Most psychoanalysts think only orphaned adults, terminally-ill patients, those recently bereaved by the loss of a loved one, and elderly analysands talk of their own death during their analyses. This is not true. References to one’s mortality appear in all analyses.
When a patient in termination phase talks about death, the allusion is not only metaphorical. The patient is saying to the analyst: “Look, I am leaving treatment for good and we have not talked about an extremely important topic yet. Can we please do it now?” Or, when such a patient laments that he shall never see “this office” again, the analyst might consider it as a displaced fragment of the patient’s mourning over separation from him or the analyst might take it as a cue that the patient is prepared to talk about the day when he will not be able to see “this whole world” ever again. Listening to the terminating patient’s talk of death in a skeptical fashion yields interventions about separation and mourning. Listening to the same material in an accepting fashion permits an exploration of the patient’s feelings and fantasies about death.
…the topic of death is not to be introduced by the analyst. It is to be unmasked since its derivatives are inevitably present in the patient’s material.
Once the patient’s concern with mortality has been discerned, the next step is to help him get in deeper contact with feelings and fantasies surrounding it. Lest such a recommendation appear “unanalytic,” I hasten to add that the topic of death is not to be introduced by the analyst. It is to be unmasked since its derivatives are invariably present in the patient’s material. Approached this way, the exploration of the patient’s feelings about his impending (remember: it is always impending) death becomes a legitimate activity for the clinical dyad to undertake. Any extraordinary affect (e.g., excessive fear, undue longing), attitude (e.g., denial of death via counterphobic flirtations with danger), or fantasy (e.g., death as a lover) involving death would then be brought up for associative elaboration, introspection, and gaining a deeper understanding of its origins and purposes. In other words, the indirect and disguised appearance of death in patients’ associations would be translated upwards into the language of consciousness and mutual understanding.
This, of course, is not needed when patients talk overtly of killing themselves. The analyst listening to a patient talk about suicide must maintain an attitude of equanimity, non-judgmental seriousness and patience. This strengthens the boundary between thought and action. It is important to remember the patient needs to extrude the forces that threaten his existence from within. With the dreaded agenda out in the open, there is a diminution of shame and sense of aloneness. Dynamic exploration then becomes possible. When matters begin to get out of hand, however, the analyst has to depart from neutrality and undertake responsible and protective action.
While management of overtly suicidal patients has received considerable attention, the subtler ways in which patients attempt to hasten their exit from this world have mostly remained unaddressed. This, however, does not mean there are no technical dilemmas in this realm. Indeed, there are. For instance, how actively should an analyst intervene with a patient who does little exercise, is overweight and smokes cigarettes? And, should the analyst ask, during the course of an eight-year analysis, if the analysand has ever had a physical examination? What are the pros and cons of such interventions? Does the analyst’s expressed interest in such matters constitute a countertransference enactment or does it simply show a concern for the patient as well as for the analytic process itself? Doesn’t ignoring the patient’s subtle self-destructive behaviors permit a pocket of masochism to remain unanalyzed? Clearly, more thought is needed here.
As the exploration of the patient’s feelings and attitudes about his or her death proceeds, three special aspects come to attention: (1) fantasies and actual decisions about the disposal of his or her body, (2) anticipation of parting from cherished possessions and the planning required for their dispersal, and (3) participation in one’s posthumous survival in the form of the legacy left behind. Each of these realms requires exploration. Helping patients talk about their funeral and burial or cremation often yields rich information about their internal object relations with both their ancestors and the coming generations. One patient felt he should be buried because it made him feel similar to his parents who had been buried and because he desired his children to visit his grave after he was gone. Elaborations of these themes led to rich information about his internal life both within the transference and as it existed outside the analytic treatment.
The same is true of exploring the patient’s feelings about the material possessions and money he or she is to leave behind. Discussion of this gives access to separation experiences that might not have entered the therapeutic dialogue so far. It also brings to the surface the complex sentiments and fantasies implicit in the dispersal of one’s property. While such real and imaginary scenarios are beneficially explored with all patients, the fact that they are richer in middle-aged and elderly patients can hardly be denied. In their treatment, the omission of inquiry regarding such matters (including if they have written a will) betrays a collusive avoidance of omnipotent defenses on the analyst’s part.
Finally, there is the matter of the “post-self.” The term, coined by the renowned thanatologist, Edwin Shneidman, asserts that all individuals entertain notions about what their participation in the world will be like when they’re absent from it. The fact is, an individual can—while living—exert control on how he survives in others’ minds. In fact, there is a broad range of intensity with which people handle such endeavors. The main point is neither to idealize the laborious assembly of credentials for a glorious obituary nor to devalue the desire to leave a little trace behind after one’s death. The point is to help the patient explore that the realm of post-self does exist and one can, consciously or unconsciously, affect it.
The problem is that a culturally transmitted blind-spot pertaining to death often precludes psychoanalysts from noticing patients are talking and/or are expressing a wish to talk about their death. Analysts are more comfortable in hearing about imaginary death wishes directed at them than in patients’ interest in their own actual deaths (especially when such discourse is not clinically noisy and dangerous in reality). When they do listen to the patients’ talk of their death, analysts readily pathologize such interest and trace its origins to guilt and masochism. What escapes them is the ubiquitous human desire to understand death and the need for help in shedding the illusion of immortality. I therefore urge that we cultivate the conceptual freedom to think an analysis is deficient if it reaches termination without a whisper about what awaits the patient as the final chapter of his or her life.
To arrive at such a stance, analysts would need to (1) shift their view of death as being apart from life to its being a part of life; (2) recognize man must make peace with the inevitable fact of mortality in order to live fully and truthfully; (3) understand fear and denial of death are mostly pathological and a calm acceptance of death is mostly healthy; and (4) work through the feelings about their own death. It is only when analysts make an earnest effort to move in this existential direction that they can help patients grasp the sham-nature of their death anxiety. In the absence of such an attitude in analysts, patients finish the treatment with a tightly protected corner of their minds where infantile omnipotence prevails in the guise of the denial of mortality.
Some portions of this article have been taken from the author’s book, Matters of Life and Death: Psychoanalytic Perspectives (London: Karnac Books, 2011).