Introduction
In the Mahabharata, the great Indian epic, Yudishthera, the eldest brother (and pathological gambler) is asked a question.
Giving the correct answer will allow him to revive his brothers lying dead at his feet.
The question is “What is the greatest wonder of all?”
Take a moment and think what you would answer.
Yudishthera’s reply is: “The greatest wonder is that people see sickness and death all around them and yet think it will never happen to them.”
Myth of the eternal analyst
Analysts suffer from this greatest wonder.
. When we begin an analysis, we give an implicit assurance that we will be there for our patients for as long as they may need us. Even when patients terminate, we often say, “My door is always open” as if to show that we will be therefore the patient in time of their need. This attitude is based on the “illusion of practicing indefinitely” (Schwartz & Silver 1990), which in archetypal terms might be called, the Myth of the Eternal Analyst, that we will live forever and forever be available to help, as one analyst put it only half humorously, “I will live forever.”
We will all become sick, even very sick and at some point we will die, often dying in ways that may be terrible for those very patients who we care about. True, disease and dying is something each person must face, but for us as analysts, it has a special significance and unique implications. Disease often surprises us, as it certainly did me. I wish someone had taught me what I was in for before I had to muddle my way through and learn from my own mistakes.
My interest in serious illness in the analyst began when my fellow candidate and comrade, Naomi Eilander discovered a recurrence of breast cancer 5 years after she felt cured. I saw close at hand how she dealt with patients, how I and others would “cover” for her while she underwent treatment in USA and especially when she died there unexpectedly, I recall calling her patients to tell them she had died and to offer them a free session.
I was also influenced when, at the end of my own analysis, my analyst was hospitalized. I recall vividly visiting him in hospital and his subsequent decision to leave Israel. I have also interviewed analysts and analysands who were seriously ill, presented workshops on the topic here and abroad and reviewed the psychoanalytic literature.
The point of this paper is, therefore, to challenge the myth of the eternal analyst and to confront the inevitable reality of a wounded-healer, wounded again.
Active Imagination
I want to begin with an active imagination:
You are sitting in the doctor’s office. You have come because you are feeling a little more tired than usual and during some sessions, you even found it hard to concentrate and still feel a irritating unfamiliar pain. You are waiting for the doctor, who will tell you about the results of the blood tests.
How do you feel? how do you feel waiting? Waiting for the doctor to come?
The doctor enters and tells you that you have cancer. You will need chemotherapy and then radiation over the next six months. The prognosis is uncertain.
How do you feel? What is the first thing you would like to do?
How do feel towards your patients?
What will you tell them?
My Experience with Illness
This active imagination is based loosely my own experience. To make the issues more experience-near and authentic, I want to first share some selected passages from my diary written at that time:
I discover my left eyelid was drooping. I felt no pain, no discomfort and only knew of it when a neighbor said, “What is wrong with you eye?” Overcoming a natural tendency to ignore health issues, I went to numerous doctors – ophthalmologists, neurologists and internists, and underwent many tests none of which uncovered the cause. At the same time, I began losing weight, eating less and feeling without my usual bounce. Sleeping became painful from what I later discovered was a hugely swollen spleen and liver. One day I became breathless. I couldn’t even walk up a flight of stairs, [when I used to zip up 9 flights to my office at the university. Even swimming became difficult after a few strokes.] Still, I felt it would pass; it was nothing to be worried about. I even traveled abroad to give a workshop. When I returned, suddenly my white blood cell count jumped to panic levels. The next day or rather night – thanks to my wife’s persistence, I meet with a hematologist. The physician [who had originally been a social worker,] had first said, “Well maybe I can see him at the end of next week.” When she heard more, she sounded more concerned, “Well maybe at the beginning of the week.” By the time, my wife had finished my story, she said, “Have him come tonight!”
