Reflections On Mortality: A Patient Faces Death

Go out of this world as you entered it. The same passage that you made from death to life, without feeling or fright, make it again from life to death. Your death is part of the order of the universe; it is part of the life of the world.

Stephen Greenblatt finds these words of Lucretius a therapeutic mediation on the fear of death (2011, p. 248). To spend one’s life anxious about death is to deprive oneself of the fullness of life and its enjoyment. But if someone is afraid of dying, as was my patient, newly confronted with a life-threatening illness, how do you overcome such fear?

My patient had been diagnosed with a cancer, a prognosis that statistically limited her life to two more years at best. “It’s just a statistic,” she would say in her characteristic manner, trying to counter her depressive proclivities with an artificial brightness. Then she would weep. “I don’t want to die. I’m too young. It’s not fair.” She was sixty years old—a very youthful, energetic, productive sixty-year-old. At the height of her profession, she had just embarked on another creative endeavor.

I had known my patient for more than thirty years. She had sought analysis in her twenties while a graduate student, unsure about her future vocational direction. Her six-year analysis revealed a woman who had had to rely on herself to make her way in the world, emotionally and professionally. While financially well provided for, her mother’s self-preoccupation and need for admiration left my patient feeling essentially unseen. She organized her self-esteem around her own achievements and ability for mastery. Her analysis enabled her to face and grieve some of what she had missed growing up, but she and I didn’t dwell in that place too long. She felt optimistic about the future and ready to just live in it. It was early in my career as an analyst. I chose, wisely or not, to assume her insight would “spread” (Poland 2013, quoting Reid and Finesinger 1952) and lead to greater growth over the years. To some extent it was true. Over time, she was increasingly successful in her career. She married a man she loved, and had children she also loved, though these were not feelings she could consistently inhabit.

However, limitations in our work revealed themselves over time. She returned when her mother was dying to talk about her unfulfilled need to find a place of centrality in her mother’s heart and mind. She remained for only a brief time. As we later understood more fully, she needed to assuage her unconscious guilt about the rage and disappointment she felt regarding her mother. Years later, when her rage became manifest, she returned for an extended and intensive piece of analytic work, in which we explored and experienced her frightening aggression in our transference-countertransference interactions. Anger, minimal in her earlier analysis, now took center stage in relation to her parents, husband, and children, and toward me in the transference. Her longing for her father and disappointment in his not rescuing her from an engulfing closeness with her mother were new to her. The work freed her to experience her loving feelings with new depth and to pursue her creative work with an expanded range of ideas. So at the time of her cancer diagnosis, she felt more fully alive and engaged than ever before. The irony and unfairness pained us both. But it also confronted us with an unresolved psychological issue.

“I can’t free myself from thinking that I have caused this to happen to myself. I know it can’t be true, but I can’t shake the idea that it is. Help me to understand this. I don’t want to die so why should I do this to myself? It seems an extension of all we have understood about how I turn on myself to protect others from my anger. But this seems . . . I don’t know. I don’t understand, but I hate and am ashamed of myself for being so self-destructive.”

What emerged as we explored her conviction that she had done this to herself was her belief in her omnipotence. Her need for self-sufficiency, to believe in her own power to control whatever happens, was familiar territory we had addressed over the years. But now it took on new meaning. If she was in control of her destiny, what would it mean that she had done this to herself? Could she be that self-hating, that self-destructive? She thought she had changed, softened in her feelings. I hadn’t helped as she had thought. She was angry and disappointed in me, and to feel that just now, when she needed me so much, was frightening. Why hadn’t I protected her? Or was I to blame? She oscillated between hating me and hating herself.

I said it seemed she was caught in a terrible dilemma. She needed to continue to believe that she and I were able to control what happened to her, even an illness she knew was beyond her control or mine, or she had to believe that she wanted to harm herself and I was refusing to protect and help her. Maybe I was even responsible for her being ill. She was silent for a long time. Then she began sobbing. It continued until the end of the hour. In the sessions that followed, she was filled with grief and began to mourn her belief in her powers and mine. This mourning segued into the grief she felt in relation to her illness.

Suddenly, her horizon was shortened in her mind. Thinking about the future introduced feelings of panic. What future did she have? She had to find a different way of thinking, a different way to create a sense of self-worth. It required a different kind of mastery. She now needed to live with uncertainty and still not become flooded by anxiety.

