Psychoanalysis and Dying

Psychoanalyst and psychiatrist Mali Mann, M.D., recalls the 50-year-old former patient who called her five years after termination of an analysis with bad news: “Dr. Mann, I found a lump in my breast. I’m really scared.” A biopsy determined the cancer was malignant.

In twice-a-week therapy for two years leading up to the patient’s death, Mann used the tools of free association, transference, and countertransference in a format modified to meet the demands of the patient’s medical care and the time-limiting nature of her illness.

In coordination with the oncology team at Stanford University, Mann worked with the patient around decisions about having a mastectomy, undergoing chemotherapy, and the need to wear a wig in the aftermath of treatment.

“The goal at the time was to generate greater pride in her life and to help her die as she wished,” said Mann, who is a clinical assistant professor in the department of behavioral science and psychiatry at Stanford University School of Medicine.

The principle that an encroaching death is better faced than denied applies with special force in the psychotherapeutic setting, she said. The dying patient in therapy is prone to falling into a “regressive state,” longing for reunion with a loved one and a magical cure—a state the therapist cannot ethically encourage.

“We are not there to be a magician or to provide a miracle, but to create an atmosphere of understanding and mutual respect that can augment the quality of life in the present,” Mann observed.

Navigating the painful realities of an encroaching death while maintaining a supportive therapeutic alliance requires abandoning traditional analytic neutrality and foregoing the in-depth analysis of defenses typical in conventional psychoanalysis.

In its place, Mann said, the therapist works to strengthen existing defenses, with the goal of “elaborating new and better mechanisms for maintaining control over decision making.”

As in the case of Mann’s cancer patient, therapy was a vehicle for enabling her to marshal the resources to proceed with life in the face of death. And for Mann, it was an experience that warranted the solicitation of a therapist’s frank admiration.

“I visited her twice in her home before she died, and I went to her funeral,” Mann said. “During my last session, I told her she had a right to know how I was seeing her, that I saw her as courageous in facing every day.”