Psychodynamic Psychotherapy
By Linda Gill, MD

Linda Gill is a MD, psychiatrist and a diplomat of the American Board of Psychiatry and Neurology. Linda completed her BS in Biology (with a minor in physical anthropology) at the University of Pennsylvania in 1992, MD at the Medical College of Pennsylvania in 1998. Her residency training was a combined Internal Medicine and Psychiatry program at the University of Rochester, Strong Memorial Hospital and was completed in 2003.

Dr Linda Gill

Holding the sacred space; the healing power of unconditional presence in the human encounter

Part One

This article is by no means a comprehensive exposition on the topic; nonetheless I hope it can offer some assistance to those seeking to alleviate the emotional suffering that often accompanies the end of life process.

Facing and integrating difficult, painful events and emotions is central to psychotherapy, and there are psychotherapeutic principles which can offer real help to those facing and those who work with terminal illness, bereavement and death. Of course death is also an existential fact of life with a profound and often painful impact on all those who must grapple with it – and we all must, sooner or later.

What is Psychodynamic Psychotherapy and how can it help?
Psychodynamic psychotherapy holds that much of human suffering is caused by seemingly overwhelming and irreconcilable emotions and intrapsychic conflicts associated with past wounds and traumas, as well as the difficult existential realities we all must face. Many of these wounds stem from childhood experiences and no life is without them as invariably one’s caregivers are human and imperfect, and unfortunately in some instances outright abusive or neglectful.

Likewise, each person will experience existential angst over the limitations and frailties of human reality, including impermanence, ageing, illness, death and loss. Ideally the indomitable and resilient human spirit can utilize these experiences as a crucible for growth, maturation and deepening compassion. However, when the intensity of the emotions and conflicts overwhelms our coping mechanisms, resources and available support, then the suffering human defends against the pain by submerging it into the unconscious and by using various defence mechanisms such as denial, projection, splitting, and the like.

Alas, the experience nonetheless continues to live inside the unconscious of the person, and to colour their present interactions and experiences in an unhealthy and painful way. It is also easily observed that the unresolved past seems to repeat itself as a theme or pattern in one’s life, causing further misery. Therefore, psychodynamic psychotherapy has the premise that human suffering and dysfunction can be relieved by making the unconscious conscious, and in such a way that the past painful experiences and emotions can now be tolerated, digested, and integrated into a more accepting and cohesive, if at times bittersweet, life pattern. In other words, by having the opportunity to face the unconscious material one can now make peace with the past and with difficult existential realities and begin to live more happily and productively in the present. The individual is then freed from the need for rigid and dysfunctional defence mechanisms and a repetition of patterns based on the past, leading to a more open and flexible life stance.

The Importance of the Therapeutic Relationship
To this end, the therapeutic relationship between the therapist and client serves as a vehicle for observing and exploring the phenomena within the client’s psyche and life, and also within the therapeutic relationship itself. For inevitably, a person’s intrapsychic experience will find itself reflected in their external experience, in their relationships – and the relationship with the therapist is no exception. But here the therapeutic relationship differs from other relationships in that its express purpose is to courageously and compassionately explore its own dynamics and the intrapsychic life of the client in a setting of safety and emotional honesty. Good psychotherapy is an art, a science, a spiritual endeavour, and above all, a human encounter.

The therapeutic relationship is thus of central importance in the healing process, and the therapist’s interactions with the client must cultivate an atmosphere where it is possible to safely acknowledge, allow, experience, tolerate, explore, digest, and integrate those overwhelming events and emotions which could not be assimilated previously. The therapist must hold the sacred space, the container, in which the work of psychotherapy can occur successfully. Likewise, the sacred space can also be of great help to those psychologically healthy persons facing the often overwhelming end of life experience. The tasks of transition (for the dying) and of bereavement (for their loved ones) are made more bearable and manageable with such a resource available. Some of the components of this container are obvious and have already been alluded to: safety, trust, respect, emotional honesty and genuineness, non-judgement, compassion and kindness, courage, and willingness for the task. I will speak now in more detail of some other elements of a healing therapeutic alliance.