Time with her family became newly precious. Her husband would drive her to her treatments. They would talk about how this was time they might never have taken to be together and appreciate each other were it not for her illness. She didn’t want to think about this as compensation for her illness—she knew she tended to counter bad thoughts with good ones—but she wanted to be sure she was really allowing herself to appreciate that she had something of great value in their mutual love and her being able to depend on him. Similarly, her children were present and loving, taking time from their busy lives to be with her and express their love, something sensed but in their family not often put into words.

Her radiation and chemotherapy exhausted her. She did not have the energy to come to my office. Frequently we needed to rearrange our time to accommodate her medical treatment. We continued our sessions on the phone. I lost the opportunity to see what was happening with her body, to see how sick she was. She was familiar with Skype from her work but never indicated a wish to use it. I believed I should follow her lead. I thought about going to see her at home, but she never suggested this. If she were dying now, I know I would have raised it. I think it would have scared her if I had suggested it at this time, interpreting my suggestion to mean her death was imminent. She worried that our sessions focused too much on her telling me how hard this all was for her and getting me to let her know I understood and was there for her. Could she permit herself to not be trying to learn something new about herself? Learning was her lifelong way of being in control, defending against dependency, passivity.

This was not the first time I had worked with a patient who was dying. About a decade before, a former patient who had, by coincidence, also been in analysis with me in her late twenties and whose mother had also been self-absorbed and inattentive to her daughter, had returned to talk with me when she learned she had a cancer that was likely incurable. This patient now lived far away and I spoke with her on the phone once a week until she died some eight months later. Although many of their conflicts were similar, the two patients’ adaptations to their situation were quite different. My former patient overtly struggled in her intimate relationships. She had ambitions she was never able to actualize. But in this last year of her life, she became able to appreciate her love for and from her family and close friends. Her envy and anger toward others diminished and then seemed to disappear as she let herself enjoy being cared for. In this period, she got the attention she had longed for throughout her life and stopped fighting her dependency wishes. What she didn’t want to burden her family and friends with, she could tell me. It made her feel less frightened and less alone. I admired her ability to face her illness, let go of grievances, to let herself be loved. I’ve missed her and think of her often, even more so now with my other patient facing a life-threatening illness. I ask myself whether I am muting the intensity of my pain and grief as this past threatens to become more alive. Probably so.

When a patient of ours faces death, we, their analysts, if we are to be of help, need to face and tolerate helplessness, fear, rage, and grief along with whatever other emotions our particular histories stir in us (Norton 1963). The impending loss of someone with whom we have had such depth of experience evokes a special kind of grief in which we are alone, unable to share it with loved ones in our patient’s life and only sparingly and confidentially with trusted colleagues in our own. As in all psychological treatments of depth, in the course of our work we will learn much about our patients, but also about ourselves (Gardner 1983). What we learn, what we need to face in ourselves, may be frightening and painful. Our devotion to our patients and commitment to, and belief in, analysis as a process that strengthens enables us to remain present. And when the patient with a terminal illness is someone we have previously analyzed (Marguiles, Orgel, and Poland 2014), we are confronted with an impending loss of someone we have known intimately over time. When we have analyzed a patient at an earlier time of life (for both of us) and the patient returns (Almond 2013; Kantrowitz 2013; Orgel 2013), we have an opportunity to appreciate what we have and haven’t recognized, understood, or analyzed previously. At a different, later stage of life, we each know more about ourselves and are better able to face our vulnerabilities. We are now older too, and thoughts of other lost loved ones and our own mortality inevitably arise (Norton 1963; Margulies, Orgel, and Poland 2014; Poland 2016). The patient’s return provides us a chance to go further. But when the return is precipitated by the onset of a life-threatening illness, or this onset occurs in the course of this later work, as was true for my patient, we know there is likely to be a very limited future. What then is our task?

Freud (1926) proposed psychoanalysis as a method to help one better face and participate in the vicissitudes of life. But what if it is death and not life that we anticipate awaits our patient? “News of a patient’s impending death,” Poland movingly writes, “awakens awareness of the end awaiting the analyst’s own life. The analyst’s belief in being an exception to the rule that all flesh is mortal is challenged. In a patient’s dying, the analyst’s own death is foretold” (Margulies, Orgel, and Poland 2014, p. 902).