I sit with her in a deserted cancer institute. We talked, she explained what a lymph node was – I barely knew – and then she said, “Lets look at the blood slides together.” She took me to her lab, drew blood and when the slides were ready, she took a deep breath but when she had a look, she said, “Oh, they are cute.” She had suspected a fatal, highly aggressive blood disease but found a more indolent lymphoma. There are 45 different subtypes of lymphoma, each with its own treatment and prognosis. Whereas diagnosis is usually done via lymph biopsy, this procedure was not possible in my case. For a whole month I had almost daily tests to discover what had been brewing in my body. On the day of body marrow biopsy, I called my colleagues to cancel my teaching who said,: "Fuck! Where did you pick that up!" CT revealed suspicious sightings in the soft tissue, near the spine, behind the kidneys, in the abdomen. Finally, my breathing got so bad – the lymphoma was blocking the drainage of the pleura, the sack around my right lung, compressing and compromising my oxygen supply – that they started treating me with even before they have a definitive diagnosis. Hematologists love histology. They need to see how the cell looks like as an individual and how it grows in culture into a community. It sounds very Jungian, the individual and the collective. But since they do not know for sure what I have got, they treat me for the worst with the strongest possible dose of chemotherapy and a new biological treatment. CHOP + R,
[ Rituxin, generic name rituxamab (Mabthera in Israel) ]
Now in a more poetic mode:
Towards evening, my breathing becomes even worse
And pain stalks each sitting position
I do not know what to do with myself.
For the first time,
I feel really miserable.
I cannot face another unslept night.
I have my first scary dream:
I am driving in a car in a city street with my wife.
We are going down a gentle incline
And I want to slow the car down
But I cannot move my foot from pedal to brake
momentarily immobilized
I cry out for help…
Lying awake in dark’s early light
I think of yesterday’s last entry:
“I will laugh this lymphoma under the table”
and start sobbing.
Lymphoma also in the bone marrow,
in clumps and more: an infected pelvic lymph node
hidden and inaccessible
But the real shock comes
when I ask about staging.
naively I had thought since there were no obvious lymph nodes
I might be Stage I
or II.
My doctor hesitates and I know it is bad.
In Hebrew, I say, "dugri." “Tell me straight.”
I have been strong
staring death down
but I am not prepared for her reply:
“Stage IV.”.
Today, there are no tests.
I am not a patient but take care of my own patients.
I think I must construct an up-to-date patient list
just in case
in the event of my death
and suddenly I am sobbing
for the first time since I heard,
alone
in the bath
I go to my office and make that list
prepare copies to give to colleagues
in case sessions need to be canceled
when I have chemo or worse.
The rest of the day, I sit and listen to other people.
one lady, a senior mental health professional
recalls the brutal abuses of her father
and then of the men in her life
She sobs, “I am damaged, so damaged”.
Later I want to transfer him to another analyst,
but she cries again, saying, “Don’t you understand,
I cannot go to another analyst. I just cannot.”
Another younger man is about to be married.
Every moment of joy brings the anguish of a missing father, murdered in a terrorist attack
He says he will never be happy again, not even on his wedding day.
I am suddenly terrified that this will also be
my children's fate.
How Freud and Jung Dealt with their Illnesses
Before continuing with my own story, I want to discuss how the founders of psychoanalysis dealt with their own illness.
Freud and Jung both suffered serious illness, cancer of the jaw and a heart attack respectively. Neither discussed how their condition affected the treatment of patients. Freud underwent 33 operations and hundred of visits to doctors. He suffered severe pain and discomfort. His jaw prosthesis made talking impossible at times and deafness in one ear. In a letter, he writes, “I am of course reminded every hour of the mutilation caused by the operation on my jaw” (E. Freud 1960, p.224) in Schwartz 1990, p. 143). In addition to the cancer, he also suffered from various cardiac symptoms, irritable bowel, migraine and nicotine addiction. Freud had severe fear of death most of his life and ongoing anxiety about dying at specific ages. Synchronistically, he was trying to formulate his views on the fear of death when the cancer was discovered (Schur 1972, p.347). He continually asked his doctors not to let him suffer. Ultimately, he did die from an injection of morphine provided by his physician who had agreed to this act of active euthanasia. (Schur 1972).
Yet for all of his therapeutic concern, Freud repressed and denied the impact of his disease on himself and especially on others. Freud hid his condition from his own family who only learned about it after his first operation when he unexpectedly had to stay overnight. His denial was also expressed in such unhealthy activities. He ignored repeated requests to give up cigars despite its adverse impact on his health because he could only write creatively with a cigar.
Many times, he unexpectedly had to break off his clinical work for operations and for cardiac problems, and on at least two occasions had to stop in the middle of a session. He was in continual pain, “a life of endless torture.” (Schur 1972, p.364). The “monstrous” jaw prosthesis had to be altered and changed often and at times made it difficult even to speak. Around that time (which also coincided with the death of his favorite grandson), he experienced “the first depression” in his life that killed something in him and after which he never formed new attachments.
