All of us have them. Key developmental experiences. Ones that stick in our memory, make a permanent “dent” in our thinking or behavior.
I was sitting behind a one-way mirror watching a therapy session. The young man being interviewed was dying, his immune system failing due to the AIDS virus. It was the early days of the outbreak. Lots of fear, death, helplessness, and indifference.
“He’s in denial about dying,” the resident physician told us before my fellow psychology intern entered the hospital room, “If things need doing, they have to be done soon as he doesn’t have long.”
The conversation that ensued was painful to watch. The young man talked about what he was going to do when he was released from the hospital. My colleague gently but firmly focused on the man’s impending death.
Pointing to a magazine on a bedside table, “I’m planning a trip, going to sail around the world.”
Following a brief pause, “I know this must be hard to accept, but you are dying.”
“I have been looking at sail boats,” he continued, “I learned how to sail when I was coming up.”
Silence. Then, “Perhaps we should talk about what’s happening right now.”
Once again pointing to the magazine, “Can you hand me that? I’ll show you sailboat I’m thinking about getting.”
And on and on it went.
As a grad student, I’d learned about resistance and denial – according to Freud, “the violent and tenacious” rejection of the therapist’s efforts “to restore the patient to health, to relieve him of the symptoms of his illness.” It was the challenge of therapeutic work, the precursor to being able to help.
To me, however, it seemed like torture. “I don’t get this,” I said to the group, “He’s dying.”
“The point,” our supervisor responded, “is to help him address this, and take care of what needs to get done before he dies.”
“And what if he doesn’t?” I thought to silently to myself, “What’s the worst that can happen? Either way, he’s dead.”
The interview dragged on for another 15 minutes or so. I just watched, feeling helpless. After all, at the time, I didn’t have any alternate suggestions for what to do – something that wouldn’t be seen as participating in or perpetuating the man’s … “denial.”
Next morning, I learned the young man had died during the night. It took my breath away. Then, as now, I felt we really missed … the boat.
Maybe just loving and holding the man as he passes over is all that can be done. Going with his dream of sailing, going into the sunset of his dream, like the ferry man’s journey across the river Styx. The therapist is not god, just an angel.
That’s a lovely story, and a poignant reminder to myself as a therapist that we can sometimes get lost in our own agenda. It would have been nice if the graduate student talked about the different boats and what the man liked about them and so on.
My thoughts exactly! Help him visualize his unrequited dream.
A painful but wonderful story Scott.
One of my ‘rules of thumb’ is to go where the energy appears to be.
It’s based on another working hypothesis that the client knows best
I hope this young man died dreaming of the boat he wanted to purchase.
Thanks for this. It’s very real. I’ve actually been in that exact position – trying to figure out what my role is as a counselor with someone who is likely to die soon. I don’t know that there is an easy answer, actually, but I see your point.
As a master’s student in 1982, I was in a huge seminar with community therapists, my professors and fellow students given by Bill O’Hanlon. In confusion at one point, I asked “What about resistance?”
Bill instantly got a look of concern, walked down off the podium and walked all the way to me, and with an increasing look of compassion said : “Oh, you haven’t heard!?Resistance is dead.” I was flooded with embarrassment but it provided a good starting story to students and supervisees through the years.
Resistance only indicates a reflexive reaction and/or subconscious positive intent usually contradictory to the conscious goal. Our skill in realizing this, and then speaking to that positive intention with a respectful frame at the same time that we honor the conscious intent relaxes clients and speeds up therapy significantly, I find.
Maybe there’s some kind of middle ground approach. Yes, show me the boat. Look at it with the man and seek to understand what it means to him. I expect his focus is a combination of true gratification and avoidance. After acknowledging his wishes maybe gently help him reality test, in a neutral way – have you thought about how you will do this, where (specifically) you would [tentative] go? And at an opportune time, what else is on your mind now?
The man is dying. The doctor know’s the man’s death is inevitable. He wants the man to know this too, but why is it so important he says, “Yes doctor I know I am dying”? Perhaps he is saying as much in his own way. He tells the doctor he is planning a solo trip to the other side of the world. A trip like this is made maybe once in a lifetime. Even for a skilled sailor there is always the risk they will not return. However, this man is prepared to risk death for one more big adventure. The doctor missed the opportunity to join the man in his metaphor. If he had been able to listen not just to what the man said, but what he was saying he could have graciously ferried the man across the Styx in his chosen boat.