I am pulled here to personal reflections. I recall Dylan Thomas’s line, “After the first death there is no other.” Looking up the poem it’s from—“A Refusal to Mourn the Death, by Fire, of a Child in London” (1945)—I see there are many different interpretations of what he may have meant by the line. I have never before explored how others have understood it. Many people think he intended to convey that the first death forces one to recognize the reality of death itself, the shattering of a belief in immortality that changes one forever. I cannot remember ever having that belief, though surely I must have had it once. My mother told me that at four I had cried begging her to think of and tell me about someone who had not died. The power of my fantasies shaped by my own wishes and fears must have had a strong impact on me as a child.

I don’t want to die, but it is being alone without those I love, the loss of loved ones, not death, that I consciously fear. Of course, I do not know what I will actually feel when facing death. I had interpreted the Dylan Thomas lines to mean that the first time someone we love dies, we experience a grief that is deep and powerful and that is revived with every other death of a loved one that follows, shaping and containing all subsequent experiences of loss and grief. I don’t know if that is what he meant, and I continue to think about whether I believe it is true. I do think each death leaves one with an experience of sadness that revives the emotion attending earlier losses, though ones not of death. These losses Shelley Orgel (2000) describes as “a revived necessity to face again the wounds inflicted by the developmental calamities of his or her own childhood—those we abbreviate as the loss of the primary object, loss of its love, oedipal defeat, castration, superego criticism, or awareness of death” (p. 732).

Orgel was writing about the analyst’s experience ending analyses with patients, experiences foreshadowing the death of loved ones and ourselves. The first death of a loved one concretizes these earlier wounds as one loses the part of oneself that has been invested in the other and the relationship. There is an irrational, emotional expectation that when one loves deeply, those we love will always be with us. The loss of this conviction leaves something more than just sadness. It leaves an anxiety about allowing closeness, intimacy, dependence, an anxiety that can be evoked by separations, illnesses—an awareness of our existential aloneness.

With patients, one knows better, at least intellectually. Termination is expected, with the possibility that there may be no future contact. A necessary loss. With people in our lives whom we love, who are not our patients, we don’t imagine such endings, unless like our parents they are much older than we are. And even then with people in our lives, there is a way that when we love, we don’t really anticipate loss until we need to face it (though some people, depending on their early life experience, lack this shield against traumatic loss). The death of older loved ones undermines a fantasy of protection—both in terms of how they may have nourished us, cared for us in illness, mentored us in crisis, served as a model, helped us grow. It also makes us all too aware of our own mortality. As we age, more and more people around us whom we love become ill and die. We lose an intimate and comforting surround. When a beloved young person dies, we lose our investment in the future, our anticipation that this beloved person would carry on even when we are no longer alive. Each emotionally felt death piles upon the deaths before, reverberates with and echoes previous grief. This is what I took Dylan Thomas to mean. And while I think it is true, I, think something else seems lost in this construction.

For each loss is also unique and specific in terms of the meaning of the relationship we have to the loved one. We love in a particular way in each relationship, and so we lose and grieve for that particular person and what it means for us to go on in life without them. What we lose, what we grieve and need to mourn, is highly specific, even while the experience of grief is already familiar. Sometimes, particularly as we age, losses accumulate too rapidly to assimilate, and we need to find time and space and ways to facilitate our mourning. We need to cherish our memories of who each loved one was and what our relationship was, to impress this in our memories, honoring them and their meaning to us, acknowledging the loss of a future while marking what it is in us that we retain—how the relationship changed us in ways we do not lose with their death. Such is the case for me when thinking of our deeply loved son who died at the age of thirty-one of a brain tumor. Memories of him make me laugh and then make me cry. I return to them frequently, but do not want to dwell there too long.

So all this, and of course much more, was stirred in me when my patient told me her diagnosis. She needed my help, my accompanying her through this physically and emotionally terrifying, painful time. My patient knew of my son’s death and feared what her illness revived for me. Could I tolerate hearing about her pain and fears? Would I leave her as thoughts and feelings in me evoked a need to return to my own loss and grief? Could she tell me that she envies and resents me for being well while she is ill? Can she talk about the unfairness of her situation? Does she dare to do so while feeling so dependent on me to stay with her and provide a place where she can say to me what she worries will drive others away? I tried to help my now deceased patient do these things. I am trying to make it possible for my current patient to do so as well. We have a history from which she knows I can withstand her hate and aggression. She also knows I hold positive, warm feelings for her. But in her panic about her mortality, I worry that all she “knows” could evaporate.