Few of his patients have written about how they experienced the impact of his illness on their analysis but at least two indicated that Freud actively discouraged any discussion of it (H Doolittle 1956; Jones 1957, p.13). Eissler who was perhaps the first to seriously address the issue of illness in the analyst, wrote, “when an analyst denies his own illness it seems inevitable that the patient denies it also.” Eissler, K.R. (1977) On the possible effects of aging on the practice of psychoanalysis. Journal of Philadelphia Association for Psychoanalysis 3:138-152. in Kaplan, Alex H. and Rothberg, David (1986) The Dying Psychotherapist Am J Psychiatry 143:5.561-572:
In at least one letter, Freud did admit to Princess Marie Bonaparte that his preoccupation with his cancer kept him from recognizing aspects of the transference (letter in Schur 1972, p.382). In another letter to her, he writes: “Every analyst who has suffered a serious illness knows how difficult the situation becomes especially when a patient is alternating between cruel fantasies and the suppression or repression of any awareness of the analyst’s illness, owing to anxiety and guilt.” (op. cit.)
In this regard, I recall one patient who actively denied my weight loss and general decline. When I told him of my cancer, he exclaimed, “How could I have not seen!” His core conflict revolved around cyclical feelings of abandonment-dependency, yearning for safe attachment yet fearing being brutally rejected. When I was undergoing treatment, he was unable to contain this conflict and exclaimed, “Why don’t you die already!” For him, my demise would release him from an intolerable dependency.
Despite this insight, Freud encouraged a stoical, conspiracy of silence. The analyst’s illness was not something to be openly discussed either inside analysis or outside. Nor did he develop any theoretical or organizational frameworks to deal with its complex consequences.
I doubt whether he understood how much analysands, especially those with early losses who fear rejection if they express angry feelings toward the analyst, especially when he/she is ill. Ill analysts need patients in therapy in order to reassure themselves about his own viability. Patient and therapist often collude to avoid the mourning of terminal separation (Kaplan & Rothman p.570). Freud felt this and I certainly did. The result is that analyst’s
illness places a burden on patient concerning which the analyst is unaware. Patients were aware of this burden but were unable to do anything about it since it felt like abandoning a beloved parent.
Pamela Power (2005) one of the very few Jungian analyst to describe the impact of her analyst’s serious illness – who with terrible synchronicity had two analysts die while she was in treatment. Around the time of the death of her second analyst, Edward Edinger, she also discovered that she was suffering from lymphoma.
She goes on to speculate between a possible link between her illness and her analyst’s:
My psyche knew that he was ill and dying before it was a known fact to him or me. My illness as in part an attempt to take on his illness and cure him. It was in part an attempt to live my loyalty to him so fully that I would follow him into death…Once upon a time I felt free to “have it out with him” about some issue, get into an argument or disagreement over something he had said. At those times I found him remarkably open and receptive toward my viewpoint. In the last months, whether I felt he was less open or
I was more fearful (probably both) I did not engage parts of myself freely. These unfelt feelings, “unthought” thoughts, not just unexpressed, but kept unconscious, yet needing to be conscious, needing to be born, grew in my body as “well encapsulated masses”.
As shocked and bereft as I felt when my former analyst died, there was relief about which I felt conflict and guilt. When people would commiserate with me over my loss, I was non-plussed. There was a secret joy in me that I was free to discover deeper layers of my own self, for better or worse, but equally so, I was terrified at the prospect. I had been professionally active and creative in my own right for many years, but with the death of my analyst, things came to a halt. I was no longer interested in teaching or being involved with the professional life of the Institute; I resisted because inside myself, I didn’t know what the hell I thought or believed anymore. My analytic practice did not suffer as I was, for the most part, able to find my bearings during each hour. Moving on and beyond my analyst was accompanied with grief and a sense of betrayal….
Other patients state that the analysis became for the analyst and not for the patient. The patient feels trapped, but is unable to leave, without feeling monstrous and guilty.
Eissler puts the issue most directly: “It cannot be sufficiently stressed how important it is that the patient continue his treatment with another analyst, while his therapist is still alive (op. cit. p. 571). How often do colleagues in your society follow this advice?
Jung’s Visions
Jung had a very different experience with serious illness.
