Abstract
A significant part of my psychoanalytic identity is the writing that accompanies my practice. When I suddenly became ill two years ago with acute myeloid leukemia, I was forced to shut down my practice the day I received the diagnosis. It was a never-to-be-forgotten doctor’s visit to receive blood work results after a full day of patients. In the months that followed, prolonged hospitalizations and a bone marrow transplant ensued. Informing my patients in person of the need to stop working was not possible—there was no time. Instead, I spoke with each on the telephone from my hospital bed. When I resumed my life and my practice I made the decision that I would not write about my illness. I knew that writing would thrust me back into the experience of illness, and I wanted to move far away from that in my mind. When I was invited to review this book, Flirting with Death, I was one year out from my return to life and work. For me, writing on this topic now might better be titled Flirted with Death. Approaching the second anniversary of my diagnosis, I feel at a safer distance, one that does not have to bring the immediacy of illness and dying, and now I am interested to read how colleagues bring their minds to illness, to facing death in themselves, and in others.
Flirting with Death, edited by Corinne Masur, is a collection of essays, all related to mortality but in different ways. Many of the contributors are renowned senior analysts who bring their courage to express their thoughts on this difficult topic. They disclose aspects of their personal lives, their histories, their experiences with integrity and professional reflection in ways that invite readers to engage in their own reflections.
I offer my review of the contributions to this book along with my own personal reflections. The paucity of contributions about mortality in psychoanalysis has prompted Masur to assemble her own chapters and those of a small group of analytic colleagues into a finely tuned edited volume. She dedicates her book to an exploration of “how we work to . . . become more open to our patients’ feelings and fear about death and loss when they evoke such terror both in them and in ourselves” (p. 3).
As a child, Masur suffered the early unexpected loss of her father. Later, as a young mother, she was hit with a sudden heart attack, bringing her close to her thoughts about death and dying. She emphasizes the denial of death that is endemic to our profession and cites Freud, who observed the impossibility of imagining one’s own death. He did not give mortality any psychic significance. The paper she cites on the fear of death and the wish for immortality (Zilboorg 1943) was written during World War II. This collection of essays is highly personal, and exceptionally accessible. Each writer reckons, in an informal, reflective manner, with very personal, painful experiences: losses, illnesses, and the challenging, sensitive clinical work that we do.
In Masur’s introductory chapter, “Mortality and Psychoanalysis,” she writes that there are times in life that can be too much to bear. She remembers the cardiology fellow treating her during her hospitalization who recorded in her chart “highly anxious patient”—and reflects on the problem in medicine of the physician’s limited capacity to recognize the terror and loss involved with life-threatening illness. This brought to mind an experience I had during my own illness. In the days following my hospital admission, when I was contacting my patients and informing them of the need for a six-month hiatus in our work, I was frequently sad and tearful, especially just before or after a call with a patient. On one occasion the oncology fellow walked into my room and, witnessing my sadness, commented, “Perhaps we need to bring in the ‘benzos’” (Benzodiazepine, a sedating anti-anxiety medication). In the moment, I responded that medicine was not necessary and that I was simply feeling sad. I took the opportunity a few weeks later, when his rotation on my unit was ending and he came into my room to say good-bye, to talk with him about what I viewed as the challenge of emotionally tolerating patients’ sadness. I urged him to recognize the importance of understanding that illness brings many experiences of loss that need not be treated with sedation.
Masur’s chapter addresses the commonality of the fear of death, a fear shared by all, including the analyst, and examines the relative absence of attention to the topic in the psychoanalytic literature. Masur thoughtfully considers the impact of the denial of death on the analyst and on the practice of psychoanalysis by discussing the analyst’s defensiveness to exploring one’s own mortality, the reluctance to work with one’s patient on mortality, and the difficulty in preparing one’s practice plans in case of death. Masur suggests that “recognition of the finite nature of life is a goad for productivity and creativity” (p. 11), yet at the same time acknowledges that there can be terror associated with mortality. When facing a life-threatening illness, there is both—managing the terror of facing death and at the same time appreciating the precious elements of life that may have been taken for granted. Masur contrasts the defensive nature of narcissism and omnipotent grandiosity with efforts to sustain a consciousness of death’s proximity when openness to awareness of this subject is our professional responsibility to our patients. In discussing clinical material, Masur draws our attention to how historically concerns with death would be analyzed as a symptom (for instance, of castration fear or narcissistic insult). Yet Masur emphasizes the shared inevitability of death for patient and analyst and the challenging countertransferences both in working with our patients and in establishing a plan to prepare for the possibility of our sudden illness or death. The need for a plan becomes clear through Masur’s clinical material demonstrating the devastating impact of the analyst’s unexpected death or illness on the patient. Each of us is responsible for putting in place a professional will.
