Fears of Death and Fears of Dying in the Counter-Transference

Abstract

It is commonplace for people to say they are not afraid of death but they are afraid of dying. I discuss unconscious aspects of fears of dying and fears of death which are revealed in counter-transference experiences in therapy with people suffering from terminal illnesses and with older people. Studying the counter-transference shows that fears of dying, which usually refer to lingering and disabling illnesses, unconsciously are linked with fears of dependency and the apprehension that if one becomes dependent then no-one will want to look after you. This apprehension is often a residue of failures in the early dependency relationship which can be re-enacted in adult life through projective identification when therapists and carers may be induced to abandon the caring role. Despite the ubiquitous denial, fears of death surface in the counter-transference, often obliquely but always with a particular terror for the survival of the self. This unconscious terror confirms Freud’s insight about the denial of death that what is unthinkable is the annihilation of the self. I conclude with a discussion about the importance of setting an ending date in therapy with those who are old or terminally ill.

Keywords: death, dying, counter-transference, projective identification, dependency, superego.

Introduction

In this paper I offer some reflections on fears of death and fears of dying arising from my clinical work with older people and supervising therapists working in palliative care and hospice settings. Though these fears overlap, I will study a distinction people frequently make when they say they are not afraid of death but they are afraid of dying, and address unconscious aspects of these fears as they can be understood through the counter-transference. I begin with my understanding of counter-transference and how it reveals aspects of unconscious communication, and then describe clinical vignettes and theoretical perspectives firstly in relation to fears of dying, then about fears of death. I conclude with a discussion about the importance of setting an ending date in therapy with people who are old or terminally ill.

Counter-transference and unconscious communication

My appreciation of counter-transference as a means of understanding aspects of unconscious communication is derived from the Kleinian and post Kleinian school of thought. Counter-transference refers to thoughts and feelings experienced by therapists in their encounters with their clients. Upon reflection these conscious thoughts and feelings, which might also include bodily experi- ences, can provide clues about unconscious communications from clients. This communication is mediated by projective identification which Klein and her followers have developed following Freud’s original discovery of projection and his assertion that the unconscious of one person can communicate directly with the unconscious of another. The unconscious phantasy underlying pro- jective identification is that unmanageable aspects of the self can be disowned, split off and at- tributed to another who is then identified with these aspects. Often this phantasy is made real by verbal and non-verbal behaviour with the result that the recipient of the projection experiences as- pects of what has been projected and mistakenly believes these to be only his or her own thoughts and feelings. Unconsciously thoughts and feelings are mobilised in the recipient which find reso- nance with what needs to be disowned. A central motive for projective identification is a wish to communicate about what may feel unbearable with the hope that if another can bear what is pro- jected then perhaps the self may come to be able to bear and retrieve more of what is disowned and thus feel more whole.

It is not within the scope of this paper to review the developments in counter-transference, for ex- ample in the use of Bion’s concept of reverie (Ogden, 1997; Ivey, 2011) For the purposes of clari- fying the difference between fears of death and fears of dying I have found it useful to draw upon Racker’s (2007) distinction between what he describes as ‘complementary’ and ‘concordant’ counter-transference. Complementary counter-transference refers to a traditional view of counter- transference experiences which are re-enacted in the therapy often from earlier, traumatic relation- ships and which have become part of the client’s unconscious internal world, when the therapist be- comes identified with the traumatising figure, such as the abandoning mother, cruel father or abu- sive persecutor. Concordant counter-transference refers a wider view of counter-transference expe- riences when the therapist becomes identified with the client’s own traumatised position and emo- tions in such relationships, such as the abandoned child, the angry child or traumatized victim. Much depends on the capacity of therapists to be open to unthinkable and unbearable states of mind and, rather than enact their counter-transference, to reflect on how their conscious experiences with clients may indicate unconscious aspects of this projective process. Training, personal therapy and supervision can all provide a reflective space to help the therapist maintain an observing stance in relation to his or her thoughts and feelings, disentangle him- or herself from the projective process- es between client and therapist, sort out what belongs to the therapist and what belongs to the client, and discover aspects of what has been projectively communicated.

