Ch. 5: Death and Psychotherapy

Question 1

Importance of reality of death

Answer 1

The reality of death is important in therapy in two ways:

1. Death awareness may act as a “boundary situation” and instigate a radical shift in life perspective
2. Death is a primary source of anxiety

Question 2

Death as a Boundary Situation

Answer 2

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.

Question 3

DEATH CONFRONTATION AND PERSONAL CHANGE: MECHANISM OF ACTION

Answer 3

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.

Question 4

Structured “disidentification” exercise

Answer 4

• 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

Question 5

Therapist’s task

Answer 5

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.

Question 6

Stay-at-home mums

Answer 6

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

Question 7

Death of Another and Existential Awareness

Answer 7

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.”

Question 8

The loss of a parent

Answer 8

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.

Question 9

Loss of a spouse

Answer 9

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

Question 10

Loss of a child

Answer 10

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”

Question 11

Milestones

Heidegger

Answer 11

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.”

Question 12

Marital separation

Answer 12

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.

Question 13

Passage into adulthood

Answer 13

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

Question 14

Midlife

Answer 14

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.”

Question 15

Threat to career or retirement

Answer 15

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

Question 16

Birthdays and anniversaries

Answer 16

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

Question 17

Fraulein Elisabeth

Answer 17

Freud of course just asked Fraulein Elisabeth to meditate at the site of her sister’s grave.

Question 18

Dreams and fantasies

Answer 18

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

Question 19

Severe illness

Answer 19

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.”

Question 20

Artificial aids to increase Death Awareness (7)

Answer 20

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.

Question 21

Invite “everyday patients” to visit a group of terminally ill cancer patients

Answer 21

1. 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.
2. 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.

Question 22

Invite a terminally ill patient to become a member of a group of everyday patients

Answer 22

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

Question 23

Death as a Primary Source of Death anxiety

Life

Answer 23

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.

Question 24

REPRESSION OF DEATH ANXIETY

Answer 24

As a result of repression and transformation, existential therapy deals with anxiety that seems to have no existential referent.

Question 25

The death anxiety framework

Answer 25

The death anxiety framework provides a frame of reference that increases the therapist’s effectiveness.
A belief system regarding the importance of death anxiety helps the therapist to not become overwhelmed and enhances the therapist’s self-confidence and sense of mastery, also leading to more trust in the relationship.

A belief system that is rooted in the deepest levels of being (deepest fear) has the advantage of having no taboo topics.

Question 26

Search for a genetic causal explanation

Answer 26

Further, “I believe that the search for a genetic causal explanation is a wrong steer in the therapeutic process; nevertheless, the explanation of the past often serves an important function: it provides a joint, purposeful project, an intellectual bone to gnaw upon, and brings the psychologist and patient together while the therapeutic relationship grows.”

Question 27

Rigidity

Answer 27

The therapist must also balance between too much certainty - rigidity - and too little - loose, no trust. The therapist has to help the client face one of the core concepts in existential therapy: that uncertainty exists and that all of us must learn to coexist with it.

Question 28

INTERPRETATIVE OPTIONS: CASE STUDY OF BRUCE

Answer 28

He was always “on the prowl” for women to whom he didn’t relate to as people but as “piece of ass”. He had a wife, but also always made sure he was spending the night with someone else (went to looooong extents to achieve that) also when on business trips.

Yalom asked him to at some point spend the night alone, he was terrified, saw a dead woman lying on his bed, feared being touched by a skeleton etc. He gained enormous relief from the presence of a dog: “What is needed is not necessarily a human companion but something alive near you.”

Spending the night alone made the function of sex clear: it was death defiance (as were his passions like parachuting, rock climbing, motorcycling), it was specialness belief (being the center of the universe, of women).

These realizations helped him to start thinking about what people are for? - which helped to start working on his isolation, and will be continued in chapter 9.

Question 29

DEATH ANXIETY IN LONG-TERM THERAPY

Answer 29

“As long as I am with you (the psychologist), I will not die” is often said in late stages of therapy.

Question 30

May Stern describes patients

Answer 30

1. “Finally, transference material referring to a wish to get from the analyst a magical formula elicited the interpretation that he conceived of analysis as protection against fear of death, and that no one was able to protect him against inevitable death.”
2. “Finally, the therapist interpreted that through fusion with the analyst, he wanted to win protection against death. /…/ He remembered having thought a lot about death as a child. ‘I have solved my fear of death through submission… Being raped anally is protection against death.’”