Her treatments make her weaker and more tired. It creates a crisis of her identity (Rando 1993). She is someone who has been tireless. Even in the early stage of illness she continued to be able to work creatively. Now she is forced to adjust to the reality of her situation, to confront that she cannot continue to be progressive in orientation (Rando 1993). All our sessions now take place on the phone. Not seeing me is a mixed blessing. She cannot feel reassured by looking at me, but she also does not have to fear what she will see or what I will see. She tells me she has lost twenty pounds. She loves sweets but will not eat any, having been cautioned they may cause her harm. I wonder with her about the severity of her regimen.

Having rescheduled a recent session for an earlier time, I momentarily forget the change and don’t hurry as quickly as I usually do to pick up her call. The phone is ringing and stops as I enter the room. (I do not keep a phone in my office. I do my phone work from a different room in my home.) A moment later it rings again and I answer. I apologize, telling her that I just missed the earlier call, that I had for a moment forgotten that we had moved the time earlier. Is my forgetting also an effort to forget that the time of her death has been moved earlier? Immediately I worry that my countertransference wish not to cause her more pain will have shut off the opportunity for her to be angry with me.

She begins: “The last twenty-four hours have been hard. The hospital has been having trouble with their equipment. All treatments were delayed. It’s hard enough to go through this, but to have to wait. And it is in my interest for them to like me. I don’t want to seem like a difficult patient. I will be doing this with them for months. I told them that they were having a very difficult morning. As I was leaving I heard one nurse say to another, “Aren’t we lucky to have such lovely people as our patients.”

Her anger with me expressed in displacement here is so blatant. I wonder if it is conscious for her. I let a few moments pass. Just before I am about to say that it would be understandable if she were to feel the same anger and fear of expressing it with me, she begins to speak.

“I have to admit, I felt angry with you when you didn’t answer the first time I called.”

I wondered with her what she thought and felt when I didn’t answer. “I thought you were angry with me. Maybe you didn’t want to talk to me. It can’t be easy listening to me going on and on about my treatments and my fears. You like to help people get better, to understand things. I think sometimes it must seem like all I do is say how hard it is and you let me know you understand. That can’t be very interesting or satisfying for you. Why wouldn’t you want to forget our time? But then you explained and I stopped feeling angry because I knew from what you said that you weren’t angry with me, that you felt bad you had kept me waiting.”

Me: “But you had imagined I didn’t want to talk with you, that I was impatient or dissatisfied with what we are talking about together. You reassure me you were reassured, but maybe as with the nurses you feel a need to reassure me that you are understanding about my feelings, about what I am doing with you, so I won’t be angry with you, so I will want to continue to work with you. So I will think you are a lovely, caring person.”

My patient cries. “I’m afraid I’m frightening you. My illness may make you feel frightened you can become ill. I make you think about your death. Why would you want to think about death? It will make you think of your son’s death. It will make you think of your own. So why would you want to talk to me? You’ve lost a child and you’re a lot older than I am. Closer to death.”

There is a long pause. After a while I note that she has stopped. I wonder aloud what she is thinking and why she has become silent.

“You’re a lot older. You may be thinking about your own death. Maybe you are thinking you are glad it is me and not you who is ill. That would be natural.”

Me: “And it would be natural for you to think because I am much older that it should be me and not you who has a life-threatening illness. You’ve had those thoughts about older people before. And you worry I will turn away from you because your illness revives memories of my son’s illness and his death. That I cannot bear a revival of this grief or this fear about my future.”

She sobs, “You must hate me for making you think about your son’s death and for wishing it were you and not me. How can you stand being with me?”

