Lesson 6: Never Send to Know for Whom the Bell Tolls

One day, in the fourth year of therapy, Irene arrived carrying a large portfolio. She put it on the floor, slowly unbuckled it, and pulled out a big canvas, keeping its back toward me so I couldn’t see it.

“Did I tell you I was taking art lessons?” she asked in an uncharacteristically playful manner.

“No. First I’ve heard of it. But I think that’s great.”

And I did. I took no umbrage that she mentioned it en passant; every therapist is used to patients’ forgetting to mention the good things in their lives. Perhaps it’s simply a misunderstanding, a mistaken assumption by patients that since therapy is pathology-oriented, therapists want to hear only about problems. Other patients, however, who are dependent upon therapy choose to conceal positive developments lest their therapists conclude that they no longer need help.

Now, taking a breath, Irene flipped the canvas. Before me gleamed a still life, a simple wooden bowl containing a lemon, an orange, and an avocado. While impressed with her graphic skills, I felt disappointed in her subject matter, so flat and pointless. I would have hoped for something more relevant to our work. But I feigned interest and was convincingly enthusiastic in my praise.

Not as convincing as I had thought, I soon learned. In the next session she announced, “I’m signing up for another six months of art lessons.”

“That’s wonderful. Same teacher?”

“Yes, same teacher, same class.”

“You mean a still-life class?”

“You’re hoping not, I think. Obviously there’s something you’re not sharing.”

“Like what?” I began to feel uncomfortable. “What’s your hunch?”

“I see I’ve hit on something.” Irene grinned. “Almost never do you fall back on the traditional shrink practice of answering a question with a question.”

“Never miss a trick, Irene. Okay, the truth is that I had two very different feelings about the painting.” Here I invoked a practice I always teach my students: when two opposing feelings put you in a dilemma, your best recourse is to express both feelings and the dilemma. “First, as I said, I admired it greatly. I have absolutely no artistic talent and am filled with respect for work of such quality.” I hesitated, and Irene nudged me:

“But—”

“But—well—uh—I’m so pleased with your finding pleasure in painting that I dread sounding even slightly critical, but I guess I was hoping that you might do something with your art that might be more—uh—how to put it?—resonant with our therapy.”

“Resonant?”

“One thing I like about our work together is that you invariably respond with substance whenever I ask about what’s passing through your mind. Sometimes it’s a thought, but even more commonly you describe some mental image. With your extraordinary visual sense, I was hoping you could combine your art and therapy in some synergistic manner. I don’t know—possibly I was hoping the painting might be more expressionistic, or cathartic, or illuminating. Maybe you could even work through some painful issues on canvas. But the still life, while technically wonderful, is so—so—serene, so far removed from conflict and pain.”

Seeing Irene’s eyes rolling up, I added, “You asked for my feelings, and there they are. I’m not defending them. In fact, I suspect I’m making a mistake by being critical of any activity that provides you an interlude of peace.”

“Irv, I don’t think you know much about painting. Do you know what the French call a still life?”

I shook my head.

“Nature morte.”

“Dead nature.”

“Right. To paint a still life is to meditate on death and decay. When I paint fruit, I can’t avoid observing how my still-life models are dying and decomposing day after day. When I paint I am very close to our therapy, pointedly aware of Jack’s passage from life into dust, very aware of the presence of death and the smell of decay in everything that lives.”

“Everything?” I ventured.

She nodded.

“You? Me?”

“Everything,” she replied. “Especially me.”

At last! I had been scratching for Irene’s last statement, or something like it, since the very beginning of our work. It heralded a new phase in therapy, as I recognized from the strong dream she brought in a couple of weeks later.

I am sitting at a table—like an executive board table. There are others there as well, and you are sitting at the head of the table. We are all working on something—perhaps reviewing grant proposals. You ask me to bring some papers to you. It is a small room, and to get to you I have to pass very close to a row of windows that are open and reach all the way to the floor. I could easily fall out the window, and I woke up with a powerful thought in my mind: How could you have exposed me to such great danger?

This general theme—her being in danger and my failing to protect her—soon gathered steam. A few nights later she had two companion dreams, one following immediately upon the heels of the other. (Companion dreams may convey the same message. Our friend the dream-writing homunculus often amuses himself by composing several variations on a particularly arresting theme.)

The first:

You are the leader of a group. Something dangerous is about to happen—I’m not sure what, but you are leading the group into the woods to some safer spot. Or you are supposed to be. But the trail you take us on gets rockier, narrower, darker. Then it disappears entirely. You vanish, and we are lost and very scared.

