Most psychotherapists have specific experience in one or multiple fields and one of mine happens to be death.
From 2012 to 2016, I worked at a large UK hospice as part of the clinical team supporting both patients and relatives. The work was confronting, humbling and hugely varied and it taught me a few things about death which I would like to share.
Why did I choose death?
Every psychotherapist who is well trained and has undergone their own analysis or depth psychotherapy knows that they cannot be ‘good’ at working with every patient group. None of us can be good at everything and this is especially true in the field of psychotherapy where we have our own history, traumas and blind spots. Equally, we also know not only where we are not so good, but also which challenges or pathologies we like working with and with which we get good results. For me, one of these is death.
I understand why – I was raised by a father who was already 60 when I was born. Throw in his fairly volatile and depressive personality, no other relatives and being moved from country to country as a kid, and I was left hypervigilant about his health.
I remember I would come home from nights out in my late teens, ears still ringing from whichever nightclub I had been in, and intently try to listen for his snoring as I passed his bedroom door on my way to bed. Sometimes it would take quite some time for my ears to pick up signs of life and during those moments my mind would anxiously imagine that he had died and I was all alone.
As it happened, despite my father’s depressive nature, his diet of sugary drinks and biscuits and his penchant for getting divorced (six times), he managed to live to 94. So much for the predictability of death!
Being reminded about death makes us anxious
This first point brings together empirical research in the field of how we cope with death anxiety – terror management theory (TMT) – and my own lived experience working as a clinician with patients who were dying.
TMT is a research field I used in my MA on this topic and the underlying premise is that we are all, at our core, terrified of death; we are, as far as we know, the only mammals who have sufficient consciousness to know we are going to die and yet, alongside this, need to somehow lead meaningful lives.
When exposed to direct or indirect reminders of death, the research shows that our anxiety levels increase exponentially and heavily influence our decisions in favour of safer, more conservative choices. It’s fascinating stuff.
My experience of working with patients versus their relatives was quite distinctly opposed, even though on the face of it, I was dealing with a similar ‘presenting issue’. Working with relatives who were either pre- or post-bereavement was often messy – there would be a lot of tears, for example – and sad, but it did not make me feel anxious. They had gone through something and I hadn’t. There was a separation between us. And the work,
however hard, was grief work, which has a trajectory.
What rendered me anxious was working with patients, which quite literally meant sitting with death. My first experience of this was in seeing a patient for an initial consultation who had resisted having any therapy for quite some time and finally decided that the time had come for him to do some work with me. He was relatively young, reasonably fit (given he had stage four cancer), middle-class and clearly a positive character. I liked him. We agreed some key areas he wished to look at and parted company planning to meet at the
same time and same place (the hospice) one week later.
A week later I arrived at my office and opened the patient record system to check on him and other patients who had been referred to me. I had been looking forward to my session with this first patient, only to read that he had died. Not only that but he had died the evening after I saw him and yet had walked out of the hospice comfortably under his own steam. This was not the plan (his nor mine) and was not supposed to happen. But it did.
Working with death is both the easiest and hardest thing to do
Grief work has been extensively written about and, if you are that way inclined, there are numerous models of how to work with grief that can be applied including the now simplistic and ubiquitous ‘Five Stages of Grief’ by Elisabeth Kübler-Ross. The models are not complicated and nor are the steps. What’s hard is being with death and the feelings that death brings up for us.
Part of my role at the hospice was to recruit and train volunteer counsellors at our yearly intake. These volunteers would go through a ten-week training programme on top of the basic clinical training they had already undergone, and did so in part to gain clinical experience and for many also because they had an interest in death.
We would generally over-recruit by 100% as invariably there would be people who would drop-out of the course for family reasons, personal reasons or a general lack of skills.
However, there was one particular week during the training when we would see the most leavers and that was week four – this happened year after year. In week three the trainees left the classroom environment for the first time and were given a tour of the hospice including the inpatient unit.
The inpatient unit in any hospice is generally where patients come to die. Nothing advertises this reality and compared to most hospitals the ward was bright, cheerful and airy with views over a beautiful garden. The trainees would see one of the empty rooms and be aware of the presence of patients behind the other closed doors. The unease was palpable. Death had become real.
By the following week we had usually had four or five counsellors leave ostensibly for ‘personal reasons’ but after four years the pattern was impossible to ignore: it is one thing to conceptualise death; quite another to be face-to-face with it.
In death there is no ‘us’ and ‘them’
Most of the issues or challenges that I work with, are not ones I have directly experienced and nor will I. I can work with addiction without having been an addict, I can work with eating disorders whilst always having had a healthy appetite and I can work with abandonment as the person doing the abandonment is not my parent.
Death is different.
