Ch. 5: Death and Psychotherapy Flashcards
(41 cards)
Importance of reality of death
The reality of death is important in therapy in two ways:
- Death awareness may act as a “boundary situation” and instigate a radical shift in life perspective
- Death is a primary source of anxiety
Death as a Boundary Situation
A “boundary situation” is an event that propels one into a confrontation with one’s existential “situation” in the world.
“Though the physicality of death destroys an individual, the idea of death can save him.” - It can change how one lives in this world; wondering how things are vs. wonderment that they are.
DEATH CONFRONTATION AND PERSONAL CHANGE: MECHANISM OF ACTION
Cancer Cures Psychoneurosis:
- A patient had disabling interpersonal phobias that miraculously dissolved after she developed cancer. “Having faced and later conquered fear of death - that dwarfed all other fears - lead to strong sense of personal mastery.”
Existence Cannot Be Postponed:
- A patient with cancer dreamt how people are saying that she should go on a final traveling trip. “Then I heard my dead father saying “I know you have lung cancer like me, but don’t stay home and eat chicken soup, waiting to die like me. Go to Africa - live.”
- Realization that one can really only live in the present; in fact, one cannot outlive the present - it always keeps up with you. Even in the moment of looking back at one’s life - one is still there, experiencing, living.
Count Your Blessings:
- Patient with esophagus cancer couldn’t swallow properly anymore. She looked around in cafeteria and thought “Do they ever realize how lucky they are to be able to swallow?” She then realized herself that there is still so much that she could do: notice seasons, touch, see, listen, love.
- Nietsche: “Out of such abysses, from such severe sickness one returns newborn, having shed one’s skin, more ticklish and malicious, with a more delicate taste for joy, with a more tender tongue for all good things, with merrier senses, with a second dangerous innocence in joy, more child-like and yet a hundred times subtler than one has ever seen before.
- Santayana: “The dark background which death supplies brings out the tender colors of life in all their purity.”
Disidentification:
- The neurotic not only protects their core but defends many other attributes: work, prestige, role, vanity, sexual prowess, athletic ability.
- The therapist wishes to say: “You are not your career, your body, not your mother or father or wise man or eternal nurse. You are your self, your core existence. The other things can vanish without you vanishing.”
- Unfortunately such self-evident exhortations are rarely effective in catalyzing change.
- Chronic illness often leads to this sort of disidentification, e.g. a patient who had been very active and had to give up climbing etc.
- Disidentification is an obvious mechanism of change, not easily available for clinical use.
Structured “disidentification” exercise
- 30-45 minutes
- Quiet peaceful setting
- Answer “Who am I” on 8 separate cards
- Reexamine and reorganize the separate cards according to importance: top to bottom
- Then ask to take the top card and meditate on what would happen if they would give up that attribute (2-3 minutes)
- Then next one, and next one, with 2-3 minutes on each card
- Following that it is advisable to integrate by going through the procedure in reverse
- Powerful emotions: I once led 300 individuals in an adult education workshop through it, and even years afterwards participants gratuitously informed me how momentaneously important it had been to them
- Roberto Assagioli does something similar when he asks an individual to “reach his center of pure self-consciousness” by asking him to imagine shedding, in a systematic way, his body, emotions, desires, and finally intellect
Therapist’s task
Facilitate a patient’s awareness of death
Yalom: “The most important point I wish to make in this regard is that the therapist does not need to provide the experience; instead, the therapist needs merely to help the patient recognize that which is everywhere about him or her.”
It’s important for the therapist to reverse the mechanisms of denial, for reminders of death are not enemies but powerful allies in the pursuit of integration and maturity.
Stay-at-home mums
Yalom compares to patients who were both stay-at-home mums who felt anxious shudders after sending their youngest kid off to college after 20-25 years of rearing for them
- One patient was treated (as part of a research project) with Valium, supportive psychotherapy, assertiveness training in a women’s group, several adult education courses, a lover or two, and a part-time volunteer job, the shudder shrunk to a tremble and then vanished.
- Results excellent on each of the measures - symptom checklists, target problem evaluation, self-esteem.
With a similar patient himself, Yalom decided to instead nurse the shudder to explore the meaning of the fear. Through exploration of dreams for example, the woman came to accept that she was holding on to life with her child still at home. “Yet whether I like it or not, time moves on. It moves on for John and it moves on for me. It is a terrible thing to understand, to really understand.” To understand finiteness.