Jung in MDR. Ch. X “Visions” describes how after he broke his foot he had a heart attack, probably brought on by negligent hospital care. He was in hospital from Feb 11, 1944 thru the end of June when he was still ‘so weak that he could not mount the stairs to his second-floor bedroom.’ He gives a moving description of what we would now call a “near death experience” in the period after his heart attack. I will only give a short extract of this amazing document. During the day, he was usually depressed, weak and wretched, scarcely able to move, then in the evening he would sleep and wake in ecstasy:
Everything around me seemed enchanted. At this hour of the night a nurse brought me some food she had warmed – for only then was I able to take any, and I ate with appetite. For a time it seemed that she was an old Jewish women, much older than she actually was, and that she was preparing ritual kosher dishes for me. When I looked at her, she seemed to have a blue halo around her head. I myself was,, so it seemed, in the Pardes Rimonin, the garden of pomegranates, and the wedding of Tifereth and Malchut was taking place. Or else I was Rabbi Simon ben Jochai, whose wedding in the afterlife was being celebrated. It was a mystic marriage as it appears in the Cabbalistic tradition. I cannot tell you how wonderful it was. I could only think continually, “now this is the marriage of Malchuth with Tifereth!” I do not know exactly what part I played in it. At bottom it was myself; I was the marriage. And my beatitude was that of a blissful wedding…All these experiences were glorious. Night after night I floated in a state of pure bliss…
It is impossible to convey the beauty and intensity of emotion during those visions. They were the most tremendous things I have ever experienced. And what a contrast the day was: I was tormented and on edge; everything irritated me; everything was too material, too crude and clumsy, terribly limited both spatially and spiritually…
After the illness a fruitful period of work began for me [as it did for Freud] A good many of my principal works were written only then…something else, too, came to me from my illness. I might formulate it as an affirmation of things as they are: an unconditional “yes” to that which is, without subjective protests – acceptance of the conditions of existence as I see them and understand them, acceptance of my own nature, as I happen to be. p.325-8.
In this passage Jung describes part of his mystical experience. But he also describes how difficult it was for him to return to the hum-drum reality:
The view of the city and mountain from my sick-bed seemed to me like a painted curtain with black holes in it, or a tattered sheet of newspaper full of photographs that meant nothing. Disappointed, I thought, “Now I must return to the ‘box system’ again.” For it seemed to me as if behind the horizon of the cosmos a three dimensional world had been artificially built up, in which each person sat by himself in a little box. And now I should have to convince myself all over again that this was important! Life and the whole world struck me as a prison, and it bothered me beyond all measure that I should again be finding all that quite in order. I had been so glad to shed it all, and now it had come about that I – along with everyone else – would be hung up in a box by a thread.
[…I felt violent resistance to my doctor because he had brought me back to life….”Now I must go back to this drab world… (p. 323,4)
Jung does not describe how this experience impacted on his clinical work. He was unable to work for at least 6 months and I wonder how he was able to return to clinical work with all of its emphasis on the box system. Jung describes a phenomenon that I also experienced.
When I was undergoing chemotherapy, life seemed to have a special intensity. Every moment was precious. There was no time to waste on trivialities. I felt over and over again the key message of individuation: What am I here to do? What is my destiny? I was at the time editing a special edition of the journal Harvest on Erich Neumann who died prematurely at 55. Neumann’s tragic death accompanied me everywhere and energized me. Yet in this energized hypomanic state I. I had a incise acumen, but had little patience.
Like Jung, it was hard for me to return to ‘the box system’. I suspect that this is true for many analyst’s returning to life and their practice after such peak experience of the encounter with their own dying. Jung concludes, “After the illness a fruitful period of work began for me. A good many of my principle works were written only then…something else, too, came to me from my illness. I might formulate it as an affirmation of things as they are: an unconditional “yes” to that which is, without subjective protests …It was only after the illness that I understood how important it is to affirm one’s own destiny” (MDR p. 328)
Jung’s experience highlight how much serious, life threatening experience can have a positive, creative impact on one’s creativity, on one’s self and even by implication on one’s clinical work. Klitzman (a psychiatrist who himself suffered from depression) interviewed 50 doctors who suffered from serious illness and discovered that they reported increased sensitivity and empathy toward patients.