Me: “I think you hate yourself, and you said before, feel ashamed, when you wish it were someone older, now me, rather than you. And when you fear your illness, reviving memories for me of my son and his death, you are frightened I will leave you in anger about what you stir in me. Then, as you said, you imagine I will hate you and not want to be with you. You are afraid that your thoughts can harm me and drive me away, so when I was a few minutes late today you imagined that was what had occurred. That frightened you and made you angry that not only were you the one who was ill but then you imagined that I couldn’t tolerate the fear you imagine your illness stimulates in me, that I would abandon you. Then you can be your own advocate, feeling the unfairness of being younger, having this awful illness, and be angry with me, but then it frightens you that I would leave you and you have to be empathic with me to keep me on your side.” And I thought: Having said all this—and there are so many words—am I also trying to hide the truth from both of us? That I too want to turn away, that not only is my forgetting likely based on a reality, but that part of me doesn’t want to be there with her, identified with her, unable to ward off the return of my own past grief.

She cries and says all I’ve said is accurate. But how can she bear to go on when she has reason to fear that all she has would be gone, that she would be gone. She could not bear it and does not see how I could. What had the purpose of all she tried to do been worth? I ask what she had imagined. After a long silence, she says, “I guess I imagined it would go on forever just getting better and better if I tried hard enough.” The vestiges of her omnipotent belief are now clear to both of us.

The reality in sessions like the one I have just described is easier for me to bear than it is in others. I feel I am doing our work, that it is useful to her. She is right that I find it harder to sit with her sense of helplessness and pain, feeling all I can do is be with her and for us to bear the grief and fear together. I admire her. She is brave. She has grown so much over the years. I have watched her growth, been part of some of it. She is one of my analytic children. Almost like my own child. I ask with disbelief how she can die before me. She is right; it’s not fair. I am left by others as they die; the frequency of this increases as time goes on. It is painful. Sometimes the grief does feel unbearable.

In a later hour, she says, “I do not want to call myself ill. I am afraid if I say that other people hear it as I am about to be dead.”

I say: “You are afraid that they will jump ahead in their minds, as you do in yours.”

I need to be with her. But what does this mean? To be attentive to her state—not too far ahead or too far behind? To monitor my own state so it does not obscure hers. I talk to myself, to a few trusted others, in order to keep my own feelings as clear as I can. I try to hear where she is. I know I need to be honest with her, not unrealistically reassuring, but also not depriving her of the hope for whatever pleasure she can have in the time she has left.

It makes me treasure the time we have. We cannot know how long it is, but it is possible now. There will be a time when it won’t be. My task, I think, is to try to help her feel this way about time—to cherish what we have, face that it’s finite, and invest in the present while we have it and to let go when there is more suffering in holding on (Adams-Silvan 1994).

Later: My patient is in the last months of her chemotherapy treatments. She is thinking about what comes next. Should she return to teaching, which she loves? She misses contact with her students. Perhaps she could do it less than full time. But she worries about money. She also wants time to be with her children. Time? She still doesn’t know what time she has left. Her husband has always wanted to live abroad. Perhaps this is what they should do. Take six months in Rome. Yes, this seems like a good plan. She seems settled into this idea.

I asked her how she imagines it. She begins to describe the meals they would eat, the things she would buy. She stops. Then she begins to sob. She can no longer eat what she wants because she is told her diet likely affects her health. Food and buying things have been such a huge pleasure in her life. Clothes and jewelry always are connected with the delight of her imagining wearing them in the future. But will there be a future? She is so grateful to her husband for all his care and attention. She wants to do what he would want, but… We have been here before. This is about her willingness to sacrifice all her own wants and wishes to someone on whom she has been dependent. She reminds us that she knows this and thanks me for helping her remember this and what it costs her. Actually I have done no more than ask her what she imagines it would be like. The rest is her evoking what she already knows about herself.

After the session, I am thinking about my patient and her willingness to be self-sacrificing out of gratitude. We know she hates being dependent. And with this thought I realize that I have not been thinking of something in my own history, something I know very clearly and have known as long as I can remember but which amazingly has not come to mind in the context of my patient’s illness. When I was five, I had typhoid fever. It was before antibiotics, and I was home in bed for three months. My mother took care of me, reading me the whole series of The Wizard of Oz. I was critically ill, yet my memories of this time are only pleasurable: a sunlit room; the endless engrossing stories; my mother’s attentiveness. Clearly that cannot be all, but memory is merciful. But, of course, something I wrote a few pages back needs to be modified. I had been faced with the possibility of dying, and perhaps my asking my mother to “think of someone who didn’t die” occurred during or after my typhoid. I am an only child; there is no one left to ask. I was very close to my mother as a latency child, pulling away as an adolescent with much guilt about the pain it caused her, not understanding until my analysis in my early twenties what I felt I had to sacrifice to her in my gratitude. But gratitude is from the word “gratis.” It is meant to be something freely given, without sacrifice. My anger about what I relinquished was covered over.