The second:

We—the same group—are all in a hotel room, and again there is some danger. Maybe intruders, maybe a tornado. Again, you are leading us out of danger. You take us up afire escape that has black metal steps. We climb and climb, but it goes nowhere. It just ends at the ceiling, and we all have to back down.

Other dreams followed. In one she and I take an exam together, and neither of us knows the answers. In another she looks at herself in the mirror and sees red spots of decay on her cheeks. In another she dances with a wiry young man who suddenly leaves her on the dance floor. She turns to a mirror and recoils to see her face covered with sagging red skin pockmarked with hideous boils and blood blisters.

The message of these dreams was crystal-clear: danger and decay are inescapable. And I am no savior—on the contrary, I am unreliable and impotent. Soon a particularly powerful dream added a further component.

You are my travel guide in an isolated site in a foreign country—maybe Greece or Turkey. You are driving an open Jeep, and we are quarreling about what to visit. I want to see some beautiful old classical ruins, and you keep wanting to take me to the modern, tacky, flimsy city. You begin to drive so fast that I get scared. Then the Jeep gets stuck, and we are tottering, swaying back and forth, over some huge pit. I look down and can’t see the bottom.

This dream, involving the dichotomy between beautiful ancient ruins and a modern tacky city, reflects, of course, our ongoing “treason versus reason” debate. Which route to take? The old, beautiful ruins (the first text) of her old life? Or the deplorably ugly new life she saw stretching ahead of her? But it also suggested a new aspect of our work together. In the earlier dreams I am inept: I lose the path in the forest; I take Irene up a fire escape that leads to a ceiling with no escape; I do not know the answers to the examination. In this dream, however, not only am I inept and fail to protect her, I am also dangerous—I lead Irene to the brink of death.

A couple of nights later she dreamed that she and I embrace and gently kiss. But what starts off sweetly turns to terror when my mouth opens wider and wider and I begin to devour her. “I struggle and struggle,” she reported, “but cannot wrench free.”

“Never send to know for whom the bell tolls; it tolls for thee.” Thus, as John Donne observed nearly four hundred years ago in these now familiar lines, the funeral bell tolls not only for the dead but also for you and me—survivors, yes, but for a limited time. This insight is as old as history. Four thousand years ago in a Babylonian epic, Gilgamesh realized that the death of his friend Enkidu foreshadowed his own: “Enkidu has become dark and cannot hear me. When I die shall I not be like unto Enkidu? Sorrow enters my heart. I am afraid of death.”

The death of the other confronts us with our own death. Is this a good thing? Should such a confrontation be encouraged in the psychotherapy of grief? Question: Why scratch where it doesn’t itch? Why fan the flame of death anxiety in bereaved individuals already bowed low by loss? Answer: Because the confrontation with one’s own death may generate positive personal change.

My first awareness of the therapeutic potential of an encounter with death in the therapy of grief occurred decades ago when a sixty-year-old man described to me his terrible nightmare the night after learning that his wife’s cervical cancer had dangerously metastasized and was no longer treatable. In the nightmare he’s running through an old deteriorating house—broken windows, crumbling tiles, leaking roof—pursued by a Frankenstein monster. He defends himself: he hits, he kicks, he stabs, he throws the monster off the roof. But—and this is the central message of the dream—the monster is unstoppable: it instantly reappears and continues the pursuit. The monster is no stranger to him, having first invaded his dreams when he was a boy of ten, shortly after his father’s funeral. It terrorized him for months and eventually vanished, only to reappear fifty years later at the news of his wife’s fatal illness. When I asked for his thoughts about the dream, his first words were: “I’ve got a hundred thousand miles on me as well.” I understood then that the death of the other—first of his father and now the impending death of his wife—confronted him with his own. The Frankenstein monster was a personification of death, and the deteriorating house signified his bodily aging and breakdown.

With that interview I believed I had discovered a wonderful new concept with significant implications for the psychotherapy of grief. Soon I began to look for this theme in every bereaved patient, and it was to test this hypothesis that, a few years prior to my seeing Irene, a colleague, Morton Lieberman, and I embarked on our research project in bereavement.

Of the eighty bereaved spouses we studied, a significant proportion—up to one-third—reported a heightened awareness of their own mortality, and that awareness was, in turn, significantly related to a surge of personal growth. Although return to a previous level of functioning is generally considered to be the end point of bereavement, our data suggested that some widows and widowers do more than that: as a result of an existential confrontation, they become more mature, more aware, wiser.

