have taught me about the challenges people encounter—or assume they will encounter—in following my recommendations for mending, tending, and celebrating relationships. They also report benefits that I had not foreseen in saying the four things that matter most: “Please forgive me. I forgive you. Thank you. I love you.” People who have attended readings I’ve given or called in to radio talk shows have asked questions about troubled relationships and situations that seemed to make saying the Four Things impossible. The people who have taught me the most were those who wrote or spoke to me of their doubts. They agreed they wanted to say the Four Things but had questions regarding whether these principles could work after they’d had so many painful experiences in their relationships. Often the situation they described involved a parent and, although this was hardly a scientific sample, most often that parent was a father.

I’m grateful to each person for his or her willingness to ask me those hard questions and share sometimes excruciating details of their personal lives, and I admire their strength and determination in moving forward to say the Four Things. Our conversations have given me a fuller understanding of how saying the Four Things can positively affect people’s lives. Hopefully, I have become a better doctor and teacher as a result of their feedback. And hopefully their stories and the varied situations in which they benefited from saying the Four Things can help you better see how you can use the Four Things, too.

Why the Four Things Work

One winter morning, the week after The Four Things That Matter Most was published, I was sitting at home at my desk in New Hampshire being interviewed by phone for a news radio station in Philadelphia. One of the show’s cohosts began the interview in a lighthearted way, asking, “I liked your book a lot, Dr. Byock, but why would anyone buy it? After all, you give the book’s main message away in the first paragraph.”

I laughed out loud. She had a point. Chapter 1 begins by explaining what the four things that matter most are. But the stories of real people that fill this book are necessary to convey the value of saying the Four Things and give you the full picture of how the Four Things can help and the contexts in which you can say them. I don’t profess that if you just say these Four Things to someone, your relationship will be healed. Saying them will certainly help, but while they are the right words, you need to say them at the right time and place.

Life can be very hard. Many of us have suffered badly broken relationships with important people in our lives—the results of past lies, disloyalties, broken promises, frank betrayals, painful divorces, or emotional or physical abuse. When people are deeply hurt, they often cannot imagine any end to the anger or hatred they feel. In the clinical work I do, I’ve learned that sometimes the barrier to healing is exactly that: people’s inability to imagine that any healthy resolution is possible. Stories of people who, against all expectations or odds, mended or reestablished fractured relationships can expand what each of us imagines is possible in our own lives.

By the way, I don’t try to talk people out of being angry about past injuries. Anger is an entirely legitimate emotion. If you have been wronged—if someone was mean-spirited to you or intentionally harmed you in some way—you have every right to be angry. And if you consciously decide to stay angry, you have my blessing. I just want you to know that you have other, healthier options, and the four things that matter most can help you find those options.

True stories expand the possible—they open your imagination to possible future outcomes and often bring tangible results. The saying “Where there is a will, there is a way” applies to long-standing, badly broken relationships between people who love one another—or once loved one another. For instance, when parents and adult children who have been at odds for years and rarely see or speak to one another breach the barrier of assumed impossibility, some mending almost always occurs. At least they will experience a lessening of tensions, which is beneficial for everyone, but sometimes they gain or regain much more, including the ability to communicate, to be together, and even to enjoy one another’s company.

It is human nature to long for closeness—and it’s also human nature to be able to experience emotional healing. Children are hardwired to love their parents—even bad parents—and mothers and fathers are hardwired to love their sons and daughters. When there is hurt and hate between them, you can bank on the fact that there is also love between them, even if it is buried deep. In broken relationships, where there is a will to heal on the part of one or both people—simple tools such as the Four Things can provide a way.

More generally, stories about real life matter because they show that an idea can translate into action and get results. The new stories I selected for this anniversary edition of The Four Things That Matter Most will hopefully give you a tangible sense of what forgiveness might look like in your own life. The Four Things allow you to leave nothing left unsaid, and honor and celebrate the people who are important to you.

More About Forgiveness

Forgiveness seems to be the most difficult to express of the four things that matter most. Misconceptions about what forgiveness is—and isn’t—frequently keep people from considering that forgiveness is possible for them. Some people conflate forgiveness with absolution, as if by forgiving someone who wronged you, you could relieve the person of responsibility for the harm they caused. But forgiveness is not about making excuses for someone’s bad behavior; it is not the same as forgetting someone hurt you.

The old saw, “Forgive and forget,” is ridiculous advice. To forgive someone, you do not have to forget his or her misdeed or act as if it had never happened. If this were how forgiveness worked, few of us would be capable of it. Thankfully, forgiving doesn’t require forgetting (that’s amnesia!). Real forgiveness requires remembering. It involves opening your heart in full awareness that you have been harmed or hurt and that you still feel it.