Presence or Deep Listening
Of paramount importance, presence is the sense that the therapist is energetically and emotionally with the client, here and now, available, attentive and listening. So often in human interaction the parties are distracted by their own internal thoughts, worries, obligations, etc., and are also busy with any emotional reaction triggered by the interaction itself, so that a full attention to the other is not possible. In other words, one is more present with oneself, one’s own internal reactions, than with the other person. As the joke goes: “Are you listening, or merely waiting to speak?”

Indeed, it is a sad fact of human life that mostly people are not truly present in the here and now because of this internal preoccupation. In the healing relationship, the therapist makes an effort to give her full focus and attention to the client. Of course, it is not possible to stop all one’s thoughts or reactions – and the therapist indeed must acknowledge and monitor their own reactions – but these are put aside to focus on the client and are not acted upon in a reactive way.

This presence leads to what I call “deep listening”, because what is heard from the client can be much deeper than what is heard in “ordinary” conversation. It is clear that every human being can sense genuine presence and finds it profoundly nurturing and healing. The healing comes from several sources – firstly, to be truly heard and seen, is something needed. To be able to tell one’s story in detail, and have it received, brings the experience of connection and validation. Also, the telling of it can help clarify it in your own mind and heart. The naming of experience acknowledges it and makes it less amorphous, allowing one to grapple with it more effectively.

Sadly, sometimes therapy is the first place where a client experiences presence and deep listening. In the case of those confronting death, this is such a difficult experience and society is generally so ill-equipped to deal with it, that often those around the dying and bereaved don’t feel they know how to speak to them, or feel unable or unwilling to do so because of their own discomfort about death. So, to have a space to honestly air feelings is a real gift to the dying and bereaved.

Additionally, the therapist’s ability to maintain consistent presence indicates that she can, indeed, tolerate and receive the client’s story, as well as their intense feelings or “affect”. This gives the client permission to be open, to be relieved of any guilt that their story is a burden, or fear that it will trigger rejection, criticism, or retaliation, or shame that their story is not permissible. The continuous presence of the therapist also inspires the client to believe that presence with their pain is possible for them as well. Finally, the experience of being truly present is healing for the one who is present – it quietens the mind and heart. The therapist‘s ability to be present can be “contagious”, encouraging the client to also be more present.

An Unconditional Quality to Presence
It is important, for obvious reasons I think, that the presence of the therapist be perceived as benign and unconditional. By unconditional, I mean that the therapist’s motivation in being present with the client is: 1) to be useful and helpful to them, and 2) having (hopefully) cultivated the capacity for presence in their own work and life, this tends to be a habitual state for the therapist.

The therapist is not offering their presence with “conditions” or stipulations, or in exchange for fulfilment of their own need and agenda, as is so often the norm in human relations. Indeed, care must be taken that even the “agenda” of helping doesn’t become an unhelpful insistence that the client get “better” to alleviate the therapist’s anxiety or frustration, and to reassure them that they are a good therapist and a good human being. This unconditional quality allows the client to trust the therapist, and to believe the therapist is benign and has their best interest at heart, and frees the client to be frank and open and pursue the healing work in earnest. Likewise, in the setting of working with the dying and bereaved it is important to cultivate unconditional presence and to be clear about one’s own motivation and agenda for helping. It’s also important to respect the individual nature of the grieving process and not to push the bereaved into rushed resolution of their grief to alleviate our own discomfort.

Psychological Insights
By Sri Dhira Chaitanya

Sri Dhira Chaitanya practised for years as a child pshychiatrist in New York and later he studied and taught Sanskrit and Vedanta. He is therefore able to address both the psychological and spiritual issues involved in death and dying with a special insight. He has kindly permitted Ganga Prem Hospice to reproduce parts of his book on Bereavement and Final Samskar in Hindu Tradition.

