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Death Anxiety and Clinical Practice

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Robert Langs argues that death anxiety is neglected - in part, because of treatment failures due to countertransference interferences during treatment. He then discusses the technical issues connected with this, whilst introducing the controversial concept that mental activities are derived from immune system activities.

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1. A ubiquitous but elusive dread

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The existential mix of human existence couples the celebration of life with the awesome awareness of the eventuality of death. Indeed, personal mortality is a compelling issue for every human being from early childhood on. Given the universality and intensity of this adaptive issue, we would rightfully expect that death-related concerns have a great bearing on emotional well-being and psychological dysfunctions—and on the psychotherapies designed to ameliorate the more disturbing consequences of death-related conflicts.

The long reach of death into human life, emotional adaptation, and the intricacies of the therapeutic process are the central concerns of this book. Given the scarcity of psychoanalytic writings in this area, the hope is to provide the reader with a deeply wrought set of much-needed perspectives and insights into the many ramifications that death anxiety has for all patients and therapists as they struggle together, in whatever fashion, to resolve a patient’s emotional maladaptations in the course of a treatment experience.

 

2. Death themes, manifest and latent

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While affects, intuition, empathy, and action play a role in psychotherapy, the essence of the treatment experience is conveyed through words. Meaning, experience, interaction, communication, and adaptation are most tellingly language-based. Indeed, the other aspects of the therapeutic experience cannot be precisely formulated or understood without addressing the words and contexts that characterize their nature and meanings. Grasping the problems posed by death itself and by the threat of death and death anxiety similarly requires language-based formulations, whatever affects it may arouse.

LANGUAGE AND DEATH

The development of the great adaptive resource of language for both internal representation and communication is perhaps the most distinctive feature of our species, Homo sapiens sapiens (Bickerton, 1990, 1995; Langs, 1996; Lieberman, 1991). Language allows for a well-articulated sense of personal identity, a capacity for reflective self-awareness, the ability to remember definitively and to think about the past and anticipate the future, and an incisive sense of me versus not-me, self and not-self or other.

 

3. Death anxiety and psychotherapy

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As I have indicated, death is a universal and inherently unresolvable adaptive issue, and conscious and unconscious forms of death anxiety are ever-present. As a result, these grave concerns are significant factors in the development of virtually every type of emotional dysfunction.

But here, too, there is a notable trade-off. Whereas on the one hand maladaptive and failed attempts to adapt to death-related issues and the anxieties they arouse contribute significantly to emotional disturbance, on the other hand efforts to cope consciously and especially unconsciously with death anxiety are a source of considerable inventiveness and creativity. Thus, the successful negotiation of death anxieties may contribute to emotional health or emotional ills, depending on how they are negotiated. In addition, emotional health requires that an individual successfully adapt to his or her death-related conflicts and anxieties.

The widespread effects of death and death anxiety similarly infiltrate virtually every aspect of the psychotherapy situation. Death-related issues consistently play a major role in the therapeutic process. However, many of these effects, which are quite strong, go unrecognized because the influence operates indirectly and outside direct awareness—unconsciously. Both parties to therapy are under rather unrelenting pressure to adapt within the treatment situation to the plethora of death-connected adaptation-evoking stimuli that arise in their personal lives and especially in their shared therapy experience.

 

4. Death issues in the clinical situation

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To sharpen the clinical sense of how death issues materialize in and affect the course of a psychotherapy experience, I turn now to a brief clinical excerpt.

Dr Denton is a male psychotherapist who works within a psychoanalytic framework. His patient, Mrs Peters, is a woman in her mid-thirties who came to therapy for repeated episodes of depression.

A year into the therapy and three weeks before Dr Denton was due to take a month off for his summer vacation, Mrs Peters suffered and described in her session several recent traumatic incidents. Her father had fallen ill with a serious heart attack; he was in the hospital and near death, but surviving. There had been bitter arguments with her husband because he had had to travel for business and the patient felt deserted at her time of need. The patient was also distressed because her 14-year-old daughter had been out late, and the patient had fantasied that she had been killed in a car accident. When her daughter finally returned home, Mrs Peters, with uncharacteristic loss of control, had hit her daughter rather severely.