Nancy McWilliams’s chapter, “Psychoanalytic Reflections on Limitation: Aging, Dying, Generativity, and Renewal,” begins with personal testimony of her struggle with illness, and her experiences of losses of those most dear to her. She then moves to a consideration of facing human limitations and the particular challenge in North America, the land of opportunity—where the ruling myth is that all is possible—of facing human limits, the limits of health, limits of mortality, and the limits that aging introduces. McWilliams also reckons with experiencing her own aging limitations. She emphasizes the need for more conversation about aging with the younger generation so that it does not remain a forbidden topic. Such conversations and thoughts should become acceptable and appreciated as valuable so that there can be communication about the actual pleasures and gratifications of aging. McWilliams makes a plea for analysts to join with our communities for support and discussion around aging issues and late-in-life practice issues. She notes that there is a quality to our limitedness that offers us something psychologically valuable. Culturally, our emphasis on an individualistic ethos makes communal values seem less important. Analysts value the capacity to accept what cannot change and move toward satisfactions that are possible but involve a grief process. Acceptance of limitations and grieving what cannot be possible enables a creative generative process. McWilliams notes here the psychologist-analysts who early on lived within great restrictions and limits in North American psychoanalysis and yet within those limits found ways to open up psychoanalysis in creative ways. Her long-needed call to conversation and community is refreshing and inspiring.
Salman Akhtar, in the section “Early Exposure to Danger and Loss,” contributes a chapter that departs from the others in this book. “Orphans” is not a reflection drawing on personal experience. Rather, Akhtar focuses his professional lens on the place of psychic “orphans,” those who in early life have suffered the death of parents. Akhtar sensitively attends to the lifelong impact of childhood parental loss by weaving together his scientific consideration and clinical experience. He cites Freud in addressing the work of grief, along with Bowlby, Spitz, Klein, and Kohut, and considers the nature of mental pain. He points to the narcissistic imbalance that results from parental loss, difficulties in the smooth development of aggression, problems in loving and sexuality, and disturbances in the experience of time and perspectives on one’s own mortality. Frequently he accompanies his discussions with clinical vignettes that bring life to these concepts. In the latter section of the chapter he offers clinical guidelines for treating these orphaned adults. Many of his clinical points—for instance, the crucial importance of the clinician’s empathic position vis-à-vis the loss—emerge organically from his earlier discussions of the mind of the orphan. He cites the need to attend to expected defenses against awareness of the loss’s impact, to patients’ defensive use of their orphan status, and to special problems around termination. Akhtar also discusses the place of countertransference in this work. He makes a final call for the resumed study of early loss, noting that the last formal efforts were published some thirty years ago.
In Henri Parens’s chapter, “Mortality—the Inevitable Challenge: The Development of the Acceptance of One’s Mortality,” the author looks at his clinical work in the context of his own experiences with mortality. He draws on his childhood experience of escaping the concentration camps in France to frame the impact of early trauma of threats to life on his thinking about mortality. This contribution, while profoundly personal—it includes excerpts from his memoir (Parens 2004)—draws also on Parens’s scholarly work on his longitudinal mother-infant project, his clinical publications with an adolescent, his exploration of the use of humor, the place of inner sustainment when facing mortality, children’s understanding of death, parenting, and working with children’s aggression. The chapter brings rigorous scholarship to the subject of mortality, yet at the same time Parens allows for a personal emphasis in his close consideration of his own early life trauma. The chapter’s epigraph is a poem by the author that speaks to his conclusion in celebrating the life he has created in his family and the resulting acceptance of his mortality. The chapter moves through a developmental line of what it means to face one’s mortality, beginning with childhood and proceeding through adolescence, adulthood, late adulthood, and old age, and includes his clinical work with patients on mortality awareness, fears, and the intrapsychic forces that yield particular compromise formations at different developmental phases. In Parens’s consideration of one’s readiness to face mortality in old age, he writes that “for individuals who have lived a painful life the awareness of one’s mortality may of itself become overly distressing” (p. 87) and that it is more relevant to the creation of this painful life that one has been maltreated by one’s mother rather than by one’s father—mistreatment by the mother is the ultimate trauma. I have to consider this idea a bit old school and in need of revision to include all parenting figures. “The ultimate trauma can destroy the ability or opportunity to structure and internalize a representation of the loving parent, which can then provide the older individual with an ‘inner sustainment’ that . . . could survive unmodified for the end of life” (p. 88). “The true love of one’s mother is a balm to the existential anxiety of mortality” (p. 88), and it is for this reason that Parens reconciles his own capacity to manage the threat to his mortality at age twelve when escaping the concentration camp on his own.