Forgiveness is a generous act (or process), but at its core, forgiveness is about yourself rather than the person being forgiven. Forgiveness is a sophisticated, remarkably effective strategy for improving your own emotional well-being. The comedienne Lily Tomlin observed, “Forgiveness means giving up all hope for a better past.” Exactly right. It involves accepting that the past cannot be changed, while recognizing that your past need not control your future.

I learned a great deal about compassion, courage, and love from the people I interviewed while writing The Four Things That Matter Most and from the many letters and spoken comments and questions I’ve received since it was published. In this edition, I have included some of their stories.

Try to Act Soon

There’s a saying in my field: “It’s always too soon, until it’s too late.”

Consider that roughly 33,000 Americans die in motor vehicle accidents every year. That’s about 90 people a day. Those people weren’t thinking of dying when they left home that morning. They didn’t know that their remaining time was brief. Yet that day each one lost valuable opportunities to say important things to important people in their lives.

So, if there are important things that you feel a need to say to someone, why wait?

A radio talk show host told me that one of his sisters had died in a scuba diving accident in her early twenties. He was twelve years older than her and had left home when she was in second grade. They had never been close, but had always mutually wanted and intended to know each other better. Looking back, he said he has always regretted missing opportunities to visit with her. His work and other competing priorities now seemed puny in comparison.

I admired his willingness to talk about such personal matters on air. The reason I chose A Book About Living for the subtitle of this book is that in allowing the hard lessons, such as the one the host just described, we can all reclaim our human capacity for love, connection, happiness, and joy.

Life tends to get better when people can move from leaving important things unsaid to broaching these topics and feeling confident that they have communicated clearly with good intentions to the most important people in their lives. The change is often both remarkably quick and long-lasting. In reality, we live each day just a heartbeat away from eternity. We are all better off when we don’t allow what-ifs, could-haves, and should-haves to arise.

It’s never too soon. Don’t wait.

If You Didn’t Say Good-bye

An interview with a local TV news anchor gave me new appreciation for the importance of communicating the Four Things. My host had agreed that expressing these feelings could help people resolve strains in their relationships while strengthening them. But, he asked, “What do you advise people to do if someone they feel the need to speak with has already died?”

This is an important question because our relationships with people we have loved and lost do not vanish. The writer and actor Robert Benchley remarked, “Death ends a life, not a relationship.” That’s true, but death undeniably changes a relationship in profound ways. We can no longer see and touch one another or speak in person or by phone, but people who die live on in our thoughts and our feelings. In particularly close relationships, for instance after the death of a husband or wife, a strong sense of communication continues. Even after someone has died, your relationship with that person can change in healthy ways.

For instance, if a relationship was seriously damaged before a person died, some professional guidance could be invaluable for the survivor, and it may well be helpful to work with a grief counselor. Many counselors use a technique such as the “empty chair,” in which you talk with the person who has died as if he or she were present in the room. Other approaches involve writing a letter to the person—asking for and offering forgiveness, expressing appreciation and love—and then in some manner sending the message into the world. People have written letters on rice paper that they then wrapped around a stone and threw into the ocean; others attached a letter to a helium-filled balloon or sky lantern, then released it into the blue.

Some counselors guide people to intentionally use their nighttime dreams as a vehicle to shift the relationship with the person who has died. Many people find that simply by making it a practice to write down their dreams—first thing in the morning, before getting out of bed, as well as when they awaken in the middle of the night—they notice that the person who has died shows up a lot. More remarkably and importantly, the intention of saying one or more of the Four Things—or in other ways mending the relationship or leaving nothing unsaid—influences the storyline and dream-state interactions with the deceased person.

When the cameras were off, the news anchor said, “I’d like to tell you a story. You can share it with others if you like, but please don’t use my name.”

He explained that he and his father had never gotten along. His father was a good man, but a workaholic. He knew his father had loved him but, in fact, his father had largely neglected him and his siblings. He’d always craved a closer relationship with his father, but as he became an adult, they drifted even further apart. There was no animosity between them, but through the anchor’s forties and into his early fifties, he and his father rarely saw each other nor did they speak by phone. And then his father died.

“We weren’t close,” he said, “so I didn’t think his death affected me. But it did. Outwardly, I was okay. At first I didn’t feel a lot different, but over time I realized that something was gnawing at me. Three or four months went by and I realized I wasn’t sleeping well. I was anxious and irritable, which isn’t like me. What you said about dreams was right. I had several dreams in which I saw and talked with my father, and others in which I talked with my brothers or my sister about him.”