Fears of Dying

A therapist brought a dying woman who was in her early fifties. She had a long history of physical illness but a few years previously there was a breakthrough in her treatment when she began to experience better health. Only a short time later she was discovered to have a terminal condition with little time left to live. Her therapist told me her client was frightened of dying. Each time the therapist saw her client she felt a ‘heart racing sense of panic’. She felt it imperative to try to relieve the client’s fear. She drew on techniques such as mindfulness to try to help her client manage her fear. The medical staff were impatient with the client. She had been on the ward a bit longer than usual and they thought she was well enough to be treated from home. In a ward round the consul- tant said that ‘of course they could not put themselves in her shoes but...’ . Her husband had said to her that at least she knew when she was likely to die. She described a ‘tough love’ mother.

The snapshot of this woman’s mother suggests a mother who offered poor containment for her daughter’s vulnerable feelings, and was probably not a mother on whom this woman could depend but an external and internalised figure who insisted on toughness and perhaps condemned helpless- ness. I suspect this internal tough mother had not much time for her daughter’s fears, nor it seems did her husband or the medical staff whose impatience with her suggests they indeed had some inkling of being in her shoes but couldn't bear it. Her therapist’s ‘heart racing panic’ gives some in- dication of how unbearable her client’s fears felt in the therapist’s identification in a concordant counter-transference. I think the client’s fears of dying were linked to an underlying fear of depen- dency that no-one would want to care for her in her dying state. These fears were enacted and made real by being unconsciously mobilised in others through projective identification which was evident in the medical staff’s somewhat atypical impatience to discharge the patient. Her husband seemed to be similarly impatient with her. The staff and husband were identified in a complementary counter-transference which were likely enactments of earlier failures in the dependency relation- ship. When the therapist reached for behavioural techniques to alleviate the client’s fear and her own feelings of panic, the therapist’s departure from her psychodynamic approach indicates a counter-transference enactment in which by abandoning her usual containment it was as though she could no longer bear the intensity of the client’s projective identifications. Gavin Ivey (2015) de- scribes how the dynamic therapist is vulnerable to such enactments when there is felt to be pressure in the counter-transference to introduce active interventions. In particular he argues convincingly of the overlap between psychoanalytic / psychodynamic therapy and mindfulness approaches. In examples of how the introduction of mindfulness techniques during a dynamic therapy may reflect an enactment, Ivey shows the importance for therapists to reflect upon the counter-transference.

Here is another illustration of the fear of dying. A therapist in a hospice was seeing a woman in her sixties. Her somewhat older husband was a patient of the hospice and had become quarrelsome and verbally abusive. The client told the therapist she planned to leave her husband but when he was diagnosed with an incurable Motor Neurone Disease she could not do it. He was no longer allowed to drive their car. She described driving him on a long car journey during which he continually shouted abuse at her with the result she had to stop the car. She burst into tears. She said she felt trapped because she was unable to leave him. Her therapist was aware of feeling a strong wish her client would leave the husband. At a later session her client reported the husband saying he thought the therapy was helping her and he wondered if he should have therapy too. She then told the therapist her husband had been adopted at an early age. He was told repeatedly by his adoptive parents how special he was because he was specially chosen by them. He was a perfectionist and had achieved a successful professional career.