My patient’s thoughts of gratitude had triggered my preconscious link to these memories. I was so glad to now be the one who was depended on rather than the one depending. But with this thought comes the recognition that my battle with typhoid occurred more than seventy years ago. If I do not die quickly, as I would wish, then I will inevitably become dependent again, as age or illness is my fate like everyone’s. No wonder I dread being alone, left by those whom I love and who love me. I know my dependence but I also fear it—what if I am alone? The dread that arises has parallels to my patient’s dread of dying. I return to my earlier thoughts with greater poignancy and understanding.

I was in my early forties when my father died. He was in his seventies. He too had undergone a painful course of cancer. Given a history of early deaths in his family, though, he had never expected to live as long as he had. He felt he had had a good and full life. A year after he died I dreamed that I was walking with him. In the dream I knew he was dead, that I was dreaming, and that when I awoke, he would be gone. We continued walking and talking. I awoke in tears with a renewed and condensed appreciation that he was not mine to keep.

I have always loved Freud’s paper “On Transience” (1915). I now think I better understand why. “Not long ago,” Freud begins, “I went on a summer walk through a smiling countryside in the company of a taciturn friend and a young but already famous poet. The poet admired the beauty of the scene but took no joy in it. He was disturbed by the thought that all this beauty was fated to extinction, that it would vanish when winter came, like human beauty and all beauty and splendor that men have created or may create. All that he would otherwise have loved and admired seemed to him to be shorn of its worth by the transience which was its doom. . . . I could not see my way to dispute the transience of all things. . . . But I did dispute the pessimistic poet’s view that transience of what is beautiful involves any loss in its worth. . . . the value of all beauty and perfection is determined only by its significance for our own emotional lives, it has no need to survive us and therefore is independent of absolute duration” (pp. 305–306). Freud concludes: “What spoiled their enjoyment of beauty must have been a revolt in their minds against mourning. The idea that this beauty was transient was . . . a foretaste of mourning over its decease” (p. 306).

Mourning is easier to experience when one can imagine a future—other springs that will come, new loves or friends or lives to invest in—but when people are dying, they have to let go of that imagined future time. Our own age also affects us, as do our responses to a patient facing death (Houlding 2013). As we age, it is hard to accept that there may not be future loves, future friends; no future analytic children or new lives to replace those we have lost. It is hard to relinquish such a hope, but it makes us aware of what Freud is suggesting: what we have is now. We need to appreciate it, not deny that it or that we, or those we love, are only transiently present. We need to try to live in that space. And all I can do for my patient is stay with her to help her with the unfinished business (Nuland1993) represented by her omnipotent belief that she could control her destiny with her thoughts, to help her mourn her loss of omnipotence, to tolerate her helplessness, to grieve what is likely to be her premature death, and to live as fully as she can, while she can. I hope our work together will make it possible for her to enjoy and savor what she has now, to access reality, to appreciate the present. I try to convince her that she can count on my presence for as long as she wishes and for as long as I am able. We both need to know, but not be paralyzed by, an awareness of the painful reality that our current life, all we have, can end at any moment.

Over the following months, my patient and I continue to talk about her fears of death, of her grief over anticipating never being with her loved ones again. Simultaneously, with increasing frequency, she talks of current pleasures. When her chemotherapy is completed, she selects a necklace to celebrate the event. Then she buys new clothes for her slimmer figure. She spends a weekend visiting one of her children. They laugh a lot and don’t talk much about her illness. Another weekend, they visit old friends. The friends want to talk about her illness, to know what she is going through, but one of them has been ill too. Talking about her illness with them isn’t so painful. She feels close to them, not so alone. It is harder when she is home; everything reminds her of her illness. Even so, as she begins to regain her strength, she feels better more of the time. She is no longer collapsing time as much. Her future, of whatever duration, is a time she can find some pleasure in, for as long as she can. It is all we can hope for. And while today I am healthy, I know that most of my life is behind me. Together we face the heartbreaking reality that all we have is now, which we must cherish and enjoy.