These patients underwent marked improvement, but the author was careful to note that “the dramatic turn in the treatment situation of these patients might be due to the fact that the interpretation of fear of death was introduced after years of tedious working through, after a possible termination of the analysis had appeared on the horizon.”

Question 31

DEATH ANXIETY AS A MAJOR SYMPTOM: Sylvia

Answer 31

Sylvia, patient in Charles’s therapy group. Wealthy, divorced 36-year-old architect with alcoholism, severe conflicts with 13 year old daughter, and two older kids who had elected to live with the father.

Charles’s presence helped her start thinking about her own aging, fear of cancer, her dread of loneliness. She became preoccupied with her own mother’s death.

She had had insomnia for 15 years, but after Charles entered the group she also added (also thanks to the switch in the therapist’s attention) that she had woken up between 2AM and 4AM saying “I don’t want to die, I don’t want to die”.

Also eating and drinking was an insult to her body, suggestion of physical illness or deterioration

Implicit message to child: “Don’t grow up and leave me, I can’t bear to be alone.”

The more Sylvia confronted these themes, the more anxious she became, and soon needed individual meetings next to the group.

She vividly remembered nursing her mom at the age of 25, and saw her bloody, excremented, nasty death. Also when she was 7 her grandpa died, and six months later her grandma as well, saw them in a casket. Also had severe illness when young, and her mom repeated to her often how close she had been to dying.

A lack of care from her mother and a father who left also meant that she didn’t develop appropriate denial-based responses, no expectation of rescue from parents. Instead, death was an imminent presence and it made her fragile.

Once a man in the group brought her flowers for her birthday, and she realized how much she would like to have a lover. She realized that she had been on the edge of living and not living for years.

She slowly started facing death rather than being paralyzed by it. She stopped being afraid of loneliness and began to feel that it would be possible for her to live a satisfying life even without a comforting dependent relationship with a child or a man. “One who carries their own light need not fear the dark.”

She began to groom herself, to lose weight, and to build up social life outside the group. At one point she announced that she has to leave 30 minutes early because of a dinner date. The most striking was however that she started meditating daily on her mother’s death - not obsessively like in the past, but a conscious meditation on all the horrible aspects with the deliberate plan of mastering it through familiarity.

After announcing that she will stop with the group, the symptoms reemerged for a while (nightmares, desires for an ultimate rescuer, death panics in the middle of the night). However, she directly confronted the separation process (incl. the underlying death reminders) and moved through anxiety to experience a richer life than she had known before.

Question 32

DENIAL BY PATIENT AND THERAPIST

Shamans

Answer 32

Patient’s obviously have a lot of denial, but it’s important that the therapist perseveres, also when feeling like drilling a dry well.

Furthermore, it’s important to notice that the therapist can have a lot of (often deeper-layered) denial of death as well. “When we could tolerate our anxiety and follow the patients’ leads, then there was no subject too frightening for the group to deal with explicitly and constructively. If a therapist is to help patients confront and incorporate death into life, he or she must have personally worked through these issues.”

Parallel from shamans: a Tungus (Siberian tribe) shaman described his initiation as consisting of a confrontation with shaman ancestors who surrounded him, pierced him with arrows, cut off his flesh, tore out his bones, drank his blood, and then reassembled him. Several cultures require that the novice shaman sleep on a grave or remain bound for several nights in a cemetery.

Question 33

WHY STIR UP A HORNET’S NEST?

Bugental’s “Existential crisis”

Answer 33

Many therapists avoid topics not to aggravate the patient’s condition.

Yalom: “The approach I describe is not supportive or repressive; it is dynamic and uncovering. /…/ It is not possible to plunge into the roots of one’s anxiety without, for a period of time, experiencing heightened anxiousness and depression.”

E.g. Sylvia when she heard about Charles’s cancer or later when she had grown and told the group she is going to terminate therapy. Also Stern’s patient’s, one who realized transference and the other who realized he had submitted all his life to establish boundaries.