[Power’s analyst was a very serious analyst whose name is probably known to you:
I had been in analysis with my former analyst weekly, at times twice weekly, and for the last several years, analytic sessions occurred every other week. I went to my regularly scheduled appointment in early May of 1998. My former analyst began the session by telling me he had been diagnosed with wide-spread metastatic cancer in the lungs. He told me that it was the bladder cancer he had lived with for over twenty years that had metastatized. He further informed me that the doctors gave him 9 months to a year to live. Hardly able to speak, he answered my unformed question: “You are probably wondering what impact this will have on our work. I plan to continue to see you as long as I feel well enough.”
When I returned to my next session, two weeks later, he began by telling me he was “going downhill fast” and this would be our last session. At the end of the he invited me to contact him if I had any wish to do so. Almost two months to the day he was dead.
With negative synchronicity, around this time, Pamela, discovered enlarged lymph node; after much medical tsures, turned out to be lymphoma, cancer of the lymph – the system of white blood cells which serves to protect the body. When finally diagnosed, she was became a difficult patient ‘ in emotional turmoil’ and adds: “I was distraught, confused and desperately missed my dead analyst. I felt he could give me the larger psychological perspective and help I needed which I was getting from no one. I thought about the course of his cancer. He was diagnosed with a slow growing bladder cancer in the early 1970’s. He received no treatment except to have it scraped out when it caused symptoms. He refused radiation treatment which the doctors tried to insist upon. I wanted to learn more about how he thought about his illness so that I could learn from him and perhaps follow his course. After all, he lived 26 years after his initial diagnosis. I was full of regret that I had not asked him more about his condition and especially his attitude toward it. I felt very alone…I felt stuck in my grief over the loss of my analyst, I felt stuck in my physical condition, endlessly trying to make meaning of my situation, trying to find a way to move on…
Her vulnerability was clearly related to the fact that her own father died suddenly a few months after her 6th birthday. With devastating synchronicity, a previous analysis begun at age 27, ended after 4 years with the illness and death of the that analyst. In the sparse literature, Pamela’s case is far from unique to have not one but two analyst die while in treatment! We often think of synchronicity in positive terms but clearly it is not always so.
Pamela Power goes on:
In spite of a lengthy analysis, the death of my analyst felt abrupt and premature. It precipitated a period of inner turbulence that lasted several years…When the analyst dies suddenly, before these [a release of creative energy and…resolution of transference..] have been accomplished, a precarious and dangerous situation can result. A premature end can bring about a state of “negative creativity”, a “transference chaos” expressed in somatic and psychological disturbances….
Many of us will have experience of taking on an analysand whose previous analyst died either suddenly or after an illness. The phenomenon of “transferring the transference” will be unique to each situation. Among other issues, it presents an unparalleled opportunity for old material around mourning, earliest feelings of loss, hopelessness, and helplessness to emerge. There may be depression around the inability to save the analyst as well as…rage, betrayal, revenge and conflicted loyalty… ]
A second active imagination
Now imagine you are sitting with your most demanding patient.
What are you going to tell about your illness?
How much are you going to tell?
What are you most afraid of?
Goldilocks Dilemma: How much to tell?
For the analyst who is sick, a crucial dilemma is when and how much to tell patients. Strict Freudians dogmatically claimed that one should tell nothing but leave everything to the transference. Numerous accounts have revealed how destructive this approach can be (Galanter-Levy). Patient’s sense of reality is undermined (such as when the analyst interprets inquiries into health as “Why do you want to see me as ill!” ). It is humiliating when others know more about your analysts than you do. Interruptions of clinical work are traumatic and worse there is no possibility for working through the loss. I have come to call the dilemma of how much to tell
Goldilocks Dilemma after the little girl who sits and sleeps on chairs and beds that are at first too hard, then too soft and finally just right. Telling too much is no good; telling too little is often worse, but what is just right? One author has tried to provide a formula for guiding the Goldilocks dilemma in terms of the stage of the analysis:
Tell nothing for those in analysis; tell all for patients in supportive psychotherapy; tell something for those ending analysis; minimal disclosure for those in the middle of the treatment. Few have agreed with his formula but it suggests that differing patients will need individualized approaches. In addition, one must monitor counter-transference as in those following account by an analyst with breast cancer:
While I have tried to contain my needs, I have been aware of a set of exhibitionistic wishes: for others to know of my trauma; to get expressions of love and concern; to get admiration about my strength and courage in handling the whole thing.” (Morrison in Schwartz and Silver 1990, p.240-1)
Careful deliberate disclosure can be beneficial and lead to “quantum leaps” in therapeutic process; forcing the patient to deal with it only subjectively denying the reality can only lead to what Power calls, “transference chaos”.