- She learned to wonder at and to appreciate time and life in richer ways than she previously had (not the way things are but that they are).
- Yalom: “In my opinion, the second was helped more by therapy. No way to measure this by standard evaluations. In fact the second probably had more anxiety, but anxiety is part of life and an individual who continues to grow will never be free of it.”
Nevertheless, is the therapist assuming too much? Does patient want guidance in existential awareness or do most patients actually say “I feel bad, help me feel better”
- If the second, why not use the speediest, most efficient means at one’s disposal
Death of Another and Existential Awareness
For many, the death of a close fellow creature offers the most intimate recognition one can have of one’s own death. Paul Landsburg: “My community with that person seems to be broken off; but this community in some degree was I myself, I feel death in the heart of my own existence.”
The loss of a parent
if our parents could not save themselves, who will save us?
Yalom’s colleague knew that dad was going to die for a while and took the news with equanimity, but when he had to get on the plane to fly to funeral he panicked, he suddenly lost faith in the plane’s capacity to take off and land safely.
Loss of a spouse
reminder that there is a basic aloneness that we must bear.
A patient after finding out about wife’s cancer saw a dream where he was in his childhood house being chased by Frankenstein
Tim, the guy who masturbated next to his dying wife, had a dream where he was cast aside in a back room area, and couldn’t breathe (like his wife), and wanted to complain to someone upstairs, but there was noone to complain to
- When Tim confronted his own fear of death he managed to become more caring towards his dying wife, possibly avoiding a considerable measure of guilt that would’ve ensued after her death.
- He was still promiscuous after his wife’s death, but gradually it faded, also he became less of a high achiever at work (“Who will see it?”) and began to grapple with the question of what he wanted to do in life for himself. An enormously fertile period in therapy began
Loss of a child
often the bitterest of all, simultaneously morning our child and ourselves
Hits on all fronts at once
- limit of having more motivation than at any other moment to save their child, yet are helpless.
- Confronted with their own death as well.
- Gardner study: many parents suffer considerable guilt, but rather than emanating from “unconscious hostility” was four times more commonly an attempt to assuage his or her own existential anxiety, to attempt to “control the uncontrollable”
Milestones
Heidegger
Anything that challenges the patient’s permanent view of the world can serve as a boundary condition.
Heidegger: “Only when machinery breaks down do we become aware of its functioning.”
Marital separation
These experiences are so painful that therapists often focus attention entirely on pain alleviation and mis the rich opportunity that reveals itself for deeper therapeutic work.
For other patients, committing to a relationship can be a boundary situation, “this is it”, no more glorious dreams of continued ascendancy.
Passage into adulthood
Clinical syndrome in adolescents is called the “terror of life”: preoccupation with the aging body, the rapid passage of time, the inevitability of death.
Also in seen in psychological treatment with medical residents who finally in their thirties have to start working can go through a period of major inner turmoil
Midlife
suddenly an ascending life shows signs of death at the end of it.
“Now I suddenly seemed to have reached the crest of the hill, and there stretching ahead is the downward slope with the end of the road in sight - far enough away, it’s true - but there is death observably present at the end.”
Threat to career or retirement
A study indicates that midlife career changers often made the decision to “drop out” or to simplify their lives in the context of a confrontation with their existential situation
Birthdays and anniversaries
Despite signaling a deep passage of time, they are often celebrated joyously (reaction formation)
Looking in the mirror and seeing oldness (“I’m sixteen inside but sixty on the outside”)
Loss of stamina, senile plaques, wrinkles, stiff joints, balding or even recognizing that one enjoys old people pleasures
Fraulein Elisabeth
Freud of course just asked Fraulein Elisabeth to meditate at the site of her sister’s grave.
Dreams and fantasies
Careful monitoring of dreams and fantasies will invariable provide material to increase death awareness.
- Every anxiety dream is a dream of death
- Discussions of unsettling television shows, movies or books may similarly lead to essential material
Severe illness
Obious marker to start contemplation about death.
“I have seen death in life’s pattern and affirmed it consciously. I am not afraid to live because I feel that death has a part in the process of my being.”
Artificial aids to increase Death Awareness (7)
Some therapists have used LSD.
Existential shock therapy: asking members of a group to write down an epitaph (text on gravestone) or obituary (e.g. news paper paragraph about death).
Line exercise: draw straight line. One end represents your birth, the other your death. Mark where you are on the line. Meditate upon this for five minutes.