 

5. Observing and formulating

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The communicative approach, and its particular means of observing and formulating the transactions of the therapeutic interaction, is the basis for the ideas presented in this volume (Langs, 1982, 1988, 1992, 1993, 1995). I will therefore briefly present the essentials of its methods as they pertain to the study of death and the anxieties it arouses.

COMMUNICATIVE FORMULATIONS

The communicative approach is a significant departure from the standard model, which is based, in essence, on a weak adaptive position and is focused in the manifest contents of patients’ material, their evident implications in terms of fantasies, wishes, and needs, and their personal genetic connections (Langs, 1992,1993). In contrast, the communicative approach is based on a strong adaptive and interpersonal viewpoint of the patient as a human being who copes on two levels—one attached to awareness (i.e. consciously) and the other entirely without direct awareness (i.e. unconsciously). Thus, communication is both conscious and unconscious, direct (unencoded) and disguised (encoded).

 

6. The emotion-processing mind

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The communicative approach embraces adaptation and communication as its fundamentals. This strategy has led to the careful definition of conscious and unconscious communication as described in the chapter 5. Communicative listening and formulating made it possible to explore and map the architecture of the emotion-processing mind—the cognitive mental module that is responsible for adapting to emotionally charged impingements or triggering events. Definition of this module has made feasible a scenario for its evolutionary history and development and generated fresh insights into its immediate adaptive functioning.

The emotion-processing mind is composed of two systems—the conscious system and the deep unconscious system. Each system adapts in very different ways to death and death-related issues. It therefore behoves us to define the distinctive adaptive resources and strategies utilized by each system so we can appreciate the differences between conscious and unconscious coping efforts in these areas.

 

7. Death and the two systems of the mind

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As indicated in chapter 6, humans operate and adapt by means of two very different systems of the emotion-processing mind, one linked directly to awareness, the other connected only through encoded images and unseen effects. Each system has distinctive properties—selective areas of perception; processing capabilities; motivational tendencies and needs; resources, defences, and frame-related attitudes; ways of assessing, thinking and formulating; and overall adaptive capacities and inclinations. Not surprisingly, then, these two basic systems also differ in their experience and processing of death and its related impingements. These differences are best appreciated through an understanding of the evolutionary history of the awareness of death as a twofold danger situation—one existential and the other predatory in nature.

THE EVOLVED AWARENESS OF DEATH

An individual’s ontogenic development of the awareness of death and of responsive adaptive resources to cope with death-related triggering events is grounded in phylogeny or evolutionary history. How, then, did awareness of death—predatory and existential—evolve, and what effects did this awareness have in shaping the design of the emotion-processing mind?

 

8. Death anxiety and the psychotherapy patient

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I have endeavoured to broaden our perspectives on death-related issues and death anxiety as basic concerns of all humans. In this second part of the book, I concentrate on the therapeutic interaction and on how death anxieties evoke adaptations by both patients and therapists in the course of a treatment experience.

Death concerns are a universal problem for every human. Each person adapts to these issues on the basis of individual propensities activated by specific death-related triggering events. In the therapy situation, however, the roles specifically assigned to the patient and therapist define and constrain the means by which death issues are, in general, activated, expressed, and responded to— and, especially, how they can be resolved. While some overlap exists between patients and therapists regarding aspects of this problem, there are significant differences as well.

Three major interrelated facets of death anxiety play a role in psychotherapy:

Several types of triggers, distinguished for the most part by degrees of evident connection to death, activate these issues in psychotherapy. When approached through the communicative vantage-point, the psychotherapeutic situation affords a unique opportunity to study these triggers and the manner of response and evolved adaptation. The conscious and deep unconscious systems tend to be responsive to different death-related triggers and to different aspects of these triggering events. Here, we focus on patients’ responses.