Sri Dhira Chaitanya

Attitudes Toward Death and Dying
Emotional Reactions:
A person deals with one’s own impending death in a variety of ways. The kinds of responses that one has are influenced by one’s culture, beliefs, personal values and personality. Upon becoming aware of one’s impending death, it is natural and quite common to become anxious. Every individual cherishes his life. So, the real likelihood of its coming to an end is an unwelcome thought that one does not want to entertain. Often a person’s initial reaction is one of denial. The anxiety in such a person’s mind does not permit him to accept the reality and inevitability of his own impending death. There is an apprehension in talking about death or dying, expressing one’s feelings, planning for the well being of one’s family and taking care of one’s personal affairs. Initially the person talks and behaves as if everything is as usual. Denial is not a conscious, deliberate decision not to talk. It is an unconscious protective mechanism of the mind to cope with a highly anxiety provoking situation at a particular time. The period of denial may be transient or remain with the person until his death. Denial may at times lead to a feeling of invulnerability, even leading to reckless behavior.

Sometimes a person does not deny the inevitable but avoids dealing with it directly. This is done in order to protect himself or others from the unpleasant and difficult emotions associated with death. Such a person may preoccupy himself with mundane matters that are unconnected with the fact of his death and thereby spare himself and others the agony of painful feelings.

Fear is another common emotion experienced by a dying person. The possibility of impending death evokes a fear of the unknown. No one knows for sure, what would happen after one’s death. The continuity of one’s very existence is put to question. And, no one is ready to die to find the answer. Additionally, there is the fear of loss of one’s family and friends. These are the people who have been the source of support in one’s life and have helped one deal with many difficult situations in the past. However in this particular instance, when death is at one’s doorstep, they are as helpless as oneself in doing anything to prevent it. Often, there is illness associated with dying which gives rise to fear of pain and suffering. Quite often, one has ideas of the process of death that are dramatic and frightening, because one may have witnessed a traumatic death, or have been influenced by what one sees in the media.

An individual who is aware of his impending death often experiences sadness. He worries, his sleep gets disturbed and he may lose his appetite. He is unable to enjoy anything pleasant. He may cry and appear morose. Any experience of loss or the possibility of loss evokes sadness in an individual, even when it is the loss of oneself due to death. To begin with, there is the concern that one would cease to exist and thus be lost forever. Even if one were to continue, it certainly would not be in the current shape and form, as one has to necessarily give up one’s body at the time of its death. Whatever complaints one may have about one’s body, it is the only one that one has had and is familiar with. The thought of losing it forever naturally evokes sadness. Besides experiencing sadness, one may go through a process of mourning for the impending loss of oneself, much the same as one goes through bereavement process after any loss. Sometimes, one can become melancholic and withdrawn to the extent that one isolates oneself from one’s own loved ones emotionally and/or physically.

Individuals may also experience guilt in varying degrees. One starts recalling a lifetime of acts of omission and commission. In retrospect, one realizes that there is much that one would like to have done, and maybe much more that one could have avoided doing. This is not only in regards to one’s personal pursuits, but also in one’s relationships with others. Knowingly or unknowingly, one invariably becomes instrumental in causing hurt in another individual, either by one’s action or by one’s words. No individual wants to maliciously and deliberately hurt someone he is related to. Thus, one experiences guilt and given a chance would like to make amends for all the hurt that one may have caused. Guilt can cause considerable fear in an individual who has grown up to believe in the prospect being punished after death for eternity, with varieties of horrible experiences for not conforming to prescribed codes and dogmas.

Anger is another common emotion experienced by the individual facing immanent death. Anger arises when one perceives oneself as a victim of an act of injustice that one has been subject to. It also arises when one feels helpless in a given situation. Even though death is an inevitable fact of life, it is also true that one does not willingly accept its occurrence. Moreover, a significant part of ones time is devoted to maintaining one’s life and extending it as long as one possibly can. Even if one acknowledges that death is bound to occur one day, the timing of it’s arrival always seems premature. One wonders, “Why am I the chosen one at this time, I am not ready to die, to leave my loved ones” and so on. These thoughts make one feel helpless and give rise to anger. Sometimes, sadness is also expressed as anger. Thus we find that a person facing impending death becomes irritable, easily angered and may even unreasonably blame others such as family, friends, doctors and sometimes even God for what is happening to him or her.