My approach following consultation with a wise colleague, Jan Weiner, was to give the basic facts and encourage patients to explore their fantasies. I did not deny my reality but tried to keep the therapeutic focus on the patient. For me and most of my patients, I believe, it was “good enough”.
When I had accepted the reality of my illness, a great deal of uncertainty remained. I realized that I should offer patients a choice about how they wanted to proceed in connection with the analysis. I gave them following alternatives: transferring to another analyst, temporarily, or transferring permanently; waiting for me, e.g. until the fall; or, finally, not deciding but taking time to talk and think over what would be best for the patient. I tried to give the feeling that any choice they made would be ok with me. Almost no transferred and this is again typical as reported in the literature. At other points in my illness, I did not behave so altruistically and suspect at least in one or two cases discouraged patients from leaving.
At this time, synchronisitically, I had a number of doctors in treatment and I believe with some of the I went wrong in my approach. Once I was diagnosed, I learned a tremendous amount about my disease – before I barely knew what a lymph gland was – now I was an expert on small B-cell indolent marginal zone lymphoma, one of the rarer kinds of lymphoma and much better than large T-cell aggressive subtype. Knowledge helped me cope with the panic and gave me a sense of control. In retrospect, I realized I had a “medical transference” to my doctor-analysands and gave them too much information, rationalizing that as doctors they would need to know more medically. I think I was reassuring myself by the knowledge I had gained. Telling patients always embodies the issue of the hidden meanings of the disclosure: telling often brings relief for analysand but may imply a hidden agenda of patient taking care of analyst.
Morrison who struggled with many recurrences of breast cancer some of which did and others did not disrupt her analytic schedule. She described how her third episode of cancer required no interruption of her work schedule and so none of her patients were told. She writes:
“I found this very difficult. When sitting with patients I was alone with my most depressing news, and without the particular challenge of listening to hear what was in their material in reaction to a disruption of mine. I was depressed anyway, and I was less “there” for my patients, at least during the first few months. (The silence of my disease was, this time, deafening – for me.)…(Morrison in Schwart & Siler)
She also puts her finger on a issue I know from the inside – how much is the telling of the illness, diagnosis and prognosis for the benefit of the patient and how much for the analyst.
Supervision clearly helped me sort this out.
And another analyst, Judith Wander, who had suffered a broken pelvis warned me to decide who you want to work with and who not. As Winnicott said our first obligation is to survive the patient and at times this may mean disengage from overly demanding or toxic patients. One analyst even went so far to choose only to work with patients who had been supportive during her illness.
The Goldilocks dilemma does not disappear even after recovery.
Even once you have recovered, as I did, Do you tell every new patient about your past illness? How many ill analysts also become excessively attentive to slight bodily sensations as indicative of disease’s return – or the opposite?
Danger of a premature return:
Another key dilemmas iss when to return to my practice full time. I told analysands that if I was working then I was well enough to focus on them. But as the literature and my experience showed often therapist return somewhat prematurely because of the need to escape the sick role and feel productive. In an extreme case, a dying analyst said, “doing analysis has kept me alive.”
Another dying analyst told a candidate who want to leave, “You are my last analysand.” The candidate stayed. For some analysts, the plea to continue is implicit even when it was clear that the analysis had been compromised.
Freud letter to Eitingon may have understood this (March 22, 1924 quoted in Schur p.338):
“The right thing to do would be to give up all work and obligation and wait in a quiet corner for the natural end …I am constantly tortured by something…”
towards the end of his life, the most painful decision for Freud was to give up seeing patients.
The analyst changes – persona vanishes.
Active Imagination:
Think of aspects of your physical appearance or persona that is most central to your identity. Now imagine that the illness has caused a dramatic change in that very aspect distorting and spoiling your usual persona.
Physical changes are the most striking aspect of illness, hiding the old and revealing the new persona. The following extract is a quote from my diary:
“To be well is a hobby;
to be sick is a full time job.”
One of the central experiences of illness is loss.
In English, the word for illness is “Dis-ease”
The loss of ease –
the ease not to know
when you next treatment or blood test is coming.