There is a part of us all that lies hidden, that knows that we face the same fate and try to escape it. And we all can, at least temporarily. But, no matter how hard we try, how much money we have and how ‘good’ a person we are, we will all have to face an uncertain death. Death is ‘us’.
I am a good clinician but I have never felt the same degree of helplessness as when sitting with a patient who is dying and somehow trying to be of use as they face regrets and terror. It is extremely humbling and difficult.
Psychotherapy treatment does not always take place in a consulting room
I am psycho-analytically trained and that means that I tend to see my patients in private practice at the same place, on the same day and at the same time every week. Ongoing. I attempt to remain as consistent as I can and with most of my clinical work the relationship we build lasts many months if not years. This is not how it is working with death.
I have ‘treated’ patients by their bedside, quite frequently with nurses busting in and out of the room and yet been able to offer something.
I have given sessions that lasted little more than minutes as that was all the patient could endure before the pain or hallucinations took them away from contact with me. They were worthwhile.
One session that remains firmly embedded in my mind was with patient who was dying from a brain tumour. She was in many ways hardly recognisable as a human; she had lost her hair, her body shape, was covered in scars from operations and swollen from steroids.
I will admit it was hard to sit with her.
This patient told me about a door at the bottom of her bed that led to her sister’s beach hut in Devon where she was able to run on the beach with her sibling. She asked me if it was real. I thought about this knowing full well that her experience was, at least by way of clinical explanation, a hallucination caused by the morphine. She seemed to gain a lot of joy and peace from her ‘hallucination’ and so that is what we talked about. This was
therapeutic for her. It was a way of escaping her predicament and feeling like the master of her own life again.
Oh, and unlike the planned ending I usually co-create with my private practice patients, it was rare to have a ‘planned’ ending with a hospice patient. Whilst they would happen on occasion, the ending was usually dictated by death and I would learn of this via the digital patient record system at the start of my day.
Grieving is not complicated when the relationship is one that is secure and loving
Prior to working in this field, I had naively assumed that the closer a relationship – especially between parent and child – the more complicated and sadder would be the grieving process. This is not the case.
The complicated cases of grief were often those where parent and child were estranged and the now adult child was suddenly involved in providing care for their parent. What made the grief complicated was that it was not just the grief of the death of that parent, but the grief of never really having had the parent they wanted and needed. The death symbolised the loss of all hope that things could and would be different.
In secure and loving relationships, the lost loved one (often a parent) could be mourned and grieved for but it was generally something that the bereaved could do themselves and with other loved ones – I was not needed.
Hidden psychopathology surfaces when approaching death
Part of my role was to attend multi-disciplinary clinical meetings, particularly in the cases of patients who seemed to be psychologically struggling.
It was from working with these patients that I came to understand how severe psychopathology can find a place to hide throughout a lifetime and it is not until the approach of death, as more and more of the socially sanctioned hiding places are stripped away, that the patient’s real pathology surfaces.
In one case I recall working with a patient who was successful both professionally and personally and yet who was now clearly fragmenting and displaying all the signs of having a personality disorder. He had the whole clinical team running after his every whim and would present contradictory parts of himself to different team members. The result was that his internal conflict played out in the clinical team as overt conflict. It was only through helping them (and them helping me) to think through what was ‘being put into us’ that we could understand his pathology and step out of the projections. He created chaos in lieu of being able to control his life as he had done for 70-odd years, and the chaos protected him from facing death.
We can only stare at the sun for so long
Irvin Yalom, the great existential psychotherapist wrote a book on death with the title ‘Staring at the Sun’, which I believe to be an apt analogy for how we humans deal with the reality of death. Just as it is blinding and impossible to stare at the sun for any length of time, so it is with death. We can squint at it, consider it, intellectualise it, rationalise it, but we can only really be with it for a short while before it starts to overwhelm us and we must look away.
I used to leave the hospice with a skip in my step and noticed that I would generally play my music louder than usual in the car on the way home. I got curious about this and realised that I had been unconsciously playing my own little game with death which went something like ‘Ha! Today you don’t get me!’. Nothing wrong with this and if death can make us feel more alive that is a good thing. But I also recognised my own history
repeating itself stretching back to me listening at my father’s bedroom door for signs of life – ‘not today…’.
After four years I made the decision to leave palliative care and focus more on private practice. Interestingly within a couple of years the whole team I had worked with had moved on and most had also left palliative care. I think we had perhaps collectively stared at the sun long enough and turned away to instead be a little more in denial like everyone else.
Mark Vahrmeyer, UKCP Registered, BHP Co-founder is an integrative psychotherapist with a wide range of clinical experience from both the public and private sectors. He currently sees both individuals and couples, primarily for ongoing psychotherapy. Mark is available at the Lewes and Brighton & Hove Practices.
Further reading by Mark Vahrmeyer –
What is Love?
What is the difference between loving and longing?