In conclusion, some individuals are more accepting of the inevitability of death than others. Even though they feel a certain degree of sadness for various reasons such as loss of their loved ones, they have essentially reconciled to the fact that they are dying. They can articulate their thoughts, feelings, and fears, seek and gain comfort and support from those around them. Their beliefs and traditions provide them with strength, reassurance and comfort.

For one who ascribes to Hindu traditions, one’s beliefs and the basis of the Hindu religious and cultural traditions become a source of strength, reassurance and comfort. Hindu tradition emphasizes that the occurrence of birth underscores the certainty of death at some point.

‘Know that for the individual who is born, death is inevitable indeed.’

The Vedic tradition places a certain value on dispassion, vair¡gya, in regards to the world and the people one encounters in one’s life. This attitude is based on an understanding of the ephemeral nature of the whole universe. Vair¡gya is not viewed as a fatalistic attitude that impairs one from functioning in the world and relating to it appropriately. It is an appreciation of the truth of it’s nature, which in fact makes one relate to the world as it is. It permits one to make the most of one’s association with the world and the people one spends one’s life with.

The following verse highlights the attitude of vair¡gya based on the transient nature of the world:

‘One’s possessions are left behind at home and relatives (left behind) on the cremation grounds. The body is consumed in the funeral pyre; only punya ( merit) and papa (sin)accompany (one).’

Vedic tradition also enquires into the ontological status of the world of experiences, and the relationship between oneself, the universe and it’s cause. An understanding of these matters helps an individual deal with not only himself and others, but also with life and death.

Bertrand Russell eloquently described death as a concluding episode of one’s life and an integral part of existence. Using a metaphor he said that an individual’s existence should be like a river –small at first, narrowly contained within its banks, and rushing passionately past boulders and over waterfalls. Gradually, as the river grows wider the banks recede, the water flows more quietly and in the end, without any visible break, it becomes merged in the sea and painlessly loses its individual form.

Reactions in Family Members:
The ones who are close to a dying person also have to deal with a variety of emotions of their own. They too get anxious about what is happening around them. They may be engaged in the medical and nursing care of the person that can be tiring and overwhelming, not to mention confusing. They feel a profound sense of helplessness because of their inability to prevent what is happening to their loved one. They feel that they are letting him down.

Their profound sense of helplessness sometimes evokes anger at others for not doing more than what they are doing. This anger can get directed towards other caretakers, such as doctors, nurses or other family members. It can result in petty misunderstandings between family members that in turn, evoke guilt as one feels embarrassed at one’s own reactions. Anger can also get directed towards God, who is seen as being responsible for causing them pain and not responding to their prayers to spare the one they love.

They experience fear of losing someone they love and perhaps rely upon. The possibility of never again being able to see and live with a loved one evokes both fear and sadness. They begin to imagine what it would be like to live without their loved one. Ruminating over the future is the way a person’s mind tries to prepare itself for an undesirable experience that it anticipates and fears.

Families also feel pressured to maintain an appearance of normalcy in front of their dying member. They are afraid that if they reveal how upset they are, the person may not be capable of handling their distress. Thus, they avoid showing their feelings, which does not really serve any purpose, as people who are close to each other can usually sense each other’s unexpressed feelings. Thus, their attempt at protecting one another in this manner does not usually work.

There is no ideal way which would be universally applicable, in order to cope with the difficult situation of impending death in a family. Every individual affected by it, deals with it in the way he knows best and in the manner in which his mind is comfortable and capable. However, one can say that, in general, it is advisable to be as communicative as one possibly can. When a person does not know what another thinks, they start guessing what might be in the other’s mind. Very often what they imagine is not only inaccurate, but also exaggerated and worse than it is. Additionally, it is generally easier to deal with something that one knows than with the unknown. This is so even with respect to dealing with another person’s thoughts and feelings. Protecting one another in a difficult situation that involves death, only compounds one’s sense of helplessness as one is unable to change what is happening and also unable to prevent other’s agony. Sharing one’s thoughts, feelings, concerns, fears and so on, is comforting, even though it may be difficult to do. People discover a tremendous amount of strength from each other during difficult times. When faced alone, a difficult situation looks impossible to overcome. However, a seemingly impossible situation becomes manageable when endured along with people one trusts.

