Illustrations by Sarah-Jane Crowson
If you cannot bear the silence and the darkness, do not go there; if you dislike black night and yawning chasms, never make them your profession.
I WAS HONORED to be invited to speak at the APsA annual winter meeting in February 2023, along with Alan Pollack, Stephanie Brody, Salman Akhtar, and Dionne Powell, as part of a panel on death and mortality. Our panel's starting point was the myth of Orpheus, which Alan had written about in a past TAP essay, and Stephanie's book weaving clinical vignettes, literary references, and personal reflections on the impermanence of life titled Entering Night Country: Psychoanalytic Reflections on Loss and Resilience (Routledge, 2015). A reprise of the panel was given at the Boston Psychoanalytic Society and Institute in May 2023 for their Solange Skinner Program. The following essay is adapted from these presentations.
IT IS LATE at night, and I am sitting at my younger daughter's bedside, tucking her in—the fuzzy pink and cream blankets layered just so, the pillow fluffed, her monkey lovey from infancy tightly clutched in one hand. The lights are out, the last lullaby sung, and the ritual goodnight hugs and kisses exchanged. It has been a long day, and my own eyelids are fluttering to a close when I am startled by a sudden, urgent, unexpected query: “Mama, am I going to die tonight?”
My heart stutters. “What? Oh Lilly, why are you wondering that?” My mind is awhirl—has there been a recent death or illness at school I haven't heard about? My thoughts then flash to the panel I'll be presenting at during the APsA winter meeting just a few weeks later, about death and mortality. Has this panel topic, not something that I've explicitly mentioned at home, somehow found its way into the unconscious space between us?
“Am I?” she persists. In the faint light from the streetlamp outside her window, I can make out her eyes, luminous, questioning, the slightest crescent lining of anxiety.
“Oh no, munchkin,” the protective words tumble off my tongue. “We all die eventually, and it's not something to be afraid of … but you're young, and healthy, and there's absolutely no reason for me to think that you'll die any time soon, including tonight.”
“How sure are you?” she presses, my girl who travels between the worlds of facts and fantasy, who during the day will demand courtroom-level evidence to back up any statement about the value of green vegetables or piano practice, but at night still believes in Tib the tooth fairy and that her trio of stuffies, the Dream Team, can order up a dream for her at will.
I love to play in the world of fantasy as much as my daughter. I am her nightly dream consultant; I am the morning zookeeper who feeds blueberries and chocolate chips to Ella, the invisible alligator who guards her bedroom threshold. I am the one responsible for naming our household toilets “Toily” and “Tilly,” for spinning elaborate backstories about their early childhoods and the advanced schooling they received in order to immediately squash any of the evil spirits my daughter fears might enter our house from the sewer pipes. But I am also a doctor by training, and somehow “100 percent certain” is a lie I just cannot tell.
“99.99999 percent sure,” I say with as much conviction as I can justify. She considers my answer, then seems to accept it. I breathe a small sigh of relief, noting to myself that further conversation may be warranted the next day, but not right now—not when the Dream Team is waiting to whisk her away to a library sleepover full of delicious books made of shortbread and chocolate.
“Are you going to die tonight?”
This, I'm a little less certain of. I've noticed with chagrin in the last couple years that my former magic metabolism, the “second dessert stomach” that let me eat unlimited ice cream, has abandoned me, and I'm now prone to the occasional aches and pains of middle age. Still, three of my grandparents lived into their nineties, so I feel justified telling myself that I haven't yet hit the halfway mark. I'm relatively healthy (other than the sedentary nature of our profession). But then I recall my friend Devah, mom to one of my daughter's best friends from her time in daycare, who died of pancreatic cancer four years ago, and I pause for a beat.
“I really don't think so,” I answer, and to head off her next question, I add emphatically, “and I'm 99.999 percent sure”—compromising by subtracting a degree or two of certainty and hoping she doesn't notice.
IN THE MYTH of Orpheus, the famed musician is heartbroken over the death of his wife Eurydice and finds his way into the Underworld of Hades, realm of the dead. By moving Queen Persephone to tears with his singing, Orpheus is granted the chance to bring his beloved back to the land of the living, if he can just prevent himself from looking back at her, trusting that she is following closely behind him. Tragically, he fails, losing her forever.
Is this how we think about death? By not thinking about it, not looking at it, keeping it at bay, at the very outer edges of awareness? Like the sun, Medusa, or Orpheus's Eurydice, is death too blinding, too terrifying, or too wraith-like and aching with loss, for us to look at directly? Do we keep ourselves in shimmering bubbles of denial, warding off death by pretending it is something that happens “out there,” to others? Even as he formulated a universal death instinct, Freud once wrote that “no one believes in his own death . in the unconscious, every one of us is convinced of his own immortality.” Freud's continued habit of smoking twenty cigars a day till the day he died, despite doctors' warnings, chest pain, heart palpitations, and sixteen years engaged in a painful, disfiguring, and debilitating battle with oral cancer surely suggest some difficulties in facing the reality of his own vulnerability and mortality.