Parens differentiates between the threat to one’s life historically and a present threat to one’s life as he considers the impact on the analyst’s work with patients’ death anxiety. His final section is a consideration of mortality and religion, with a recognition of the thought about there being something larger than we humans in the universe. The oceanic feeling, referring back to the mother-infant, is about being one with the universe, and the use of religion can serve as a defense against anxiety, a sublime defense.
Ruth Garfield’s chapter, “Psychotherapy—a Life’s Work,” describes her experience with the impingement of a blood cancer on her life—her very personal experience of the diagnosis and reckoning with mortality, the impact of a fifteen-month hiatus in her work, and her thinking on the challenge of working with patients both before the hiatus and on her return. Garfield presents clinical vignettes suggesting that her patients with a history of early traumatic loss had greater difficulty working through the impact of the felt abandonment of their analyst’s illness. On a few occasions Garfield notes the bias she believes that psychoanalysis has for “fac[ing] life rather than death.” Garfield expresses surprise at how many former patients called and wished to resume their work with her following the hiatus, and also discusses the challenge of listening to her patients talk about illness and death and expressing thoughts about her possibly relapsing. Some of these patients said they felt trivialized in comparison with her illness. Garfield stresses her newly discovered emphasis in her life on family and friends and less on work. She credits her intention to practice an awareness of temporal limits to her early cancer when in her thirties and the later cancer more recently.
Harvey Schwartz, in “Illness in the Analyst—Thirty Years Later,” remembers an early threat to his mortality and revisits the writing he did at that time, offering a new perspective. He had to shut his practice for two months while facing the threat of death, which aroused memories of the earlier sudden death of his father. His surgery yielded a benign diagnosis. Schwartz revisits his idea that his errors with his patients then were opportunities for growth. I take issue with his notion that these actions were errors. Instead his actions at that time were more likely enactments that carried meaning in the context of the therapeutic relationship. As Schwartz considers that his ideas at the time of his surgery were not correct, the presumption is that there is correctness and there are errors. His consideration is focused in the realm of how much of himself to make available to his patients when there are life disruptions like illness. What is neutrality, what is abstinence, and what are anonymity and ambiguity? And what is in the service of the creation of the analytic third? Schwartz states his current belief that he was abstinent at the time, and that the decision to be so may have been self-protective in the midst of the frightening regressive feelings he was experiencing.
Schwartz says he wants to focus on the best way to enlarge patients’ freedom to experience the post-illness analyst. His earlier stance was that there was one way to be with all patients; his current ideas are framed with the benefit of experience and hard-won wisdom. Having come to appreciate the shared vulnerability of human beings, he sees that curtailing self-revelation is not as crucial as he once believed. Schwartz offers some clinical vignettes of his patients’ experience of his illness. He comments on their regression not so much in response to the disruption of the illness, but more as a response to the analyst’s distance. In fact, the whole question of telling versus not telling may have a defensive aspect. Schwartz considers the question with regard to colleagues, wondering whether they will prove trustworthy, and noting how one’s sense of vulnerability and concerns about risks to one’s livelihood impinge on the decision to tell or not. He finishes by acknowledging our field’s denial of the need to effectively work with death and dying, and asserts that not being forthright with our patients is problematic. His recommendation of a “buddy system” within our institutes is a plea for the analytic community to work collaboratively with life’s limits.
Reading Sybil Houlding’s “When a Patient Dies: Reflections on the Death of Three Patients,” all I could think was how tragic it would be to endure the deaths of three patients within five years. “I am not eager to write this chapter,” Houlding writes; “I did not want to revisit the losses that had caused so much disruption in my internal life and that were now sealed over and behind me” (p. 129). She reflects that to write brings an opportunity to think more and provides a “larger purpose than my own recovery” (p. 129). She implies that the process of recovery is to unseal and revisit. Houlding’s description of the “unsealing” is resonant with me; I, too, reopen my own mind in this review. Whether to unseal, to open what is past, is a personal decision warranting careful reflection and self-knowledge. There is no correct choice. Many who take on writing about their “flirting with death” experiences do so with vigor. A friend has for a decade been publishing poetry about her flirtation with death. Others wish to keep the locker sealed and resume life. Both decisions are acceptable.
