By Sally Bloom Feshbach, Ph.D.
Emerging from a taxi in front of the radiology center, I naively stepped into the waiting arms of my handsome leather-jacket clad husband. "Honey," he said, enclosing me in his strong arms, "what I am about to tell you will change your life forever. I'm so sorry!" Those words, harbingers of his mortality, ushered in our new life, and from that day forth, this paper began germinating. How do two therapists, long-time best friends and students of separation and loss, prepare themselves for death?
A fatal diagnosis catapults the entire family on an unwanted journey of unrelenting incremental loss. One day, a once-active father no longer drives his children to school; the next, he can no longer rouse himself early enough to see his first-thing-in-the-morning patients. Before long, he no longer fills the car with gas, or attends nonessential professional meetings. Eventually, the unremitting need to rest and conserve precious energy results in a family dinner hour that converges upon the children's bedtime, and the careful selection of appropriate, and hopefully temporary, substitute therapists for each long-time patient. And by the time three years and thirty-six chemotherapies have been completed, the lengthening silence in the office next door to mine becomes an accustomed reality. Each small change in our familiar long-time routines was screamingly loud to me, attuned as I was to loss. And with each small change, I actively mourned. I cried, I got angry, I distracted myself, I sought comfort, I adjusted. My professional focus on separation, loss and life transitions was coming in handy, in a situation I never imagined I would confront.
Resistance and Catharsis
As therapists we all are well-practiced at identifying our feelings and voicing the unspeakable. But the harsh vocabulary of shock, rage and despair made its way beyond my and my husband's psychotherapy offices, and became our stock-in-trade each night, when the children went to bed. These regular "sessions," in which we consciously worked at dealing with our feelings, became an indispensable help in allowing us to clearheadedly face the daily challenges and to function in somewhat "normal" fashion. I developed a deeper appreciation of defenses—both the vigilant need to maintain their insulating cushion against intolerable affect, and their shocking fragility. I gained better insight into resistance. When a patient had difficulty voicing memories of her mother's suicide, and both of us knew that anger at her mother was the source of her rudeness toward her supervisor, I had renewed empathy for the patient's conscious desire "not to get into it." I now know better how it feels when you think your tears will wash you away, when it hardly feels worth it to express anger when you know that protest will bring no tangible improvement. But I also know first-hand that when you do force yourself to listen to your children's wrenching sense of longing, when you join them in cries and rage, when you are able to allow others to bear witness to your pain, the burden in your heart ultimately grows lighter to bear. Sometimes you must consciously avoid your neighbor, whose expressively sympathetic eyes automatically cause your own eyes to tear, despite your best intentions to control yourself. And sometimes you must consciously force yourself to cry, because you know all too well that your irritable mood is the result of the social gathering you attended alone. As a therapist who has lost a beloved spouse, I am both more empathic toward resistance and more certain of the necessity of relentlessly engaging in the internal struggle to combat it.
Humility
Battling an almost-certainly fatal illness and an equally horrendous treatment process brought me to my psychological knees. There is nothing like a devastating medically un-understood cancer to smash one's omnipotence. It is truly humbling to realize that there is no magic medicine, no omniscient doctor, no loving parent to fix everything. When the person you usually can turn to is the one requiring rescue, the sense of aloneness is acute. My own diligent and determined efforts—former guarantors of good grades, well-adjusted children and successful psychotherapy outcomes—could no longer be relied upon to save the day. Like all of us, I was accustomed to defining myself as a healer, a helper of others, a tackler of problems, a battler of pain, adversity and demons, in whatever guise they presented. This self-view, long shared with my therapist husband, remained a valuable resource in our struggle. But my abiding sense of self faced severe challenge. Clearly, I had to grow and change, or falter badly. The sense of weakness that came along with allowing others to make us dinners, drive our carpools, and sit with my husband during his innumerable lonely hospitalizations, was initially humiliating and difficult to bear. Depending on others for so much help at first highlighted my eroding sense of agency, formerly so crucial to my self-perception. But gradually, and remarkably, depending on others and truly taking in their generous, selfless, and loving care and concern actually began to help me feel stronger and less alone. The sense of being held tenderly in a community of friends, new and old, cast dependency and self-sufficiency in a new light. I felt more kinship with the simple experience of being a mortal human making my bumbling way in this fragile world, appreciating the privilege of breathing fresh air. A surprising sense of fortification emerged, as I grew more comfortable with accepting help and embracing our own small place in the march of humanity.