Bugental refers to this phase of the treatment as “existential crisis” - an inevitable crisis which occurs when the defenses used to forestall existential anxiety are breached, allowing one to become truly aware of one’s basic situation in life.

Question 34

Life Satisfaction and Death Anxiety

Answer 34

“I believe that one particularly useful equation for the clinician is: death anxiety is inversely proportional to life satisfaction.”

John Hinton studied 60 terminal cancer patients and correlated their attitudes with their feelings and reactions during terminal illness. “When life had appeared satisfying, dying was less troublesome.” The lesser the satisfaction, the greater the depression, anxiety, anger, concern about the illness.

Question 35

Nietsche & Searles

Answer 35

Nietsche: “What has become perfect, all that is ripe - wants to die. All that is unripe wants to live. All that suffers wants to live, that it may become ripe and joyous and longing - longing for what is further, higher, brighter.”

Searles: “The patient cannot face death unless he is a whole person, yet he can become a truly whole person only by facing death.”

Question 36

Foothold

Answer 36

Yet still there is a foothold. The therapist must not be overawed by the past. It is not necessary that one experiences 40 years of whole, integrated living to compensate for the previous forty years of shadow life.
Ivan Ilyich, through his confrontation with death, arrived at an existential crisis and, with only a few days of life remaining, transformed himself and was able to flood his entire life with meaning.

Question 37

Workaholic successful business executive Philip

Answer 37

Case: 35-year-old workaholic successful business executive Philip who worked 60-70 hours a week, became estranged from wife and kids.

Then got news that the company will be submerged and he will become unemployed. He sunk into crisis, worried about his department, about getting a new job.

He didn’t have problems with money, but he was afraid of what to do with all the time. His job, his specialness, his climb to glory, invulnerability suffered (especially after facing a burglar at night), and he had to face some fundamentals of life: groundlessness, the passage of time, the inevitability of death.

He managed to start telling the truth about his department to the members of the department. He also cried after Yalom offered him to contact a friend who works in a company in a similar field.

After eight months, Philip obtained another position in a new city. “I’ve gone through hell, but as horrible as it has been, I’m glad I couldn’t get a job immediately. I’m thankful I was forced to go through this.”

He began painting and learned to be vulnerable also with his wife and family (in addition to Yalom), eventually growing more intimate.

Question 38

Death Desensitization

Answer 38

It seems that with repeated contact one can even get used to dying.

A basic principle of a behavioral approach is that the set and setting are designed to retard the development of anxiety, e.g. in a group, first doing muscle-relaxation, each patient with the same illness, trust established, graduated exposure with each member moving at their own pace.

Question 39

Dissection of the fear into parts (8)

Answer 39

Another helpful technique:
- e.g. separating ancillary feelings of helplessness from true helplessness that they would probably feel in the situation of dying;
- or regarding choice, one can communicate to physician that they want to have 100% information about the illness or choose for a new physician if the existing one doesn’t feel right;
- also stress is a component, which can be approached through psychotherapy;
one can also work on their attitude.
- Pain of dying
- Afterlife
- Fear of the unknown
- Concern for the family
- Failure (especially in western society)

Question 40

DEATH DESENSITIZATION: EMPIRICAL EVIDENCE (5)

Answer 40

1. Eight-hour eight-member workshop mentioned earlier achieved, in contrast to a control no-group sample (they did nothing): “reorganization of the participants ideas about death”, they used less denial, and lower death anxiety scores
   - One alcoholic became abstinent (“he did not wish to die the demeaning death of an alcoholic”)
2. SYATD (“shaping your attitudes towards death”) program reduced death fears
3. A “death and self-discovery workshop” resulted in increased death anxiety - but also increased in a sense of purpose in life
4. Other programs have shown post-workshop reduction in anxiety with a return to pre-workshop levels in four weeks
5. A six-week death education class for nurses did not affect death anxiety immediately but resulted in a significant reduction for weeks later

Question 41

Conclusion of PART I

Answer 41

Death helps us understand anxiety, offers a dynamic structure upon which to base interpretation, and serves as a boundary experience that is capable of instigating a massive shift in perspective. However, we need each of the ultimate concerns for a comprehensive psychotherapy system.

Freedom helps us understand responsibility, and commitment to change, decision, and action.

Isolation illuminates the role of relationship.

Meaninglessness turns our attention to the principle of engagement.