Houlding experiences herself as a lifeline to her patient Julie, who has recently been diagnosed with esophageal cancer. Hearing of her patient’s feeding tubes, she writes in her notes that she sees “a glimmer of a fuller analytic process” and recognizes after the fact her own denial of the risk of death. Houlding describes her sense of knowing her patient, but privately, without the connection to Julie’s mourning community; she rues the “lost opportunities when Julie died.”
Houlding describes a couple she treated where, while she was away, the wife left the husband, who then committed suicide. Another died during her summer break, after falling and hitting his head. Houlding considers that the effect of a patient’s death on the analyst depends on where the treatment process is and also where the therapist is in her professional development, where the phase of transference is, and what may be going on then in the life of the analyst. The poignancy of Houlding’s descriptions of the lost opportunities with such losses is experienced at all times of illness and “flirtations with death.” Certainly for myself, the lost opportunities when the treatment process must shut down, and when it cannot be resumed because the disruption is too much for the patient to bear, can bring a profound sadness. The grief is so present.
Ellen Pinsky’s “Mortality, Integrity and Psychoanalysis” is a powerful reproach of psychoanalysis for neglecting the reality of the analyst’s mortality and failing to provide adequate care to our patients. To “unseal” in the sense that Houlding writes about is to face our mortality; we must recognize that we are at all times vulnerable, we are mortal. “If we do have a responsibility,” she asks, “what constitutes reasonable provision?” (p. 142). And “if we think there should be provision, yet tend to neglect it, why is that?”; “the way our work works is by our becoming important to people, in whatever individual ways they will make us important; we aim to matter. And we could say further that the psychoanalytic situation is purposefully configured to intensify our mattering. We call that process the transference. . . . if our aim, then, is to matter, and if we set out to court that condition, what is it for us to be lost?” (p. 143). She emphasizes how little is written on this topic of loss and its meaning, and recounts that her therapist died suddenly after a two-or-three-times-weekly treatment that lasted four years when she was in graduate school. At that time there was nothing in the literature on this topic. Given that our patients bring to us their mourning and grief, it is “remarkable that analysts have given so little consideration to the implications of their own mortality” (p. 143).
Pinsky revisits history. Karl Abraham died suddenly in 1925. Alix Strachey writes that there was no provision made for his death. It was a sudden shock to the community. “I propose,” writes Pinsky, “that the absence of theory and clinical provision for the therapist’s illness or death reflects underlying problems regarding termination—the ‘routine’ ending foreshadowed in the first hour the patient and therapist meet; the work begins, the work will end, just as the hour begins and the hour ends” (p. 144). Why have we resisted addressing the analyst’s mortality? No one likes to think about mortality: “the capacity to consider one’s mortality, by which I mean human frailty and limitation in every sense, perhaps defines the capacity to be a good guardian of the therapeutic situation: a medium through which patient and analyst alike may discover, and discover again, how closely related are the workings of grief and love” (p. 146). Freud, Franco De Masi (2004) remarks, “maintains that an inability to enjoy and appreciate the transience of beauty is due to an inability to mourn. . . . [The] inability to appreciate beauty comes from a rebellion against temporal boundaries. . . . there is . . . no love without loss” (p. 32).
Pinsky refers to Winnicott’s idea that the analyst must survive the patient’s attacks without retaliation, thereby maintaining the analytic function. Such retaliation would be worse than death. “[T]he analyst’s failure and the profession’s failure to think about, confront, and better provide for that eventuality” could be considered “motivated neglect, a countertransference hatred” where we are not protecting the patient (p. 147). Further, she writes, ethically this “virtual death by neglect, wherein analytic function is lost, may be more destructive than the actual one” (p. 151). The analyst’s work to safeguard that function must include “an acceptance of his own transience, both as person and in the specialized role, [and] that acceptance is perhaps another form of moral integrity” (p. 152). Pinsky recalls her experience with an analyst who refused to start an analysis because at the age of seventy-one he was concerned about dying before the analysis would finish. “I once decided not to be a cowboy,” he said, quietly rejecting a charismatic style, too often seen in analysts, that includes an implicit omnipotence and denial of mortality. This chapter is central to the power of this book. Pinsky speaks to the ethical implications of our recognition of our human limits and the disservice we do to our patients in continuing to be so negligent.