 

9. How patients deal with death-related triggers

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In ongoing psychotherapy, a patient’s death anxiety is often signalled by the appearance of death-related themes, coupled with a variety of defensive responses. These compromised communications simultaneously reveal and conceal the unconscious death issues activated by a particular triggering event. And when the trigger involves a death-related trauma in the life of the therapist of which the patient is aware, the defences unconsciously mobilized by the patient may be all but intractable. The following vignette is illustrative:

Ms Banks was in once-weekly empowered psychotherapy with Dr Tyler, a woman psychiatrist. The patient, who was in her late thirties, suffered from episodes of severe anxiety and a chronic sense of insecurity.

Dr Tyler’s teenage daughter had fallen ill with a serious form of bone cancer. On the Sunday before the session we will consider, the pastor of Dr Tyler’s church had referred to the illness and had beseeched the congregation to pray for the young woman. Dr Tyler was at the hospital with her daughter, who needed some special tests, so she was not present at the service. However, her patient, Ms Banks, had close friends in the neighbourhood and on occasion attended these services. At the beginning of this session Dr Tyler knew of the announcement, but she had no idea whether her patient had been in church that Sunday morning.

 

10. Selection principles and mental defences

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The communicative approach, with its adaptive orientation and use of trigger-decoding, calls for revisions and extensions of current understanding and formulation of mental and behavioural defences. As defined in chapter 1, mental defences are all non-action, non-somatic protective measures adopted by the human mind as adaptive or maladaptive responses to disturbing adaptation-evoking triggering events. While these defences do have complex behavioural consequences, they operate primarily in the psychological sphere.

The two basic forms of human mental defences are:

1.  Active (non-avoidance) coping efforts. This includes all measures taken by humans to deal actively with an emotionally charged triggering event—something akin to the fight aspect of adaptation as defined by Cannon (1929). For example, were a therapist to say something nasty to a patient, an active mental coping response might involve the patient’s consciously working over the experience in his or her mind. Quite often, this mental coping effort would lead to an active communicative (and behavioural) reaction as well. For example, the patient might confront the therapist with his or her nastiness, leave therapy, or take other measures to redress the situation.

 

11. Psychological defences

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In this and the next chapter, I offer a reconsideration of mental defences. I begin by identifying the major motives for defence formation, then present a recasting of the nature of psychological defences, catalogue currently known communicative defences, and show the relationship of communicative defences to psychological defences on the one hand, and behavioural defences on the other. The role of death anxiety in these processes and relationships is an ever-present consideration.

THE MOTIVES FOR DEFENCE

The design of the emotion-processing mind, individually configured within well-defined constraints, is universal. Similarly, both the general adaptive resources and the protective avoidance defences used in the emotional realm are activated by basic universal motives. Historically, these needs and motives were subject to natural selection, and they then shaped the structure and operations of the emotion-processing mind. They continue to do so each day throughout the life of a given individual.

 

12. Communicative defences

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The standard against which communicative defences can be identified involves two possible open, non-defensive communicative sequences. They are:

1. Conscious registration, followed by direct or language-based awareness and responsiveness.

2. Unconscious registration, followed by encoded language-based representation, the identification of the evocative triggering event, and then trigger-decoding so that the unconscious experience is brought into conscious awareness.

In principle, then, communicative defensiveness following conscious registration is defined as a failure to sustain awareness of a previously registered, consciously experienced event and its meanings. Psychologically, this would be termed conscious-system repression because the defence operates in the realm of conscious experience; communicatively, it would be identified as conscious-system noncommunication.

With respect to unconscious registration, communicative de-fensiveness has two major forms. The first involves the natural use of encoding or disguise, with the resultant creation of derivative representations. Depending on its consequences, this process may be adaptive or maladaptive. The second form is, however, always maladaptive to some degree; it entails the obstruction of the trigger-decoding process.