One particular experience brought this reality home to me. A young friend who had traveled in Tibet and met with Buddhist monks practiced in healing offered to lead me in a meditation. Trusting my friend, and open to all that might help me find peace of mind, I agreed. The meditation entailed imagining all of those around the world who were suffering in a similar way to oneself. We then allowed ourselves to take in, to really feel, the magnitude of that suffering. This aspect of the meditation was excruciatingly painful, as the thought of all the children losing parents, all the wives losing husbands, and all the husbands losing everyone was almost overwhelming. We were overcome with emotion. Finally, we offered our own loving and healing energies to all those who suffered as we did. This experience was incredibly powerful and inspirational. My own family's sadness came to feel less personally tragic. In addition, it felt good to be reminded of the needs of others, and to feel grateful for my many blessings.
Accepting more graciously the help of others shattered the arrogance of being a helper. My experiences further reinforced changes I had made over the years in the direction of truly embracing a two-person psychology. I saw quite clearly how all experience, in the therapy office as in the rest of life, is co-created. As my appreciation of the layers of relatedness deepened, the unconscious vestiges of arrogance that accompanied a sense of myself as therapist/helper/authority began to melt, giving way to a truer embrace of how the wholeness of the two people in the therapy office together shapes every communication. For someone like me who defensively enjoys a sense of control, the grieving process has been a good and steadfast teacher. One learns to control what one can—make sure your hospitalized loved one has someone with him to prevent and correct medical errors, and play an active role in deciding among treatment options. This applies in the work realm as well—seek supervision or consultation when you need help, and don't be afraid to set boundaries that feel comfortable to you. One also learns to relinquish control—no amount of wishful or magical thinking can alter a blood test result. And when a psychotherapy patient remains seemingly mired in a destructive relationship, that is something to come to understand, not something to remedy. The New Age health literature can prove inspiring to those suffering from awful maladies, but the popular notion that positive thinking and visual imagery can cure virulent malignancies has its limits. The longing for control that underlies this perspective can lead to unnecessarily painful self-recrimination.
Regression and Hope
Perhaps the most surprising and certainly the most wonderful legacy of my husband's illness and eventual death was a renewed hopefulness and optimism. These powerful feelings have stayed with me both personally and professionally during all of the phases of my mourning process. I have always held the view that while we cannot necessarily control the bad things that happen to us in life, we are free to make of them what we will. Indeed, one of our major goals as therapists is to help our patients experience a broader range of choices. The psychoanalytic process is designed to help free the psyche of long-held restrictions on functioning, restrictions that inhibit our ability to experience the range of choice that can permit us the fullest actualization of self. In confronting my husband's illness, my choice was clear—it was better to search for meaning in the lessons offered by our situation than to regress into helplessness, bitterness or depression. My long-term therapeutic stance that life should be lived to the fullest, that one must consciously strive for the most happiness possible, took on renewed significance. The battle against despair and anxiety, no matter what the history or circumstances might be, was not only worth waging, but winnable. I was determined not to return to the depressive tendencies that characterized my personality before my own psychoanalytic journey. I was more grateful than ever for my good fortune in having been a psychoanalytic patient myself. The liberating effects of my own treatment—a lightness of spirit, an ability to be assertive, and a greater tolerance for anger and conflict—were, along with the support of my family and friends, my greatest allies in coping with daily disappointments, the relentless rollercoaster of ups and downs, and a newly grueling schedule. Being a therapist also helped me understand that the process of working through difficult affect is itself worthy of respect. This perspective helps me remain patient with my and my children's ongoing struggle with grief and mourning. I remind myself to learn from and cherish the process of growth and understanding, not just to seek its end.