The loss of ease that each sensation, pain, sweaty night,
each ache, does not signal another medical earthquake.
The loss of a future spreading out before you like a set table (shulkhan aruch).
Above all, for every cancer person,
there is the loss of “my body as I knew it.”
For me, the bodily change was not
weight loss, a half closed eye, massively swollen spleen which stole sleep or
even panicking white blood cells
but one day after chemo, touching my chin
to see my beard fall like fresh snow.
Since I was 19. I have had a beard.
No one in Israel had seen my naked face;
Not my wife, my children, my students or my patients.
People did not recognize me; I did not recognize myself.
I would look in the mirror and say “Who stole my face?”
I would walk up to old friends and start speaking only to be told,
”Excuse me, sir, who are you?”
“Who am I, indeed?” I was another Henry: Henry the sick.
How did my patients react to me being without a beard?
Each one, of course, reacted differently:
Some with Shock, some with acceptance, some ignored it and some felt the temenos was lost.
One man towards the end of his analysis felt liberated from the Great Father archetype and his personal overly positive, idealizing father complex my beard seemed to represent.
Some old patients called wanting to see me. I was in a dilemma. Should I tell them on the phone that I was beardless and my persona changed; or should I allow them to enter and say, the voice is the voice of Henry but the face is the face of another. In one case, I put the old analysand off because with this specific patient,
I did not want to have to deal with the loss of the positive transference my loss of beard would create. Freud, apparently, preferred to warn. In a letter written to Deutsch (an internist who became an analyst) he said, “Be prepared to see something you won’t like.” (Schur p. 350),
I was able to continue working in my clinic office but other analysts whose illness compromised their physical state required a change in the therapeutic milieu, moving their Temenos such as working from home or in the case of Sullivan who worked from his bed! Or from hospital room. As I have written in the context of moving one’s clinic from one location to another, new one, there is the danger that something important may be lost in the transfer. (Abramovitch 1997)
Another analyst who was very ambivalent about her illness and trying to hide it from personal friends as well as patients (who he was seeing in his regular office), dreamt of patient entering his home and seeing the horrible mess in the bedroom.
There are many implications when the persona changes or vanishes.
Which patients are most vulnerable?
In the professional literature, there is a consensus on which patient are most vulnerable to analyst’s illness and death. These include: Patients with a history of early loss, deprivation and abandonment; a history of death and desertion within the nuclear family; and with negative synchronicity, those whose previous therapists have died. For these patients, there is already a wound in the archetypal healer/parent that involves a loss of trust in the healing archetype. When an analyst dies, the patient must be asking the next analyst (if indeed they have the courage to start up a new therapeutic relationship): How can I trust you not to abandon me like they did?
Back to my experience:
I was treated with a combination of drugs, including high doses of steroids that are effective against lymphoma. Harder than the cancer treatment was the emotional reaction induced by these very high doses of steroids.
Although I had been warned of their mood altering properties, I did not understand how easily I became hypomanic, living intensely, sleeping little, writing my diary but also been irritable, impossible to be with. In my work with patients at that time, I had what I felt was an exquisite clarity of vision in my clinical work. The work had a rare intensity and some breakthroughs were achieved, what has been called ‘quantum jumps’. I would ask them and no less than myself, “What are you meant to be doing?” and often they could respond in a new way. Denial could even function in a new way. One patient said at the beginning of the first session after I told him of my illness, said, “You are ok, right?” and we went on to have the best session ever.
During this period of a few months, I often felt like Jung that people lived in boxes hung by a thread and that it was silly for them to continue to worry about seemingly trivial matters rather than the essences. Some said it was hard discussing mundane matters at a time when I was dealing with something so much more important.
Once after a sleepless night, I even dozed off for a moment in a session, and ended early only when the patient asked me was I ok. At other times, I pushed people harder than I would have otherwise.
I do not think I made any unforgivable errors, but analysands did notice the change in me, both when I was high and even more when coming down from the steroids, I had a corresponding depressive reaction.