Sybil Houlding’s second chapter, “A Note on Retirement and Mortality,” considers the centrality of our analytic identity and the idea that not being an analyst is close to not being at all—an intimation of mortality and death. “[R]ather than facing their own aging, diminished capacity, and most difficult of all, their imminent and inevitable demise, these analysts leave their patients with the task of caring for them by continuing to remain in treatment” (p. 161). Houlding describes a patient who did not want to terminate, thinking that if she would not stop coming, the therapist would not retire. Here is the wish to keep the analyst alive by continuing the work: “denial of time passing is a hallmark of analysis, for patient and analyst alike, unless at least one party is alert to the reality of aging as time goes by” (p. 163). Retirement punctures the fantasy of timelessness, the denial of aging that analysis cultivates (p. 164). Working is equated with living, and the cessation of analytic identity and livelihood is a huge loss to endure.
Houlding observes that we avoid recognizing that retirement is not exclusively a personal decision. Besides affecting patients, this avoidance is “our collective stance toward facing the reality of the finiteness of life” (p. 165). She concludes by suggesting that “our role in the community requires a responsible and responsive dialogue about this neglected topic in our field and a recognition that for analysts, given the trajectory of our training, the close link between retirement and mortality in the unconscious may make this dialogue a difficult one to begin and sustain” (p. 166).
For me the greatest takeaway from Flirting with Death is the need to think about the responsibility we have to consider our mortality, as facing limits and loss is crucial to living life fully and practicing ethically. And yet it is in the fabric of our work with our patients that this effort is constantly foreclosed or at least averted by our human nature. In my experience of my practice, with my good fortune of surviving serious illness and being able to return to healthy living, working with patients appears to fall into categories: patients I worked with before becoming ill and who resumed their work with me; patients who did not return (about half my practice); patients who began treatment with me following my return; and patients I had worked with before my illness, had stopped, and resumed after my return, never knowing of my “flirtation with death.” With those in this last category I feel that I am withholding and containing a primary element of my present existence. Now I live with a visceral recognition of the fleeting nature of life, in great contrast to my earlier belief that life could not possibly ever stop. I know that even though life appears to move along like a reliable, never ending stream, anything can happen at any moment that can completely alter our existence. And while this core knowing that life is temporary even though it seems permanent brings a subtle but powerfully different sensitivity to my daily experience, this change is invisible to the world. I feel so different from the self I was when I had previously worked with these patients, yet I do not appear different to them. I have to internally hold this difference; it belongs to just me.
All this is to say that there are patients who never knew about my illness, and there are those who know and either could tolerate resuming the treatment or could not bear to return. I asked patients I had abruptly left, when meeting them again six months later, whether they would like to know what had happened to me. All wished to know and I explained. One patient expressed to me her envy of my strength in enduring the disease and her imaginings that I have a family that supported me—everything that she feels she lacks: family and being loved. It is with the patients that resumed that I continue to hold in mind the impact of my unanticipated abandonment, my life-threatening illness, on the therapeutic process. There were some patients who briefly resumed their work with me and then abruptly stopped. One such patient stands out. She had been in intensive treatment with me for close to fifteen years. Five years earlier her husband had been suddenly diagnosed with a blood cancer that demanded urgent and prolonged medical intervention, and their lives were interrupted for a number of months, though eventually he appeared to be cured. I believe she returned for a couple of sessions to see, with her own eyes, that I had survived. Then she had to be done with me rather than revisit that horrendous time of torture in her own life.
Some patients who have resumed, and continued, tell me of their worry a year later, when I informed them I would be away for a vacation. They wonder if I am ill again, and I believe they are entitled to know that I am going on vacation and am healthy. And there are those patients who did not return. I am left imagining that the disruption was unbearable; that they would feel their difficulties minimized compared with mine; that they would fear I would leave them again and perhaps die; that they are furious at me for dropping them. One patient told me when she returned only intermittently that she was angry with me because I did not tell her the nature of my illness when I called to say I had to be out for six months. She believed, given the intimacy of our work together for so long, that she had the right to know, even though I was not yet prepared to tell. Many of my patients who have not resumed their treatment have been robbed of something essential, as have I. There remains much that is unfinished and I feel tremendous sadness about these losses.