How Therapists Mourn

Couch

Couch is a series about psychotherapy.

Photo
Credit Jon McNaught

One day, not long after his brain biopsy, I visit Joseph in the hospital, bearing two corned beef sandwiches on rye. I figure we’ll enjoy lunch together, as best we can — he is in and out of consciousness these days.

I enter the room; I’m in luck! Joseph is awake. Eagerly he unwraps the sandwich and lays the dill pickle lovingly beside one of the halves. He peels back the top piece of rye bread and tilts his head sideways to take a look.

“Lean?” Joseph’s voice rises with incredulity.

The nurse’s aide, sitting in the corner, has been ignoring us until now. She lowers a corner of The Baltimore Sun to share a look with Joseph, who has arched one eyebrow. They unite in scorn. I may be a doctor, but my corned beef I.Q. is low.

“Dr. Weiss,” Joseph says, in something close to his old stentorian voice. “Next time, if you’re going to bring me corned beef… please, don’t bring me lean.”

I smile. This is the Joseph I know so well. But it will be the last coherent sentence I ever hear from him. Two months later I will attend his funeral.

I pull open my file cabinet drawer and extract several charts: patients who’ve died while I was treating them over the last 20 years that I’ve been in private practice as a psychiatrist. I am gathering material to write about how therapists feel when a patient dies. I make a couple of observations.

First, I see that the charts remain in my “active” file cabinet. I haven’t moved them to the much larger and cramped “inactive” file — their rightful home.

Second, I notice that I’ve developed an automatic rite of remembrance. Whenever my fingers graze one of the file folder tabs of a dead patient, I stop and close my eyes for the briefest moment. I pay silent homage to the deceased.

There is grist here for the interpretive mill. Am I asking forgiveness for having made mistakes? For not having done enough? Perhaps I’m warding off my own fears of being locked away and forgotten someday.

Whatever other meaning there may be in these small, private ceremonies, I believe they primarily speak to the isolation of the therapist when patients die, and the human need to create ritual when death occurs. Therapists do not typically socialize with the people in their patients’ lives. There is no one for me to call about Joseph — no family or friends with whom to share memories, to laugh or to cry.

Don’t misunderstand me; I’m not asking for sympathy. There is no comparing my loss to that of a patient’s family and friends. Yet this is an aspect of my profession that is seldom discussed: Just as what takes place in therapy occurs behind closed doors, so too does the therapist’s grieving after a patient dies.

Therapists mourn alone.

Before I learned that a stealth swarm of cancer cells was invading Joseph’s brain, I thought that he and I might be getting somewhere — against heavy odds. Joseph was a talented and quirky man with innumerable plans for the future. However, a cascade of emergencies had to be addressed during the early years of his therapy. His troubled business, strained family ties and alienated friends had been our focus, of necessity. But in the last several months some more fundamental pieces were falling into place.

As a child, he was never heard. There’s more to it than that, of course, but his belief that his parents actually couldn’t hear him was profound. He was being heard in therapy. Perhaps he didn’t have to yell all the time.

In what would be our last session in my office, Joseph arrived very late, as always. He lowered himself into the leather recliner, flinching in arthritic pain, and let out an existential groan: “Oy, gottenyu— vey ist mir.” Dear God — woe is me. He wiped his forehead with an old-fashioned handkerchief.

His booming tirades — overpowering the soft whoosh of the white noise machine to reach the curious ears of my next patient, in the waiting room — had given way, in sessions like this one, to tender tears of remorse. Yet it was still hard to see exactly how he would turn his life around. The wreckage of so many emotional explosions with those closest to him had blocked the pathways to forgiveness, leaving him isolated and lonely.

Joseph knew that I got a kick out of hearing him refer to me as “Weiss,” and he joked as he left the session, “I’ll tell Rosenbaum that Weiss and I did good work today.” (His friend Rosenbaum was pushing for “results already” with this therapy stuff.)

Then came a sudden medical crisis and a rapid decline. All therapy rests on hope for a better future — and we count on there being some time. But Joseph’s time was up.

Here is a secret that therapists rarely acknowledge: We often grow to love our patients.

I’m not talking about countertransference (that is, when the therapist develops misplaced feelings for a patient that stem from relationships in the therapist’s own life). I’m talking about real love, which emerges after years of being someone’s “good enough” mother, as the psychoanalyst D. W. Winnicott called a parent who provides the right environment for a person’s normal development.

A therapist may spend hundreds of hours, perhaps more than a thousand, hearing about a patient’s most exalted aspirations and most murderous, hateful fantasies. During this time, the patient may endure excruciating losses, unbearable shame, bitter sadness and great triumphs. You may accompany patients through torturous adolescence into adulthood. Or you may meet them in middle age and be with them as they age and eventually die. You collaborate in a deep process of discovery.

Few encounters are this deeply honest, and therefore intimate. The attachment engenders profound feelings, a particular kind of love.

I had therapist love for Joseph.

At Joseph’s funeral I take my seat in the back row — the therapist’s spot — Kleenex in hand. I’m not here to be seen or for the sake of the family. I’m pulled to the service by my desire to say goodbye to my patient.

Familiar characters populate the synagogue. I remember them from the stories I heard over the years in Joseph’s therapy. I now see his friends, enemies and family in the flesh. I know more about his emotional life than anyone else here. I also know quite a bit about these people — from Joseph’s perspective, of course — more than they would like to know I know. Which is another reason I stay hidden in the back row: I don’t want to cause discomfort.

The funeral ends. Everyone congregates to console one another. I slip out of the dark building into the shocking sunlight. Soon they will gather and eat my favorite type of food — bagels, cream cheese, hard-boiled eggs and smoked fish. For a moment I wish I could join them. They will laugh until they’re crying at endless funny Joseph stories. They will start the process of normal grieving, solidifying their internal pictures of him, memories they will nurture and embellish — softening the abrasive edges, just as they should.

I leave with his secrets intact. His hopes and his wondrous dreams are mine to hold, to honor him, until I lose my own memory, or I die.

Details were altered to protect patient privacy.

Robin Weiss is a psychiatrist in Baltimore.