“Calling out”: people put their names in a bowl and then start socializing. At random moments a name is pulled out of the bowl and called out. The person whose name was called out has to stop talking and turn their back to others. Many participants report experiencing the fragility of existence.
Detailed fantasy: describe where, when, how you will die in detail. Imagine your funeral.
“Life cycle”: A life cycle group offered by Elliot Aronson and Ann Dreyfus helped the participants to focus on the major issues in each stage of life. In the time devoted to old age and death, these participants spent days living like old people. They were instructed to walk old, dress old, powder their hair and attempt to play elderly people they have known well. They visited a local cemetery. They walked alone in a forest, imagined passing out, dying, being discovered by friends, and being buried.
Death-awareness workshop: single eight-hour workshop with eight members organized by W.M. Whelan.
1. Members complete a death anxiety questionnaire and discuss anxiety-provoking items.
2. Members, in a state of deep muscle relaxation, fantasize in great detail, with awareness of all five senses, their own (comfortable) death.
3. Members are asked to construct a list of their values and then imagine a situation in which a live-saving nuclear fall-out shelter is able to save only a limited number of people: each member has to make an argument, on the basis of his or her value hierarchy, why her or she should be saved.
PS! This part of the exercise is aimed to re-create the Kübler-Ross’s stage of bargaining.
4. Again in a state of muscle relaxation, the members are asked to fantasize their own terminal illnesses, their inability to communicate, and, finally, their own funerals.
Invite “everyday patients” to visit a group of terminally ill cancer patients
- Karen, the sexual masochist, reacted strongly to the observation. She realized she had sacrificed much of her life because of her fear of death - she had organized her life around the search for an ultimate rescuer, feigning illness in childhood and staying sick in adulthood to remain near her therapist.
- Susan, who had been a forcefully obedient wife to her eminent scientist husband, realized how precious time is and how important it is to live in the moment.
Invite a terminally ill patient to become a member of a group of everyday patients
Charles, a deeply rational person who was diagnosed with a terminal cancer, but who had problems opening up emotionally, especially to a woman he loved and to his son
- Charles opened up about his sickness only after 10 weeks
- For Charles himself it became clear that he didn’t take women as seriously as men
- Others also felt that he is critical and hiding something about himself (also after revealing the cancer in a very matter-of-fact and detached way)
- Another member of the group, Dave, was impressed about Charles talked about wanting to get as much as he could from the life remaining to him, because he realized he had postponed life so much himself
- Lena, whose parent had died from cancer, inappropriately panicked and described all the horrible things that eventually happened to her mum; Sylvia became angry at Charles for accepting the terminal diagnosis and said he should try any healer he can find
- Lena and Sylvia were also very angry when Yalom asked a man who had been in the group for 10 years, was doing considerably well, and most importantly, who got in a relationship with another member of the group, to stop the therapy at the group, because it impairs the work of the group
- Lena’s and Sylvia’s ultimate rescuer defense made them afraid that Yalom will ask them to leave as well
- A nurse realized through Charles that a 10-year-old patient who had died had lived their life more fully than she ever had
- For Don, Charles’s cancer helped to understand that also Yalom is not immortal
Lena eventually started to accept death more thanks to Charles, and was less afraid to establish other important relationships in her life, also regained weight, lost her suicidal yearnings, and obtained a responsible job.
- Charles had a very hard moment not being able to say “I love you” to his son who left to college, because he feared showing emotions and generally hoped to get systems-oriented solutions from authority, he didn’t want to be vulnerable
- The emotionally-stifle Charles got to a point where, tears streaming down his face, he thanked for the group for saving his life
- One younger person expressed that he would also like to have a terminal illness so he could live his life more in the moment - Charles and others pointed out to him that he does have an illness like that, it’s just that his viewing death from the back row, not from the front row
- Another older member expressed feeling like he has wasted his life, was full self pity - Charles pointed out that while he had not wasted his life, he was at that very moment in the process of “wasting” it
Death as a Primary Source of Death anxiety
Life
Important: although primal, it’s often not visible in the clinical picture of a lot of patients (under layers).
Death anxiety has a different connotation than “anxiety” in other frames of reference. Life cannot be lived nor can death be faced without anxiety. Anxiety is guide as well as enemy and can point the way to authentic existence. The job of a therapist is to reduce the anxiety to a comfortable level, yet keep it high enough to use the anxiety to increase awareness and vitality.
REPRESSION OF DEATH ANXIETY
As a result of repression and transformation, existential therapy deals with anxiety that seems to have no existential referent.