Long before psychology existed as an independent discipline, the great writers were the great psychologists, and there are in literature rich examples of death awareness catalyzing personal transformation. Consider Ebenezer Scrooge’s existential shock therapy in Dickens’s A Christmas Carol. Scrooge’s astonishing personal change results not from Yuletide cheer but from his being forced to confront his own death. Dickens’s messenger (the Ghost of Christmas Yet to Come) uses a powerful existential shock therapy: the ghost takes Scrooge into the future, where he observes his final hours, overhears others lightly dismiss his death, and sees strangers quarreling over his material possessions. Scrooge’s transformation occurs immediately after the scene in which he kneels in the churchyard and touches the letters on his own tombstone.

Or consider Tolstoy’s Pierre, a lost soul who stumbles aimlessly through the first nine hundred pages of War and Peace until he is captured by Napoleon’s troops, watches the five men in line ahead of him be executed by firing squad, and then receives a last-minute reprieve. This near death transforms Pierre, who marches through the final three hundred pages with zest, purpose, and a keen appreciation of life’s preciousness. Even more remarkable is Tolstoy’s Ivan Ilych, the mean-spirited bureaucrat whose agony, as he lies dying from abdominal cancer, is relieved by a stunning insight: “I am dying so badly because I have lived so badly.” In the few days of life remaining to him, Ivan Ilych undergoes an extraordinary inner change, achieving a degree of generosity, empathy, and integration that he had never before known.

Thus, confrontation with imminent death can propel one into wisdom and a new depth of being. I have run many groups of dying patients who welcomed student observers because they felt that they had much to teach about life. “What a pity,” I have heard these patients say, “that we had to wait till now, till our bodies were riddled with cancer, to know how to live.” Elsewhere in this book, in the chapter “Travels with Paula,” I describe a number of individuals facing terminal cancer who grew in wisdom as they confronted their deaths.

But what about everyday, physically healthy patients in psychotherapy—men and women not facing terminal illness or a firing squad? How can we clinicians expose them to the truth of their existential situation? I try to take advantage of certain urgent situations, often termed “boundary experiences,” that offer a window into deeper existential levels. Obviously, facing one’s own death is the most powerful boundary experience, but there are many others—serious illness or injury, divorce, career failure, milestones (retirement, children leaving home, midlife, important birthdays), and, of course, the compelling experience of the death of a significant other.

Accordingly, my original strategy in therapy with Irene was to use the leverage of existential confrontation whenever possible. Again and again I attempted to turn her attention from Jack’s death to her own life and death. When she spoke, for example, of living only for her daughter, of welcoming death, of spending her remaining life gazing out the window at the family burial plot, I would reflexively say something like: “But aren’t you then choosing to squander your life—the only life you’ll ever have?”

After Jack’s death Irene often had dreams in which some calamity—often a firestorm—engulfs her entire family. She viewed these dreams as reflecting Jack’s death and the end of their intact family. “No, no, you’re overlooking something,” I’d respond. “This dream is not only about Jack and the family—it’s also a dream about your own death.”

During the first years Irene promptly dismissed such comments: “You don’t understand. I’ve had too much loss, too much trauma, too many deaths stacked up.” Respite from pain was her quest, and the idea of death seemed more solution than threat. That is not an uncommon position: many distressed people consider death a magical place of peace. But death is not a state of peace, nor is it a state in which one continues life without pain; it is consciousness extinguished.

Perhaps I was not respectful of her timing. Perhaps I made the error, as I often do, of leaping in ahead of my patient. Or perhaps Irene was simply someone who could not profit from confronting her existential situation. At any rate, finding that I was getting nowhere, I eventually abandoned this tack and sought other ways to help her. Then, months later, when I least expected it, came the episode of the still-life painting, followed by the cascade of images and dreams perfused with death anxiety.

Now the timing was right, and she was receptive to my interpretations. Another dream appeared, one so arresting she could not banish it from her mind.

I am in the screened porch of a flimsy summer cottage and see a large, menacing beast with an enormous mouth waiting a few feet from the front door. I am terrified. I worry something will happen to my daughter. I decide to try to satisfy the beast with a sacrifice and toss a red plaid stuffed animal out of the door. The beast takes the bait but stays there. Its eyes burn. They are fixed on me. I am the prey.