Dying from a Motor Neurone Disease this man faced a long lingering death in which his intact mind would eventually be trapped in a body no longer able to function. He would become unable to speak, eat or eventually breathe. I suspect that signs of his degenerative condition probably already affected him before the formal diagnosis and prompted unconscious fears of becoming de- pendent and being abandoned which were revived from his infancy. In the story of his adoption, as so often happens, there was no emotional space for mourning (Kirschner, 2007). Instead he was encouraged to feel specially chosen. It was difficult too for him to begin to mourn his degenerative illness and death because he was consumed with apprehension that in becoming dependent he would again be let down and unwanted. In his abusive behaviour he projectively mobilised an en- actment of these fears of dependency and abandonment in his wife with the result that she was on the brink of leaving him before his diagnosis, just as her therapist was also inclined to identify with the wish that her client abandon this man. The therapist became identified with her client’s feelings in a concordant counter-transference and only later came to understand that her client’s feelings were an indication of an identification with a complementary counter-transference in relation to her husband. However, importantly the therapist did not discharge her counter-transference feelings into some kind of action, for example by advising the client to leave her husband. Instead her re- flectiveness and containment of the client led her client to an appreciation of her husband’s fears.

Brian Martindale (2007) has written of the fears associated with becoming dependent again in later life when there have been problems in the earliest dependency relationship. He understands these frequently expressed fears of dying as a reflection of early failed dependency relationships and the consequent dread of a lingering death where dependency needs will again not be met.

Elliott Jaques (1965) in his seminal work on ‘Death and the Mid Life Crisis’ dismisses the differences between Freud who believed the unconscious had no awareness of death, and Klein who maintained there was an awareness of death in the unconscious. Jaques says this is only an apparent conflict. He agrees with Freud that the unconscious rejects awareness of death, but in his psy- choanalytic practice Jaques found unconscious experiences of death similar to ideas about death which later appear in consciousness. He gives an illustration from one of his analysand’s dreams of what he considers to be typical of unconscious experiences and fear of death. In the dream the client was lying dead in a coffin, sliced up though with a thread of nerve connected to her brain and thus able to experience everything, but unable to communicate in any way (p.506). I think this image is more representative of a fear of dying because it captures the dread of failed dependency portrayed by the dreamer who is conscious and alone with no carers with whom she would anyway be unable to communicate. It is an image that becomes real for those who suffer incurable illnesses like Motor Neurone Disease or Multiple Sclerosis when eventually they are unable to communicate their needs. Such illnesses are often reduced to acronyms like MS or MND which slip easily off the tongue in a way that can assist not thinking about the horrific spectre of what has to be endured and which is portrayed in Jaques’ tortured unconscious image.

A therapist presented a man of just 41 years who, as a result of Multiple Sclerosis, was confined to a wheel chair with just a few remaining capacities which were diminishing almost daily. The thera- pist was worried because she found herself feeling in agreement with her client’s expressed wish he would die to to end his suffering. I was surprised at how little she knew about his life. She said she felt uncomfortable about asking him any questions about his life. It seemed that there was an em- bargo on curiosity in her and her client. When her client later talked more about his life he revealed poor relationships with both parents which seemed connected with his decision to have no children of his own. He described long periods of his mother being ill and absent when he was in his teens which I thought could be a screen memory (Freud, 1899) for earlier maternal absences. Undoubted- ly illnesses like Multiple Sclerosis are ghastly to bear but they are likely to be even more unbearable when needs have not been adequately met in the early dependency relationship which leaves appre- hension about becoming dependent again.

A woman in her mid fifties, under the care of a hospice was referred for therapy. She was at the time still managing to live on her own. The therapist mentioned almost in passing that she had ‘MS’ and went on to speak about this woman’s keen interest in exploring aspects of her early life. I returned to her Multiple Sclerosis and suggested that perhaps looking backwards in time might be taking her away from a difficult present. When the therapist brought this woman again he said that when he asked her more about her illness he discovered she had a rare form of Multiple Sclerosis which meant she could die at any time. She started talking about how hard it was being so alone. She blamed herself for causing her illness believing it was the result of her anger with her partner when they separated. She described a harrowing relationship with her sister who was often cruel to her. I thought what was coming to light was how a cruel superego, an internal version of her cruel sister, was very punitive, blaming her for loneliness and for having Multiple Sclerosis.