Clinical Work
You may be wondering what it was like to continue my practice amidst the difficult circumstances at home. I have always loved working as a therapist, and during this time, work was generally more of a refuge than a stressor. I tried to keep my practice as stable as possible—for my own sake as well as that of my patients. Fortunately, until the very end of my husband's illness, I was able to plan ahead for his treatment needs, with lots of help from family and friends. The painful emotional processing we both engaged in so determinedly helped me feel, for the most part, clear-headed and able to focus on my work in the same way that I always had. The regularity of the therapy process and the familiar relationships with my patients provided a welcome respite from the stresses and anxieties of my husband's illness. It was a relief to focus on other people's problems—helpable problems—and to think of myself as a therapist and not as a mother facing early widowhood.
The only change I made in my hours was to stop work earlier on the one day my husband had previously spent with the children after school. This necessitated shifting a few appointment times. For one long-term three-times-a-week patient, this meant losing his late-afternoon time, which had fit beautifully into his own schedule. I offered 'changing family responsibilities' as the reason for moving his appointment time. He was furious, and we spent many hours analyzing the intrusion of my needs into his treatment and his resulting feelings of powerlessness and unimportance. As it had been difficult for him to express affect untempered by intellect, this incident proved useful in our work. Three years later, after he became aware of my husband's death and surmised the reason for the appointment change, he felt ashamed of his earlier resentment. That too provided a fertile opportunity for therapeutic work, as he came to appreciate that he had been entitled to his feelings regardless of my circumstances, and went on to analyze the origins of his shame reaction.
Toward the end of my husband's illness, my schedule was briefly more disrupted, as health emergencies became less predictable. For one of my patients, a middle-aged daughter of a schizophrenic mother, with whom I had worked for only a few months before my husband's condition became less stable, a last-minute cancellation by me was clearly problematic. Realizing that I could no longer promise to be as reliable as I had always been, I decided to offer her three options. I told her that I was experiencing a temporary family circumstance that might necessitate other unplanned cancellations. I went on to say that I could see that this was not optimal for her, as she needed not only to be able to depend upon my reliability, but found it hard to contain her feelings when she was anticipating our planned session to work on them. I proposed three options: 1) she could transfer to another therapist, whom I would help her find, 2) we could suspend our sessions for three months and then reevaluate, by which time I felt I would better know about whether I could resume working with her in a more predictable way, or 3) we could continue working as we had been, with the understanding that I could no longer be certain that I would not have to cancel unexpectedly. The patient was very grateful for my straightforwardness and for my appreciation of her historical sensitivity to unpredictability. She chose to suspend meeting for three months, by which time my husband had died and I had resumed my accustomed predictable schedule. This patient never inquired into or became aware of my husband's illness or death, and our work continues to proceed very productively.
When my husband died, I called each patient myself, canceling my appointments for three weeks. I felt this would give me time to be more available and clear. I cited the reason for my cancellations as a "loss in the family." Several people expressed their sorrow, and no one asked me the nature of the loss. Once again, each person received and reacted to this information about me in his or her own way. Several read my husband's obituary notice in the newspaper, and a few attended his funeral. All of those who knew I had lost my husband wrote me loving and very touching notes of sympathy during our hiatus in meeting. Another contingent of patients never knew, never inquired, and resumed their therapeutic work where it had left off, reflecting only on the hiatus in treatment.
Reactions among those who knew varied. One long-time patient could not believe I had made the call to her myself, and allowed herself to acknowledge for the first time that there was a positive affective link between us, and that it went both ways. Never having felt that she mattered to those she loved, she was startled to find that I had thought about her in the midst of my grief. Most patients expressed shock at not having been aware of my husband's illness, and gratitude that I had continued to maintain empathy and concern for them during what they realized must have been a very trying period in my own life. More than one marveled at the blind eye they had turned to the signs of his illness, such as the quietness in the shared waiting room. For one man, this observation gave rise to reflection into his own self-absorption, long noticed by his wife, but never before appreciated as an aspect of himself.