Irene immediately identified the plaid stuffed sacrificial animal: “It’s Jack. That’s the color of his pajamas the night he died.” So strong was the dream that it lingered in her mind for weeks, and she gradually grew to understand that though she had first displaced her anxiety about death onto her daughter, she was really death’s prey. “It’s me the creature is watching so fiercely, and that means there is only one way to read this dream.” She hesitated. “The dream is saying that I’ve unconsciously viewed Jack’s death as a sacrifice so that I might continue living.” She was shocked at her own thought and even more by the realization that death was out there waiting, not for others, not for her daughter, but for her.

Using this new frame of reference, we gradually reexamined some of Irene’s most persistent and painful feelings. We began with guilt, which tormented her, as it does most bereaved spouses. I once treated a widow who had rarely left the bedside of her husband for weeks as he lay unconscious in a hospital. One day, in the few minutes it took her to slip down to the hospital gift shop to purchase a newspaper, her husband died. Guilt for having deserted him plagued her for months. Irene, similarly, had been inexhaustible in her attentiveness to Jack: she had nursed him with extraordinary devotion and rejected all of my urgings to take time off, to give herself some respite by hospitalizing him or engaging a nursing service. Instead, she rented a hospital bed, placed it next to her bed and slept by him until the moment he died. Still, she could not shake the idea that she should have done more: “I should never have left his side. I should have been gentler, more affectionate, more intimate.”

“Perhaps guilt is a way of denying death,” I urged. “Perhaps the subtext of your ‘I should have done more’ is that if you had done things differently, you could have prevented his death.”

Perhaps, too, death denial was the subtext of many of her other irrational beliefs: she was the single cause of the deaths of all those who had loved her; she was jinxed; a black, toxic, deadly aura emanated from her; she was evil, cursed; her love was lethal; she was being punished by someone, by something, for some unforgivable offense. Perhaps all these beliefs served to obscure the brutal facts of life. If she were in fact jinxed or responsible for deaths, it would follow that death is not inevitable; that it has a human, avoidable cause; that existence is not capricious; that each individual is not thrown, alone, into existence; that there is an overarching, though incomprehensible, cosmic pattern; and that the universe oversees and judges us.

In time Irene was able to converse more openly about existence fear and to reformulate the reasons behind her refusal to make new attachments to others, especially to men. She had claimed that she avoided engagement, including engagement with me, to avoid the pain of another loss. Now she began to apprehend that it was not just the loss of the other she dreaded but all reminders of life’s transience.

I introduced Irene to some of Otto Rank’s views on the life-phobic individual. In writing that “some individuals refuse the loan of life in order to avoid the debt of death,” Rank, an existentially aware disciple of Freud, was describing Irene’s dilemma precisely. “Look at the way you refuse life,” I chided her, “looking endlessly out the window, avoiding passion, avoiding engagement, immersing yourself in Jack’s memorabilia. Don’t take an ocean voyage,” I advised. “Your strategy would render the trip joyless. Why invest yourself in anything, why make friends, why take an interest in anyone if the voyage is ultimately to end?”

Irene’s increased willingness to accept her own limited existence presaged many changes. Whereas she had once spoken of a secret society of people who had lost people they loved, now she proposed a second, overlapping society composed of those enlightened individuals who are, as she put it, “aware of their destination.”

Of all her changes, the most welcome was her increased willingness to engage me. I had been important to Irene. I had no doubt about that: there were months when she said she lived only for our visits. And yet, close as we were, I had always thought that she and I met only obliquely, that we had always missed a true “I-thou” encounter. She had tried, as she had put it earlier in therapy, to keep me outside time, to know as little as possible about me, to pretend I had no life narrative with a beginning and an end. Now that changed.

At the beginning of therapy, on a visit to her parents, Irene had come upon an old illustrated Frank Baum Oz book that she had read as a child. On her return she had told me that I had an uncanny physical resemblance to the Wizard of Oz. Now, after three years of therapy, she looked again at the illustration and found the resemblance less striking. I sensed that something important was happening when she mused, “Maybe you’re not the wizard. Maybe there is no wizard. Perhaps,” she went on, more to herself than to me, “I should simply accept your idea that you and I are just fellow travelers through this life, both of us listening to the bell tolling.”

And I had no doubt that a new phase of therapy was beginning when she came into my office one afternoon in our fourth year looking straight at me, sat down, looked at me again, and said, “It’s strange, Irv, but you seem to have gotten a lot smaller.”