When the nature of this client’s Multiple Sclerosis and the likelihood of her death was taken up this client admitted that she thought about dying every day. This meant the matter of time and how long she might live, and what her priorities might be in the remaining time could be addressed. Whilst supervising therapy with those who are terminally ill I often raise the question of the client’s pro- gnosis and how long the client expects to live. Undoubtedly these are difficult questions to ask but, as Dr Atul Gawande (2014) has highlighted, important questions like these are rarely addressed with those who are terminally ill. Gwande discusses how hard it is for doctors to acknowledge the limits of the relentless treatments they feel obliged to offer terminally ill patients. He found there is frequently a great deal of relief when patients are asked how much time they think they have left, and when they are prompted to think about their priorities in the time remaining. He also observed some patients were not able to talk about these issues and might benefit from psychotherapeutic help in order to do so.

Fears of Death

Fears of death are much denied and the counter-transference indications of unconscious fears of death tend to be oblique and difficult to unravel. The following vignettes illustrate some of the dif- ferent disguises these fears may manifest in the counter-transference.

I was asked to see a man in his early seventies who was a patient in a day hospital in a specialist mental health service for older people. He was discharged to the day hospital from an in-patient ward where he had been admitted because of a suicide attempt. When I saw him he still had occa- sional thoughts of suicide but was no longer regarded as an active suicide risk. The day hospital staff had reached an impasse with him. He was physically well, had retired on a substantial pension and lived with his wife in a fine house with a garden with which he had been keenly involved. He had also been a regular golfer at the local club where he had friends with whom he socialised. But no longer. His previously active life had come to a standstill. He sat in an armchair at home or the day hospital unwilling to do anything. He agreed to see me though he soon made it clear he felt no need of my help. He offered little of his thoughts and feelings, and gave cryptic answers to ques- tions about his life. I quickly came to appreciate the day hospital staff’s sense of frustration.

He attended a second appointment and on further questioning spoke a bit about his golfing. The last time he played golf one of his friends had a heart attack at the putting green and died in front of him. He never returned to the golf course. Probably somewhat precipitately and reflecting my irri- tation with him, I interpreted that I thought he was afraid of having a stroke like his friend and fear- ful any exertion might kill him so he resolved to do nothing. He dismissed such fears with a great deal of contempt. Towards the end of this meeting he talked in a way that implied he might try to kill himself at a nearby level rail crossing, without admitting it was his actual intention. I was left worried it was just what he would do and alerted the day hospital staff. When they later did a risk assessment at his home he denied all such thoughts. He refused to see me again. In my interpreta- tion about his fears of death I failed to address but instead enacted a complementary counter-trans- ference identification with a harsh super-ego which was critical and intolerant of such fears, and which was doubtless linked with this man’s depression and his unwillingness to acknowledge his fears. Later, my dread that he would kill himself after he left the session was a concordant counter- transference identification with this man’s unconscious fears of death. It is an example of how sui- cidal threats may sometimes convey unconscious fears of death which are projectively identified into others and how very difficult it is to recognise this projective process when the client presents such opposite conscious motivation.

A therapist brought worries to supervision about a woman who was terminally ill. She had suffered a great deal, was in a very poor physical state and being treated as an in-patient. For some time this woman expressed a wish to die. The therapist told me she was worried about safeguarding issues in relation to this woman’s husband who was her sole carer. She said some of the nurses on the ward also voiced concerns about what was going on between the woman and her husband. When I ex- plored the nature of these worries in more detail the therapist was hard pressed to specify just what is was about the relationship with the husband that worried her. Although there had been recent ar- guments there was no evidence of physical abuse. Her client spoke of how her husband cared for her and how they enjoyed watching television together. The client died a little time later. The therapist was extremely distressed and puzzled about how much more affected she had been by the death of this client than by deaths of other clients with whom she’d worked.