Is death anxiety, or Todesangst, as Freud called it, possibly a cultural construct? Could one not feel calm, perhaps even relieved, at the prospect of eternal rest? In Buddhism, Taoism, and Confucianism, the three pillars of ancient Chinese philosophy and religion, death is seen as a natural and inevitable part of life, something to be greeted with peaceful acceptance. If a Chinese person dies after the age of eighty, they are buried in celebratory red, the color of weddings, good luck, and fortune.
And yet, I was taught early on that to talk about death in Chinese culture is taboo, as if one will hasten death's arrival by speaking its name. The number four is considered unlucky—many buildings in China skip the fourth floor—because the
Mandarin word for four sounds too close to the word for death. The 2019 movie The Farewell, based on writer/director Lulu Wang's own experience, depicts the extreme lengths a Chinese family takes in order to hide their beloved matriarch's terminal lung cancer diagnosis from her, believing that knowing would accelerate her deterioration. As the mother in the movie states, “It's not the cancer that kills them—it's the fear.” I've encountered similar stories: families begging their loved one's physician not to disclose a terminal diagnosis, fearing the impact of such knowledge and wanting to carry the burden themselves. I can recall such a scenario coming up in my ethics seminar during medical school, or was it in our “cultural competence” class? Our classroom debate pitted Western principles of “medical truth telling” and individual patient autonomy against Eastern values of collectivism, the family unit, and what seemed to be depicted as collusion in a kind of culture-bound, backwards superstition.
However, as noted in Jing-Bao Nie's paper “The Fallacy and Dangers of Dichotomizing Cultural Differences,” a much older and longer-standing Chinese tradition of direct medical truth-telling to one's patients has been documented back to twenty-six centuries ago, in line with Confucian principles of truthfulness; meanwhile, concealing the truth about terminal illness was historically the cultural norm in Western practice, even stipulated in the writings of Hippocrates and the American Medical Association's 1857 Code of Medical Ethics.
Freud's personal physician Felix Deutsch, upon first laying eyes on what was clearly an advanced case of oral cancer, chose to keep the diagnosis from Freud, fearing it would be too much to bear. Deutsch lied that it was a more benign case of leukoplakia. His paternalism, both in concealing Freud's diagnosis of malignant cancer and then breaking confidentiality to ask six of Freud's friends to collude in holding this “most deadly secret” (per Ernest Jones), led to an irreparable loss of trust. When Freud interviewed Max Schur to be Deutsch's replacement, he asked for two things: that they always tell each other the truth, and that when the time came, that Schur not let him suffer unnecessarily. And indeed, in 1939—as Schur recounted later, “without a trace of emotionality or self-pity, and with full consciousness of reality”—Freud faced death with a clear-eyed gaze, seeking death as relief from his suffering.
I HAVE WONDERED whether one of the draws of mythology, folklore, or even religion is the wish for some kind of playbook or preview for what comes after death. None of us living mortals have been granted, like Orpheus, a roundtrip ticket to the underworld, or however we might conceive of the afterlife. We want details.
“What does it feel like, when you die?” my daughter asked another night. “Does it hurt? Do you still get to see all your friends? Are your favorite stuffies there with you?”
As parents, we have the daunting task of figuring out how to answer these questions, when and how to shield our children from danger, when to alert them to it, and when to help them face it. While COVID's sharp edge of fear is now dulled in much of America's conscious awareness, it left an indelible mark on so many of our children. Steeped in our own fear and uncertainty, especially in pre-vaccine 2020, we were forced to share those fears and uncertainties with them; with barely any warning, we huddled together in lockdown, and their worlds (and ours) were upended. Suddenly, sources of care and comfort were now tinged with possible danger—going to school to see beloved teachers and friends was unsafe, as were playgrounds, postcards and care packages, groceries, playdates. Even their own homes and bodies were unsafe, a source of vulnerability as well as a danger to their loved ones.
“I'm sorry, sweetie, but we can't see PoPo and GungGung for Christmas — we don't want to get them sick.”
My daughter: “I touched the couch—do I have to wash my hands? I touched my face—do I have to wash my hands? I touched you—do I have to wash my hands?”
We had to balance safety with isolation and fear. We created “pods,” little bubbles of protective denial.
WE ALSO FLED our offices and the presence of our patients, each of us potential victim or killer of the other. Our bodies left “the room where it happens,” and we became halting two-dimensional images on computer screens, or disembodied voices, miles apart.
“Like the sun, Medusa, or Orpheus's Eurydice, is death too blinding, too terrifying, or too wraith-like and aching with loss, for us to look at directly?”