He saw a therapist and, together, they devised a plan.

He went on, “Growing up, my family lived near Sacramento, but at least once a year we’d visit relatives in Southern California and would always attend mass at Mission San Juan Capistrano. I’ve always loved the place. So, I decided to drive there to have a talk with my father.”

He waited for a weekend and drove most of the night. In the late morning, he sat in the chapel at the mission and thought of his father. He reviewed his earliest memories of his father and their family, he silently told his father his regrets over all he had wanted and hoped for and the sadness he still felt. He told his father he was sorry for not calling or visiting more often. He was busy with his career, but recognized that, to some extent, his career was a facile excuse for not wanting to be hurt again by his father’s remoteness.

And then he cried. “It seems like I sobbed for two hours. Maybe it was only three-quarters of an hour.” The journalist in him was keeping the record straight. “But honestly, I have never cried like that before or since.”

And then, he said, something shifted. “After what seemed like endless crying and crying, suddenly I felt my father’s love. I didn’t see him or have a vision or anything. I just felt that, at his core, he loved me. And then I cried some more, but it was different. I felt lighter. I finally felt peace with my father—or with myself in relation to my father. At the time, I hadn’t yet read your book, but I basically said those four things.”

And then what happened? I asked.

“I still wish my childhood and our family had been different. But for the first time in my adult life, I have unconfused warm feelings for my father. I miss him, but now the feelings are tender and unconflicted.”

If They Can’t Understand You Anymore

An estimated 5.4 million Americans—one in eight people over 65 years of age—are affected by dementia. Not surprisingly, how we can say the Four Things if the person has dementia comes up nearly everywhere I give presentations on the subject.

Alzheimer’s disease and other types of dementia eventually rob affected people of the ability to communicate in words with one another. It often begins with difficulty finding the right word to say or losing one’s train of thought while speaking, and gradually progresses to losing the capacity to string words into sentences. Typically, speech becomes harder over months and years—not suddenly.

Therefore, I encourage everyone to say the Four Things to people who have Alzheimer’s disease or other types of dementia early and often. The initial diagnosis—or even suspicion of a diagnosis—of dementia should sound an alarm throughout the family. “Wake up, everyone! It’s time to visit and have a heartfelt talk with Mom, Dad, Grandma, or Grandpa.”

Even people with advanced dementia who can’t speak or string words together may still understand some words. And they definitely can feel and respond to your emotions. More than once I have been in conversation with people in the company of someone with dementia who seemed oblivious to us, but suddenly said or did something that showed he or she had understood what we were talking about.

More important, there may well be value in saying the Four Things, even if you can’t be confident the person hears or understands what you’re saying. A fundamental tenet of palliative care is that we care for each patient with his or her family. The well-being of one is intricately entwined with the well-being of the other.

Whether or not a sick person can speak or understand spoken words, his or her family can express love, gratitude, and forgiveness. Families can honor and celebrate the person, their relationship, and shared experiences.

As important as words are in communicating thoughts and feelings, words are merely tools for conveying those thoughts and feelings. In this new edition of The Four Things That Matter Most, I tell the story of a father and son whose relationship continues through the father’s advancing dementia, epitomizing the profoundly rich yet nearly wordless communication that can occur.

My Own Story

I learned a great deal from the people I interviewed for this book. They enabled me to understand how much courage it can take to say these Four Things.

And writing this book forced me to have a conversation with my mother that I am forever grateful for having had—and nearly didn’t have.

My mother, Ruth Byock, lived in a retirement community called Leisure World in Southern California. (She called it Wrinkle Village.) On November 26, 2003, the evening before Thanksgiving, I received a call at my home in Montana from my sister, Molly.

Because I had been on another phone call, I first heard her emotional voice message:

“Ira, it’s Molly. This is not good news. Mom has been in a car accident. I’m going to the Orange Coast Memorial Medical Center ER. It doesn’t sound good. I’m going to take some deep breaths and pray that if she’s in bad shape, she’s gone. I’ll need all the support in the world. I love you. Bye.”

It turns out our mother had died in her car that night. She had suffered a heart attack as she’d headed north on the 405 freeway in nearly bumper-to-bumper traffic; apparently she died quite suddenly and her car had simply rolled into the one in front of her.