My grief, such a visceral reminder of my vulnerability, elicited a range of reactions. For some, the desire to comfort and take care of me felt empowering or representative of our shared humanity; for others, it was a burden and a resented distraction from their own concerns. For some, my so-called 'steadfastness,' 'resilience,' or tendency to 'make lemons into lemonade' seems to provide hope and inspiration; for others, it increased a tendency to idealize me and diminish themselves, or to see me as arrogant and unreachable. One woman in particular was enraged that I had not told her that my husband was gravely ill. Four years later, this issue reemerges from time to time, as she calls me a phony for keeping such a "secret." I have wondered, both privately and directly with the patient, about whether I should have told her that my husband was ill, knowing how hard it has been for her to trust me. It is possible that I chose to maintain the boundary with her in a futile effort to protect myself from her easily-flared rage or wishes to merge, which may have felt too much for me at the time.
The discussions I had with patients openly grappling with their own reactions to my husband's death shed light on the striking lack of curiosity exhibited by others. I believe that some of my patients simply could not allow themselves conscious awareness of my loss. Such knowledge might have made it difficult for some to continue to give themselves free license to work through issues of their own, feeling that my loss of a spouse in the prime of life made their own problems seem relatively insignificant. 'Not knowing' about my loss, they need not wrestle with guilt evoked by worries about the wish to focus on self. This stance also spared some patients the need to struggle with conscious ambivalence about assuming a solicitous stance in regard to me. Our accustomed roles could be kept intact, and our relationship could proceed unencumbered by the tumultuous events in my life. For some patients, especially those wrestling with mourning of their own, it was important to maintain an image of me as steadfast and solid; might I be too sad to bear any further sadness that a patient might need me to absorb? My attitude was to accept each individual's own way of reacting to and processing my circumstances. As in any clinical situation, this knowledge enhanced my understanding of the person. For many patients, the sadness, selfishness, love, mutuality, ambivalence, and uncertainty about roles stirred by my husband's death offered a powerful opportunity for learning about themselves that deepened the therapeutic endeavor. And for others, these issues were best left to be dealt with at a more appropriate time, governed not by a timetable set by my personal circumstances, but by the patients' own developmental needs. As I stand back from my practice, I feel that, on the whole, my ongoing struggle with loss continues to make me more accessible and attuned to the inner lives of my patients.
I also ask myself how my own mourning process has been affected by my patients' reactions to my life circumstances. In any given session, I may experience a direct stirring of my own feelings, as a patient seeks to discuss the meaning of my loss to them. Accustomed to privacy and self-containment, I have had to adjust to some patients' need to process an aspect of my own life that, at least at first, was quite raw and vulnerable. Sometimes it is a relief not to think at all about my changed circumstances, and to remain relatively detached. But at other times, it is a relief to be able to be more 'real.' Certainly there are moments in which a patient's empathy summons a quiet tear to my own eyes. Such instances have helped me mourn, providing another mechanism for processing loss in small, manageable doses. As I 'switch gears' in tune with my patients, my defenses have become, of necessity, more flexible. Not only do the well-practiced tools of our profession aid my mourning, but the very experience of functioning as a therapist facing personal loss helps me master my grief.
Concluding Thoughts
I will leave you with a few other lessons that have stayed with me as a result of struggling with the loss of my husband. I deeply regret all of the many hours I spent worrying—worrying primarily about what the future would bring. Our textbooks tell us that the function of anxiety is to signal danger. Anxiety that alerts us to take action that will protect us and truly forestall negative consequences is obviously useful. So, anxiety that directs us to buy disability insurance or seek a second opinion is likely quite valuable. Beyond serving this 'signal function,' anxiety serves only to upset us. Would that I had had the wisdom to save all the time and emotional energy I wasted on worrying about my husband's ill-health, and had invested equal energy in enjoying more wholeheartedly the time our family still could spend together. So, for me, the lasting lesson is not to focus too much on fears, until they actually come about. Hand in hand with this realization comes an appreciation of the virtues of distraction. There is a time for processing emotion, and there is also a time for putting upset aside, and living completely in the moment. Having truly limited time brings this lesson home.
And, finally, as therapists we often tend to neglect our own needs and more naturally gravitate to ministering to the needs of others. But one can only be a fully
available caregiver when one's own limits are acknowledged. Whether caring for a sick parent, child or spouse, we must try to be honest with ourselves about our own capabilities. For therapists, this may mean curtailing our schedules, being more careful about the composition of our practices, seeking support from friends, colleagues or therapists, and, finally, remembering always to identify our own needs and to nurture ourselves.
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