As analysts and psychodynamic therapists, we are both our patients' old parental objects and their new ones. Correspondingly, we may hold similar unconscious dilemmas with them, as parents do with their children. While we like to think that we are helping our patients to face their fears, to bear seeing and sitting with painful truths—in other words, to look and to be seen—I think we are often scared to be seen ourselves, and perhaps most of all, to be seen in our own vulnerability and mortality. Like children, our patients may not want to see this either. My first control case, a man who struggles with self-loathing over his self-perceived incompetence and brokenness, reacts with explosive anger if I ever try to model self-compassion or the universality of imperfection by pointing out my own mistakes or shortcomings to him.
“How can the blind lead the blind?” he sputters in outrage (and fear), and threatens to quit analysis. He desperately needs me to be omniscient and omnipotent, a replacement for the fumbling father who failed to teach him “how to be a man.”
So when my daughter asked me, “Are you going to die tonight?” and I rushed to reassure her that I would see her the next morning, I thought about the fantasy that many of us collude in with our patients, that we will always be there for them. Like Orpheus, they cling to this notion while also wondering if they have been tricked, if we are not in fact there for them, following closely behind—if it's mere illusion, our presence behind them, just out of sight. And like Eurydice, we are at perpetual risk of disappearing, abandoning, slipping away in ways both imagined and real.
A mutually determined termination, I've been told, is the opportunity to experience, perhaps for the first time, a “good” goodbye. This is how I envision a “good” Asian death, like those of my grandparents—one that is anticipated but not dreaded, accepted, ideally at home in the presence of loved ones.
Perhaps because of this experience, I don't fear death that much myself, but I do worry about those I'll leave behind. In the past year, I began working with two new patients who still feel utterly decimated by their respective therapists' sudden retirements due to aging or health problems—many days, the feelings of abandonment, of having driven their therapists away by being “too much” or “not enough,” can negate five, ten years of solid, caring work, throwing them right back into their early traumas of dead(ened) or rejecting parents. I wonder sometimes if it's the fear of abandoning or retraumatizing their patients that causes some analysts to continue working far longer than perhaps they should, trying to put off the inevitable—but in doing so, in not looking at or acknowledging their own vulnerability or mortality, they end up traumatizing their patients even more. Because what is invisible is still there. Our children, our patients—they know us, and they sense our anxiety, our vulnerabilities, the hairline fissures below the surface, the perturbations in the field. For many of our patients, one of their compounding traumas was how things went unacknowledged, unspoken, not looked at; so how can we knowingly repeat that?
Traumatic losses—the ones that blindside us, the ones that defy understanding—shatter frames and whatever illusory bubbles of safety we try to create for ourselves and for our children. In the last decade, we have had to face not just COVID, but the stark, horrifying deaths of so many victims due to racial violence and mass shootings—Black churchgoers and Jewish synagogue members at their places of worship, members of the LGBTQ community while dancing at a nightclub, Black sons and daughters in the supposed safety of their own cars and beds, children at their schools, or Asians at our most festive time of year, Lunar New Year. To Asian Americans, Native Hawaiians, and Pacific Islanders, this pandemic brought not just a fear of COVID, but a fear of violent, anti-Asian hate crimes. My older teen daughter, the fearless one, who wrote a scathing, prize-winning editorial on how Trump's racist rhetoric around “kung flu” had stoked xenophobia, began to have difficulty sleeping, worrying about the safety of her Chinese grandparents, my parents—whether they too might get shoved, punched, or stabbed upon leaving their Manhattan Chinatown apartment building. There are days when I come home numb and shell-shocked, wondering, “What do I tell my children, when I can't even begin to metabolize my own horror and helplessness?” As a parent, I want to protect them from harm, from ugliness, from fear, from traumatic loss, and perhaps from death itself. I think it is the incomprehensible loss of innocence that tears most at me—the school children of Sandy Hook or Uvalde, George Floyd or Tyre Nichols calling out, begging for their mothers as they were dying. It feels like a violent rip in the fabric of the universe, and sometimes it is too much to bear or look at.
Still, to be constantly preoccupied and fearful of death is to be, in many ways, dead already. So we live in compromise—sometimes looking, sometimes averting our gaze. We do this with our children, our patients, and each other. Sometimes this means covering my daughter's eyes during the scary parts of a movie, but also letting her peek through if she wishes, from within the safety and containment of my embrace. Wanting to teach her not to be afraid of life or death, to be brave enough to look at what is painful and scary—but also letting her retreat to the Land of Stuffies and Dreams when it is too much. And sometimes she is the one who gets me to look, with her unflinching, persistent questions. I hope that this is how it is with our patients, our loved ones, and this field of psychoanalysis — always titrating, always holding, and ultimately, looking together.
Elisa Cheng, MD, is a fifth-year candidate at the Boston Psychoanalytic Society and Institute, where she is chair of the Candidate and Affiliate Scholar Council and serves on the Ethics Education and Joint Curriculum Committees. She practices in Cambridge, Massachusetts.