 

13. The patient, the frame, and issues of death

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My exploration and clarification of death-related events and death anxiety as they pertain to psychotherapy patients has repeatedly touched on the ground rules of psychotherapy. To complete this discussion, I therefore turn now to a more focused exploration of the interaction between death-related issues and the framework of psychotherapy—the backbone, context, and most powerful influence on the patient’s therapeutic experience. The intricacies of the connections between rules, frames, and boundaries and death anxiety are one of the most unappreciated yet critical aspects of our subject.

THE PATIENT AND THE GROUND RULES OF THERAPY

Death anxiety plays a significant role in how patients and therapists deal with the ground rules of therapy, and the vicissitudes of these canons are intimately connected to how each party deals with and adapts to death-related concerns. Both frame-securing and frame-modifying efforts, whether initiated by patient or therapist, are under the influence of strong unconscious motivating sources. Conflicts involving death anxieties play a major role in this respect.

 

14. Death anxiety and the psychotherapist

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Every aspect of the lives of psychotherapists, both personal and professional, is deeply affected by death anxieties and death-related issues. These effects extend to their life work and influence their choice of psychotherapy as a profession, the particular theory and approach they select as their basis for doing therapy, their preferences regarding the kind of framework and the setting they offer to their patients, and the specific interventions they make on a daily basis.

Each patient whom a psychotherapist treats brings to therapy a specific death-related history and works over, consciously and unconsciously, a variety of death-related experiences as his or her therapy unfolds. All of these factors, in both therapist and patient, will deeply affect a therapist’s interventions and behaviours vis-avis the patient in question. Death-related issues are a critical component of every treatment situation, and they greatly influence the spiralling, circular interaction between patient and therapist. The effects of death-related traumas spread from a therapist’s everyday life into his or her work with patients, much as the effects also spread from the clinical work into the therapist’s everyday life— death knows no boundaries.

 

15. How therapists defend against death anxiety

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In the course of exploring therapists’ attraction to the various modes of therapy, I have alluded to a variety of ways in which therapists defend themselves against death anxiety. Most of these efforts are maladaptive and exert a negative influence on their patients and their symptoms and coping efforts. While both patients and therapists defend themselves mightily against death-related issues, the specific forms through which these defences are effected very much depends, as noted earlier, on their respective role requirements and the constraints placed on them by the ground rules of therapy. This context offers a framework for exploring the favoured ways in which therapists defend themselves against death anxieties.

There is a critical distinction to be made between patients and therapists. The patient can be expected to make use of maladaptive defences against death anxiety, even when they are dysfunctional; their expression, interpretation, and resolution are an essential part of the therapeutic work. On the other hand, because these same defences severely interfere with a therapist’s work—the offer of a sound process of cure through their ability to carry out the necessary frame-securing and trigger-decoded interventions—therapists are expected to have resolved or controlled their needs for these costly overprotective mechanisms.

 

16. Death anxiety and problems of technique

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Throughout this book, I have touched on problems of psychotherapy technique as they are affected by death-related issues. In this final chapter, I explore some selected but important issues of this kind and discuss their technical management.

ILLNESS, INJURY, AND DEATH DURING PSYCHOTHERAPY

Let us begin this final overview by reviewing and integrating the principles of technique that apply to the management of interludes during which illness, injury, and death take place in the life of either the patient or the therapist.

Death-related traumas for the patient

Inevitably, a therapist will be deeply affected by his or her patient’s death-related experiences. These triggering events are processed by the therapist both personally and with the patient, in keeping with the therapist’s death-related history, adaptive resources, and maladaptive defences.

Death anxieties evoke psychological, communicative, and action defences in both patient and therapist. The therapist should therefore be mindful of their likely activation and should interpret the patient’s defences while endeavouring to keep his or her own defensiveness to a minimum; he or she also should avoid sanctioning or supporting the patient’s maladaptive responses.

 

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