Presentation at Montrial conference 2010
Indian epic Mahabharata asks: “What is the greatest wonder of all?” The first task for the sick analyst is to process the illness, to mourn healthy past and understand the implications of being ill. This is not a simple task because analyst has to deal with personal issues at the same time as clinical ones. Towards evening, my breathing becomes even worse Lying awake in dark’s early light Goldilocks Dilemma: How much to tell? I call the dilemma how much to tell “Goldilocks Dilemma” (based on the story with three bears): Telling too little is too “soft” on the patient, telling too much is too “hard”; but what is just right? Let me give an example of too much and too little. How much is the telling for the benefit of the patient and how much for the analyst? To be well is a hobby; Jung’s experience highlights illness’ creative potential. Quantum Leaps The danger of premature return is paralleled by danger of practicing too long. Patients’ accounts about analysts who died while doing treatment recount how awful it is. Coming to session to find a note on the door, reading obituary, or receiving a call from a distressed spouse or colleague are traumatic. Pamela Power wrote: 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… A premature end can bring about a state of “negative creativity”, a “transference chaos” expressed in somatic and psychological disturbances….(Power 2005, p.35). Attaching to another therapist becomes very problematic because of fear of another abandonment, or unresolved idealizing transference. Patients are often enraged at Institutes who allowed these therapists to continue working. The rule is clear: “It cannot be sufficiently stressed how important it is that the patient continue his treatment with another analyst, while his therapist is still alive (Eissler 1977, p. 571). In traditional paradigm of the wounded healer, the wounded analyst is healed and makes use of his own woundedness to create conditions of healing. In physical illness, the analyst is in unknown territory. Suddenly, the paradigm is reversed. The analysand is healthy and analyst is sick. No wonder patients may be caught up in fantasy of trying to heal their analyst. Pamela Power again: 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…” Illness in analyst brings out intense, unfamiliar transference-countertransference dynamics. Bibliography 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 American Journal of Psychiatry 143:561-572 Fajardo, Barabara (2001). Life-threatening illness in the analyst. International Journal of Psychoanalysis 49(2): 569-86. Jones, Ernest (1953-7). The Life and Work of Sigmund Freud. 3 vols. Basic Books: NY. Lasky, Richrd (1990). Catastrophic illness in the analyst and the analyst’ emotional reaction to it. International Journal of Psychoanalysis, 71:455-473. Nicklin, G. (1992). Review. Journal of the American Academy of Psychoanalysis, 20:495-6. Power, Pamela J. (2005). Death of the analyst.Journal of Jungian Theory and Practice, 7(2): 35-46. Morrison, Amy Lichtblau (1990). Doing psychotherapy while living with a life-threatening experience. In Harvey J. Schwartz & Ann-Louise S. Silver (Eds.), Illness in the Analyst: Implications for Treatment Relationship. International Universities Press, Madison, CT. pp.227-250. Schur, Max (1972). Freud: Ling and Dying. International Universities Press, Madison, CT. Schwartz, Harvey J. & Silver, Ann-Louise S. (Eds.). (1990). Illness in the Analyst: Implications for Treatment Relationship. International Universities Press, Madison, CT.Myth of the eternal analyst
Answer: “ People see sickness and death all around them, yet think it will never happen to them.” Analysts suffer from this greatest wonder.
When we begin an analysis, we give an implicit assurance that we will be there for our patients. Even when patients terminate, we often say, “My door is always open” as if to say we will be there in time of need. The “illusion of practicing indefinitely” (Schwartz & Silver 1990), or Myth of the Eternal Analyst, implies we will live forever and forever be available to help, as one analyst put it only half humorously, “I will live forever.”
But reality is different. We will all become sick and die in ways that may be terrible for those very patients for whom we care. Disease often surprises us, as it certainly did me when I became wounded-healer, wounded again.
My initial interest in serious illness in the analyst began when my fellow candidate discovered a recurrence of breast cancer. I saw close at hand how she dealt with patients, and held onto to them despite her worsening condition, how I would “cover” for her
while she underwent treatment, and how she died unexpectedly. I recall the shock of her patients when I called to tell them she had died.
I recall vividly visiting my analyst in hospital pajamas at the end of my own analysis. I interviewed analysts who were seriously ill and their analysands, did workshops and reviewed the psychoanalytic literature (Deward 1982; Lasky 1990; Schwartz & Silver 1990; Fajardo 2001). Except for Pamela Power’s excellent article, “Death of an analyst” (Power 2005), I found no Jungian material.
My Experience with Illness
I want to first share some selected passages from my poetic diary written at that time:
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…
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.Processing the illness is an ongoing process.