I didn’t have a perfect relationship with my mother, and because she died without any warning, I didn’t have a chance to say good-bye. I miss her a lot, but I draw comfort from knowing that we had not left anything critically important between us unsaid before she died. The Four Things That Matter Most had not yet been published, but Mom had read the printed galleys of the book, and we both felt it would be important to have a conversation about the Four Things.

It was not at all easy, even though I’d written the book about them. I had a lot to ask forgiveness for, as I had not been a perfect son. I’d driven my mother nearly crazy with worry during my college years, which coincided with the Vietnam War protests and peace, love, and rock and roll. I’d hitchhiked across the country (several times) and had ongoing fights with my father that had threatened to tear apart our family.

I had some things to forgive her for as well. Mom could be emotionally overbearing and smothering. (In my adulthood, if I complained to her that she was being a “Jewish mother,” she’d say, “Thank you. That’s what I am!”) In the process, I realized I didn’t have to deny that she sometimes drove me crazy; I had to forgive my mom for being who she was.

I had much more to express my gratitude for. Mom loved me wholeheartedly; she was my biggest fan and ardently supported me in every and all ways she could. I thanked her for so many memories of events and for things we had done together. We reminisced about summers at the beach on the Jersey Shore, school events she’d participated in, the time I was seriously sick at home with a high fever after receiving what turned out to be the wrong allergy shot, the car trip she and I took through New England in the fall of 1967 as we toured possible colleges.

Saying “I love you” to each other was easy.

Having had that conversation doesn’t make me miss my mother any less. I think of her often and wish I could update her on what has been happening in my life and, more often, in the lives of my daughters—her granddaughters, one of whom now has a son of her own. So I “talk” with her anyhow and smile when I think of her. It’s not the same, and sometimes I ache, wishing I could have that conversation in person, or by phone. Still, I’m not sure I would smile as easily if we hadn’t talked about the four things that matter most.

Writing this book and talking with people about the Four Things has also taught me to apologize more readily and effectively than I had before. Maybe I should say it is something I am still learning, and I have regular opportunities to practice.

Despite being a loving, well-intentioned person, I am at times irritable. One of my nicknames in high school was “Irascible.” In my weak defense, I think it’s an innate character trait, one of those in the spectrum of temperaments that people are born with. But my choices contribute: I tend to work too much, sleep too little, and drink too much coffee, all of which likely make matters worse. Whatever my temperament happens to be, my behavior is my responsibility.

I have been working on listening better, having patience, and being attentive to the ways what I say or do—and how I say or do them—make my wife, children, sister, friends, or coworkers feel. I like to think that I’ve been mellowing with age, but I still screw up from time to time.

When I realize I have snapped at someone—it’s almost always a family member or someone I work with closely—or discover that I was perceived to be dismissive or disrespectful, I feel awful. Specifically, I feel embarrassed and ashamed. In younger years, I would have recoiled from the shame and avoided apologies or made them halfheartedly, by saying, “I’m sorry that you felt hurt,” in a passive voice. In the past decade, in no small part as a result of questions and discussions about the Four Things—and lots of reflections and soul-searching—I realized that real apologies require owning the embarrassment or shame that comes with accepting responsibility for doing something wrong.

In squarely facing the person I have slighted or offended, taking full responsibility for my misdeed and saying “I am sorry” and asking to be forgiven, I sometimes feel like I’m standing with my most embarrassing weaknesses exposed. It never feels good. But that’s where the power of my apology comes from, being willing to speak my mind and heart despite my discomfort. I now understand that apologizing is a way of saying to a person I care about that our relationship is worth the embarrassment (or humiliation) I feel in admitting that (once again) I was wrong.

I’ve learned that after I have authentically apologized and the person I have hurt has accepted my apology, our relationship is stronger.

• • •

Although the most powerful stories about the Four Things come out of difficult situations and relationships, they are applicable at most any time. They are a simple, straightforward means of maintaining the health of our inner lives and our relationships. Yet we avoid certain topics with the most important people in our lives. Saying the Four Things can help you express gratitude, love, and forgiveness. Most of us have no straightforward means of maintaining the emotional health and happiness in our inner lives and our relationships, although we regularly go out of our way to maintain our physical health with medical examinations, weight-loss and exercise regimens, or rigorous avoidance of certain high-carbohydrate or high-cholesterol foods.

Saying the Four Things may be the most important thing you can do for your emotional well-being and that of your family. People who have communicated with me since the first edition of The Four Things That Matter Most was published have reinforced my belief in their beneficial effects.

As this edition is published, I’m excited to think that it may reach and help many more readers. And I am excited as I anticipate the new things I am likely to learn from you.