To the therapist and other staff the threat of death seemed to be connected with the client’s husband, a threat for which there was no substantial evidence, but this woman was in the last stage of a ter- minal illness. In contrast to this client’s understandable longing to die to end her suffering, the safeguarding concerns which were mobilised in the therapist indicate a concordant counter-transfer- ence identification with her client’s unconscious fears of death. Further evidence of this projective process was apparent in the extreme grief the therapist felt about her client’s death. The client’s wish to live and fear of death were split off and projectively identified into the therapist. In her an- guished ill state the client could not manage a more ambivalent position of wanting to live and wanting to die.

A therapist in a hospice brought an older male client who was dying from two different forms of cancer. He complained of feeling claustrophobic in the counselling room and said ‘there was no way out’ of the hospice. He recalled an experience when he was just a boy playing a game with an older sibling in which he was nearly suffocated by having a pillow held over his face for too long. The therapist found herself feeling shocked and frightened by this story. The client’s fear of death was near to consciousness but it was located at some distance at a much earlier time in his life when he was a boy and nearly suffocated. In the therapist’s concordant counter-transference she was giv- en a glimpse of how frightened her client felt in the present by his impending death which was his only way out of the hospice.

Another therapist was asked to see a terminally ill client for an assessment for therapy in the client’s home because the client refused to attend the hospice but was seeking some counselling. When the therapist met the man he found himself becoming alarmed the man was going to physically assault him, not so much from what the man said but more in response to his physical presence. The thera- pist was very shaken by the experience and troubled about why he had become so fearful for his own survival. The therapist’s own fears of death were mobilised in a concordant counter-transfer- ence which on reflection reveal his identification with client’s unconscious fears. Those fears doubtless contributed to the client’s reluctance to attend the hospice which would have meant acknowledging his dying condition.

Freud wrote about our attitude towards death in ‘Thoughts for the Times on War and Death’ in 1915 six months after the outbreak of the first world war. He had two sons fighting in the war. At this time he was also drafting his paper about mourning and melancholia ideas for which had first been sketched a year after his father’s death nine years earlier. In his thoughts about war and death Freud wrote of a ubiquitous denial of death which was challenged at times of war because there were so many deaths. He described how it is ‘impossible to imagine our own death; and whenever we at- tempt to do so we can perceive that we are in fact still present as spectators ... at bottom no-one be- lieves in his own death ... in the unconscious everyone of us is convinced of his own immortality’. (p.289) At the same time as drawing attention to the unthinkableness of death, Freud emphasised how much the denial of death diminishes our lives. He left us with this conundrum which has rarely been pursued in the psychoanalytic literature.

In Melanie Klein’s paper ‘On the Sense of Loneliness’ (1963) drafted only a few months before she died, her editors comment there seems to be a premonition of her death. Klein wrote about fears of death which ‘play a part in loneliness’ (p.304). She understood that earliest fears about one’s death arise in infancy when the mother is absent and the ‘feeling that she is lost is equivalent to the fear of her death’. As a result of introjection, ‘the death of the external mother means the loss of the inter- nal good object as well, and this reinforces the infant’s fear of his own death’ (304). Klein’s formu- lation of fears of death involve an object relationship, implicitly the self is still present. Similarly in the Jaques’ unconscious representation of death in his analysand’s dream which was described earlier in relation to fears of dying, though a tortured image, the self is still present. Jaques was strongly influenced by Klein, and her notion of the death of the mother underlying fears in loneli- ness better captures fears of dependency and abandonment which are aspects of fears of dying.

A literature search indicates few references to unconscious fears of death in the psychoanalytic lit- erature. It seems Freud’s 1915 insight about the denial of death was not pursued until 2004 by Franco De Masi in his book Making Death Thinkable. De Masi writes the anticipation of death is a trauma to the mind like no other trauma because it represents nothingness, the loss of self. Annihilation of the self is unimaginable, unthinkable, and in my view underlies unconscious fears of death, and perhaps accounts for the reluctance of Freud’s followers to follow up this insight. The unthink- ableness of death may also explain why detection of fears of death in the counter-transference is often so difficult because of the client’s and therapist’s denials of these unconscious fears. By con- trast fears of dying are more accessible and include an object relationship, the self still exists in re- lationship with others who are feared will let down or abandon the self when dependent and in need.