For the analyst who is sick, the next crucial dilemma is how much to tell patients. Strict Freudians claim that one should tell nothing. Freud set the tone by hiding his first cancer operation not only from patients, but also from his family! Freud actively discouraged discussion of his illness (Jones 1957, p.13) yet admitted that his preoccupation with his cancer kept him from recognizing aspects of the transference (Schur 1972, p.382). Eissler (1977) wrote: “when an analyst denies his own illness it seems inevitable that the patient denies it also.”
Numerous accounts have revealed how destructive this approach can be. 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!”). The situation may be worse for training candidates. Members of the Institute often know more about training analyst than candidates do. Interruptions of clinical work are often traumatic without any possibility for working through.
Once I was diagnosed, I learned a tremendous amount about my disease – before I barely knew what a lymph gland was; I became 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 a doctor-analysand and gave too much information, rationalizing that as a doctor he would need to know. I was reassuring myself by the knowledge I had gained.
Morrison, an American analyst, who struggled with five recurrences of breast cancer described how her third episode of cancer required no interruption of her work schedule. 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…(The silence of my disease was, this time, deafening – for me.)… 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 1990, p. 240-1)
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 forcing patient to care for analyst.
My approach, following consultation with a wise colleague, was to give the basic medical facts and encourage patients to explore their fantasies. I did not deny my reality but tried to keep the therapeutic focus on the patient. Even once analyst recovers, Goldilocks dilemma remains: Do you tell new patient about your past illness?
Danger of a premature return:
Another key dilemma concerns when to return to practice. How do you know you are ready? I told analysands that if I was working then I was well enough to focus on them and their needs. A couple of sessions were canceled at the last minute; once I fell asleep in a session after a bad night. I should have canceled but I wanted “to be there for my patients”. The literature and my research suggest that therapists often return prematurely. Analysts wish to escape the sick role and feel productive. In an extreme case, a dying analyst said, “doing analysis has kept me alive.”
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.
The analyst changes – persona vanishes.
Physical changes are the most striking aspect of illness, hiding the old and revealing the new persona. Not every disease changes how we look but most do in obvious and subtle ways. The following extract is another extract from my diary:
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 visible shock, some with acceptance and said how well I looked, some ignored it and never commented on it and one felt the temenos was lost as my beard had been so much part of the holding presence.
One religious man with a positive, idealizing father complex felt liberated from the Great Father archetype that my beard seemed to represent. When old patients called wanting to see me, I experienced unusual counter-transference. My voice was the voice of Henry but my face is the face of a beardless, bald stranger. Greeting each patient who had not seen me beardless was an experience.
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. Harry Stack Sullivan who suffered debilitating endocarditis, saw patients from his bed! However bizarre this may sound, reports suggest that patients may be ‘strengthened and given vital hope when they know their analyst has confronted a serious illness courageously…’ (Nicklin 1992. p.496).
I think illness always creates therapeutic persona anxiety. 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.
Jung’s Visions
Following heart attack, Jung describes a loss of persona ‘in which each person sat by himself in a little box’. (MDR p. 323,4). Jung also described amazing “near death experience”:
… old Jewish women…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. 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. A good many of my principal works were written only then…something else, too, came to me from my illness… acceptance of my own nature, as I happen to be. (MDR p. 325-8).
During chemotherapy, I too felt every moment was precious. I was at the time editing a special edition of the journal Harvest on Erich Neumann who died prematurely at 55, synchronistically, my age at the time. Neumann’s tragic death accompanied me everywhere and energized me. It may have been an illusion but I felt my work then had exquisite clarity. When I first returned, analysands felt uneasy speaking about mundane problems. I reassured them that the mundane was fine. Now. I would ask, “What are you meant to be doing?” Some responded in a new way. The work had intensity and some breakthroughs or ‘quantum jumps’. 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 our best session ever.
The need to transfer
Wounded healer wounded
Response of the analytical community
In my training, the issue of being ill or disabled never arose. Now I think it is a grave mistake. As an analytical community, we need to think through the implications of Illness in the Analyst. In UK, all therapists must deposit patient list with colleagues; other institutes encourage a "professional will" indicating who will inform patients, what will be done with files etc. In my institute, we role played how to approach an ailing analyst
Illness provides dangers but it also contains hidden opportunities. Illness in the analyst is an issue for the entire analytic community and not only the ailing analyst.
Dewald, Paul (1982). Serious illness in the analyst: Transference, countertransference and reality responses. International Journal of Psychoanalysis 30(2): 347-363.