In retrospect, I should have taken more time off – acting out the dilemma of when to return and the tendency to come back too soon for my benefit while justifying it in terms of my patients – I did have to cancel sessions because I felt unable to do the work – as I had made my patients and myself the promise that if I were seeing them I would be well enough to look after them and not for them to look after me,. Patients did experience the change in my normal therapeutic style and we were able to talk about it, especially after when I was returning to myself. But if there is one thing I am still ashamed of, it is that I used my patients. One of the basic credos of our profession is that we put patient’s welfare first and do not act out our narcissistic needs. I needed the patients more than they needed me; I held onto patients, fearing feeling even more abandoned. This is something I had seen in a dear classmate in the institute who had died just before completing her training. She continued to see patients unto the end, needing them as many other have, to help keep her feeling useful, alive and as a defense against the catastrophic feeling of loss and the coming night/abyss.
I worried about the future of my practice both in terms of the loss of income, but even more in terms of the loss of identity. I feared that I would never received referrals and indeed wondered if I would refer to a colleague who had cancer. Yet I very much looked forward to my sessions. In my consulting room, I was no longer the patient, but the healer, wounded yes, but still the healer.
I am lucky. I recovered. Patients did not have to discover my death in newspaper or by a note on the door; nor worry about their files.
Wounded healer wounded
In traditional paradigm of the wounded healer, the wounded analyst is healed and makes use of his own woundedness to create conditions of healing. But with physical illness or new mental dis-ease we are also charting unknown territory. Suddenly, the paradigm is reversed. The analysand is healthy and we are sick. They may try to reconnect with the healing dimension. Paul Dewald, one of the first psychoanalysts, to write on the topic said: “As patients found out the severity of my illness and where I was hospitalized, some of them sent cards, flowers or other signs of interest, concern and sympathy. One patient, for example, wrote several lengthy letters offering suggestions in regard to the medical treatment of infectious disease.” (Dewald in Schwartz and Silver 1990, p. 78)
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In my training, the issue of the ill or disabled analyst never arose. And this despite the illness of Naomi Eilander, the dementia of Rivka Scharf Kluger – Hanale was able to work doing intakes at her takhana.
Organizationally, there was no real structure to deal with this matter. Elsewhere, analysands, patients and candidates have strongly expressed their anger at how an institute allowed an impaired analyst to continue practicing.
I know my colleagues were much concerned with me both during the chemotherapy and the subsequent depressive reaction, but none of them formally approached me. I believe they agonized what to do, as we had never confronted just such a situation in our Institute previously. As an analytical community, we need to think through the implications of Illness in the Analyst. Analysts need to prepare themselves and confront it via active imagination, via Talmudic study and open discussion. In UK, all therapist must have an updated patient list deposited with a colleague, other institutes encourage a "professional will" indicating who will inform patients in the case of unforeseen death and what will be done with files.
Illness, as we know, provides opportunities but it also contains dangers.. Illness in the analyst is an issue for the entire analytic community and not only the ailing analyst.
Unconsciously, I must have known that something was happening. In my article, Stimulating Ethical Awareness, I used a case that is hauntingly similar to my own.
SAMPLE CASE : THE DYING ANALYST
- A colleague comes to you and says that they have just received a diagnosis of colon cancer with an average survival time of18-24 months. Analyst has a full practice including analysands, candidates in analysis and in supervision. Analyst is receiving palliative care, and feels well enough to continue working. Analyst feels, in fact, that the illness has made them a better more attuned analyst. But analyst is not sure what to do. They have come to you for advice.
Questions to be discussed:
What would you like to ask the analyst?
[pause]
What are the ethical implications?
[pause]
Are the issues different for analysands, candidates, control candidates/supervisees? [pause]
Would the kind of cancer make a difference?
[pause]
Would a change in expected survival time to 3 months, 6 months or 4 years make a difference?
[pause]
Should the analyst tell his patients? Candidates? Supervisees?
[pause]
If so, what should analyst say to analysands and when?
[pause]
At what point should he stop practicing?
[pause]
If he does decide to stop practicing, how should he do it?
[pause]
Should the analyst have a mechanism in which patients, candidates and supervisees can be informed in the event of his or her unexpected death?
[pause]
Does the age of the analyst play a role? The gender?
[pause]
Would it make a difference if the case concerned a candidate and not an analyst?
[pause]
How would you deal with the situation in which the same analyst does not come to you for a consultation but you hear rumors, hear from trainees or see for yourself?
[pause]
Would you approach?
[pause]
How would you approach?
[pause]
What could you do if rebuffed? Should you try again?
[pause]
At what point would you refer the case to the Ethics Committee?
[pause]
How would you act, if you were the analyst?
[pause]
What would be your advice?
[pause]