Great story, and obviously an important lesson. I always contend that, “relevance is the cynosure of relativity.” This means sensitivity to both general and relative context within alliance – not simply the professional agenda devoid of the client’s needs as might best be intuited and empathized with. To extend your analogy: even if “we missed the boat” it nevertheless seems hopeful at the time and commendable in retrospect that you at least bought the ticket! Don’t forget that Elizabeth Kubler-Ross’s boat left the harbor not too long before this story likely took place. Those more illumined subtleties surrounding the death process were just beginning to enter both professional and public sphere of awareness and practical implementation that has gradually supplanted much of the traditional one-dimensional regime of mandatory heroic intervention.
From that latter point of view this episode might seem to represent a gross failure of response regarding an urgent opportunity to correct the patient’s “denial and resistance” and to convince, coerce, or arrogate(?) a more conventionally objective and therefore more conventionally “realistic” view. However, as you attest, an important clue here for the well attuned experiencer of these interactions is that the patient died that very night, as he was evidently extremely close to the end already. Because of the proximity of that event the patient may not have been in nearly as much denial as perhaps the doctor/therapist was themselves or thought or believed the patient was. Why assume he didn’t know? And in either case, why presume that he should be willing to squander the few remaining and irretrievably fading moments of his life energy to engage in a debate that ultimately reduces to linguistic distinctions of subjective cognition regarding one’s own imminent demise?
It seems that a feature of the death process that is similar to the birth process – even if an inversion of it – is the impending acclimation to approaching, and exceeding parity of status with these momentous transitions. Just as a woman experiences decreasing intervals between contractions prior to giving birth, there are often decreasing intervals of normal waking consciousness between increasing intervals of coma or partial slippages of consciousness into “the beyond” or altered awareness that are experienced (or observed) in the death process – just ask any hospice nurse. What the patient is experiencing during those slippages is often debatable because obviously unlike the birth process where the being appears, conversely with the death process, by that point they rarely return. Hence the fascination with consciousness and the afterlife or non-physical reality. However, it apparently isn’t unusual for a person on their deathbed to say things like, “I see Uncle Bob (who’s been dead for years) standing next to the dresser” or things of that nature. Likewise for, “I’m going sailing.” All easily dismissible via rational constructs that may turn out to be quite shallow and therefore un-navigable. Meanwhile, the expression of images or symbols specifically of conveyance like a sailboat especially when significantly timed as such and emphatic, are not necessarily arbitrary, and are possibly a much better indicator for the cognizance of that journey even if expressed supra-rationally and poetic or metaphoric.
From a rational perspective the patient was in denial or (implied) psychotic, but it is entirely possible that he was actually more aware, surrendered, accepting, and ultimately more realistic in attitude than perhaps the amazingly insensitive macho interventionist posture of the doctor, psych intern, and supervisor. Isn’t it reasonable and even appropriate that instead of saying, “I’ve been looking at sailboats” the patient could have just as easily said to the psych intern, “Are you some kind of clueless idiot?” But again, who wants to participate in an axiomatically fruitless argument with someone who’s going to punch the clock, go home, pour a glass of wine, sit on the couch, and turn on the TV? Talk about different reasons and means of release from the hospital!
How about considering the service providers’ possibly “violent and tenacious” rejection of the patient’s true subjective status as expressed in a non-clinical, non-scientific, non-rational language? True listening – and true alliance – is an attitude of reciprocal expression of oneness, identification with the subject and therefore the subjective. We tend to forget, not realize, or not acknowledge that for the primary experiencer of that experience, death IS eventually the ultimate healing. As an ethical, perceptual, and practical quandary, should the professional themselves resist that process or facilitate it?
Often the impetus for altruism turns out to be our own concealed self-interest in assuaging, suppressing, resisting, and denying our own discomfort, or in egoistically projecting urgent remedies and anodynes, attempting to control realities that are ultimately well beyond our means or position (iow, it’s ok and even necessary to occasionally feel and experience our own helplessness)… that we ourselves may have to let go of that apparent need vs. brow-beat someone else into submission to relieve our own internal often unconscious conflict for our own benefit. This is why therapists themselves should undergo therapy as part of training (imho).
In agreeing with your more holistic, pragmatic, and compassionate view Scott – yes – why was the torture of this poor guy necessary or beneficial to anybody involved?
Three questions I sometimes ask to orient myself:
Is it kind?
Is it helpful?
Is it necessary?