Setting an Ending to Therapy

I shall conclude by discussing an issue that comes up frequently in therapy with those who are old or terminally ill: setting an ending date. I have argued elsewhere ((Terry, 2008) that difficulties ex- perienced by therapists in setting ending dates with older clients can reflect unconscious aspects of ageism in which the therapists’ own fears of death are projectively identified into their older clients. It is understandably very hard to bring up finishing therapy with someone who is dying but doing so can bring an opportunity in the here-and-now of the therapeutic relationship for the finiteness of life and time to be mourned with other losses, not least the ending of one’s own life. If an ending to the therapy is not addressed it can confirm an apprehension that the emotional experience of such losses cannot be borne by the client or the therapist. Therapist and client together facing the ending of their relationship may bring some hope that unthinkable terrors of death can be faced. Thus I be- lieve it is essential to reflect on the counter-transference involved in deciding not to address an end- ing of the therapy. There are no hard and fast strictures in these distressing end of life tragedies. Alongside reflection on the counter-transference, considerations of the dying person’s particular life experiences, emotional resources and support need to guide the therapist.

A therapist brings a young woman in her thirties suffering from a terminal illness and currently be- ing treated with a gruelling chemotherapy programme. The therapist wonders how long she should see her client for. I wonder how long her client expects to live. A few months later, the therapist tells me her client, who has been longing for the end of the chemotherapy, has now been told she will have to remain on chemotherapy until she dies. The chemotherapy will not cure her illness but might extend her life. She finds the side effects dreadful to bear. I wonder why she puts up with it. Could it not be preferable to put a stop to this treatment which she finds so distressing? The thera- pist says those thoughts also passed through her mind. I say it could be helpful to put such thoughts into words. A few weeks later I hear about a session in which the therapist and her client seem nearer to talking about the reality of the client’s death. Again I raise the question of setting an end- ing date, saying as I usually do that it doesn’t matter quite when the date is set for, but it seems to me important it is addressed.

A month or so later the therapist admits she is struggling to raise ending of the therapy especially because the client feels so unsupported by her family. The earlier contact the therapist had with her client’s parents indicated they could not manage their daughter’s dying. I remind the therapist it is the discussion about ending that is important, the acknowledgment that time and life are finite.

The next month I hear the client has been given a ‘deadline’, she she was told she has no more than a year to live. She talks of how she has to keep things light and humorous for her friends whom she describes as heartless. I was reminded of how accounts of her parents’ behaviour seems so insensitive to her distress and confirm her fear no-one can bear to know about her feelings. She jokes with her therapist that at least death will mean she no longer has to struggle to find a partner and happiness. She mentions a psychiatric history which suggests she has suffered considerable time with depression which she has tried to self medicate in different ways. I notice in the accounts of the sessions it is sometimes as though the client has plenty of time in the way she talks of pursuing various projects. She is in a debilitated state and her efforts to pursue such projects seem tormenting.

Six months after I first raised the question of an ending date the therapist brings up ending with her client. In response the client says she would like to continue until she dies but she can appreciate there must be questions of resources for therapy and it may not be possible. The therapist assures her it is not a question of resources but it is important for them to think about ending. A few weeks later the therapist comes saying how guilty she feels because she and her client have still not agreed an ending date. She describes a recent session in which client was painfully reflecting on her life and so much she has missed which will be impossible for her now. Despite these regrets she was able to acknowledge some of her considerable achievements. There is a poignant sadness. The client and therapist are engaged in the crucial work of mourning the end of her life. I believe this crucial movement into mourning was enabled by confronting the end of the therapeutic relationship.

Acknowledgments

I wish to express my gratitude to the clients and the therapists from whose work and courage I have learned so much about the fears which beset us as we approach the ending of lives. I would also like to thank William Halton for his encouragement and help in the preparation of this paper and the peer reviewers for their comments.

Paul Terry