Conclusion:
In relating to individuals facing death, it is best to remain one’s natural self. It is not necessary to act as if nothing is happening. Doing so, only gives a message that one does not wish to deal with the difficult issue at hand. It prevents the dying individuals from expressing their wishes, and sharing their feelings. It places an added burden on them to deal with death alone and leaves them feeling unsupported. By encouraging them to express themselves to the extent they are comfortable, one can provide them with a lot of support. One needs to make them feel that they have someone, who though incapable of changing the inevitable, is willing to be by their side until the very final moment of their lives.

In order to help a loved one who is facing immanent death, it may become necessary to put aside for a while one’s own sadness and feeling of deprivation at one’s impending loss.

During such a difficult time one’s religious traditions and beliefs become a source of strength and comfort, for both the dying and those closely connected to him or her.

Coping with the Final Moments
There are occasions of impending death, when both the dying person and those connected to him know that death is inevitable and immanent. There is a fear of the unknown. There is fear of annihilation. And, there is fear of losing all one is familiar with. One may be overcome by a sense of helplessness. There is also sorrow at separation from all that one is attached to and one loves. Very often, those that one is connected to are also very sad. Both the dying person and his family try to protect each other, and may pretend that everything is as usual and fine. It is very difficult to suggest how one should behave during these times. People tend to do what is most comfortable to them and what may be appropriate in case of one family may not be so in case of another. When one is able to, it is very helpful to share one’s thoughts and feelings with those one is close to. To talk to a loved one about one’s feelings and fears is very comforting to both. Even if what one speaks causes sadness, when sorrow is shared with a person one loves, it is easier to experience.

It is a rare gift to be able to express oneself and share one’s thoughts and feelings with one’s loved one who is dying. This is so because, very often death comes unexpectedly, or a dying person may be incapacitated or in pain. It is a very common experience for people, to feel that they did not say what they would have liked to say to a person who is no more, and they live with this sense of incompleteness for the rest of their lives. It is in such difficult times that one’s Religious convictions and spirituality become a source of great solace.

Generally, Hindus recite verses from the Vedas such as Purusasuktam, the Bhagavad Gita, Ramayana, and Visnusahasranamam. It is believed that what one’s mind is attuned to at the time of death, determines one’s gati, direction of onward journey after death and also one’s next birth. Therefore, the family and friends of a dying person provide an environment of spirituality and comfort during the final moments of his or her life.

In Bhagavad Gita, (Chapter 8, Verse 5) Lord Krishna assures Arjuna of the following:

The one who gives up his body remembering me (the Lord) during his final moments reaches me. Of this there is no doubt.

Unless a person has lived prayerful life it is difficult for him to remember the Lord during his final moments. People everywhere have their own beliefs about what happens to an individual after death. But there is no one, who has seen a dead person come back to report to those alive about their experience, in a manner that can be verified by them with certainty. There are however, innumerable cases investigated, reports documented and available that have been verified indirectly to a greater or lesser degree about after death experiences and reincarnation. Most people do accept that there is an entity in addition to the physical body that survives death and remains in some form. However, not knowing for certain makes the unknown future frightening.

There is also a sadness that comes from the knowledge that one will never again see those that one loves and has spent one’s life with. Moreover, no one can take with them any of the possessions that they have accumulated in their lifetime and have to leave behind all that they are attached to. There can also be a fear of possible pain and suffering associated with the process of death itself.

From Bereavement and Final Samskara in Hindu Tradition
By Sri Dhira Chaitanya
Published by Purna Vidya Trust, Tiruvannamalai