Thoughts From The Couch – Terminal diagnosis

Somewhere deep inside, most often pushed away out of sight and mind, each of us knows that one day we will die. Most of us go about our day to day lives doing our best to ‘live’ and then in a moment, often when we are unprepared, fate opens a gate that allows the unthinkable to happen. To be given the news, or confirmation of fears, that one is dying is a direct blow to one’s sense of self as not only do we need to face the truth that we will no longer be, but we need to accept that we will be leaving behind all that we cherish. In my work, I have held space for many clients who have received a terminal diagnosis. Some I have an established therapeutic relationship with and others reach out as a result of the moment they were faced with the harsh reality of their mortality. There is often much uncertainty as the pattern of decline towards death varies from person to person and the timing of each death always a mystery. My deep desire is to support my client, with equanimity, as they find their way through the maze of a terminal illness diagnosis to a dignified and peaceful death. 

The work of Psychotherapist and Soul Midwife fit together perfectly as both encourage not only deep conversations but also the challenge of living life fully, until the end.  Just as a birth midwife supports a woman through the stages before a baby enters into the world, so a Soul Midwife supports people through the end-of-life stages before they leave their physical body. Most of us hope that when the time comes, we will die at home with our symptoms controlled enveloped by our loved ones. But not many of us achieve this. With dying clients, I adapt my boundaries so that I can support them on their journey, whether that be at home, a hospital or hospice. “Those who have the strength and the love to sit with a dying patient in the silence that goes beyond words will know that this moment is neither frightening, nor painful, but a peaceful cessation of the functioning of the body.” Elisabeth Kubler-Ross.

Although my work as a Soul Midwife is similar to that of Psychotherapist, there are differences. One of the first things that I do when a client talks to me about their terminal diagnosis is to establish what sort of support they need from me, which will determine how the roles merge or not. Although some consider a sudden death to be easier to deal with, it denies them and the survivors a chance to say goodbye. Anticipating death can enable a dying person to consider their options. In addition, there is the freedom for family and friends to arrange their priorities so that valuable time can be spent enabling the person who is ill to make the most of their final days. With death being one of the most critical moments in our life, there is the opportunity to treat it as such with reverence, honesty and courage. One of the starting points is to acknowledge the diverse emotions that inevitably emerge whilst coming to terms, or not, with the idea of dying.

Some diseases are known to be terminal from the time of diagnosis, whereas others may not necessarily be terminal at the first onset. I have had clients who have lived for several years with a terminal diagnosis and others for whom death came a matter of weeks from the initial consultation. Most of us struggle when things feel out of our control and dying challenges us to soften into the mystery of what will come next. Many go through Kubler Ross’s (1969) five stages: denial, anger, bargaining, depression and acceptance, and for some, the journey to acceptance is more manageable than for others. Each of us is our own expert as to what we can cope with and, because of that, I see my role to walk alongside my client, to guide them, educate them and trust them in every step they take towards their death – in their time and way.

Working with death has been one of my ultimate counter-transference challenges, and at times, I have relied heavily on supervision when I have felt as if the stitches holding closed an old wound have come undone. Thankfully, I have been encouraged and understood in ways that have strengthened my trust in myself to feel deeply and work effectively. As a result, I can draw on my own internal supervisor, therapist and mother to calm and guide me when facing not only my client’s mortality but also in the moments when I am being reminded of that of my loved ones and my own. The more I have explored my own history around death I have found the ability to be more open and honest with my clients who have touched my sensitivities with their fears, regrets, sadness and the unfinished business of living – thus enabling me to provide the much needed and meaningful support to them in their final days of life.  

There are a multitude of different reactions as clients come to terms with their life ending earlier than they had imagined. For some, they want to talk about and understand every detail. For others, they simply do not wish to know. Clients speak of the challenges they face in accepting their diagnosis and the fear at the thought of uttering the words to their loved ones. These moments can feel isolating and overwhelming, and therapy is a place where clients can share their truth without feeling the need to edit or adapt for me. It is inevitable that well established relationship patterns will influence how many of the important issues are addressed along with the various challenges faced by family and friends. It is not uncommon for clients to work on estranged or broken relationships in the hope that there can be some healing in the midst of their dying. It is essential for everyone involved to be cognisant that the environment within which they are operating is one of sadness and grief at the impending loss, but that does not mean that peace and solace cannot be reached for all involved.

Helping to facilitate a good death that enables growth and breakthroughs throughout the dying process and beyond, requires the sick person, their loved ones and their medical advisors to have the courage to have honest, transparent conversations in fiercely difficult moments. Gaining clarity as to what services are available is critical in offering additional peace of mind along with the experience of receiving and feeling support. Depending on what is required, these can range from financial aid, support groups, online forums and sites to a palliative care team who provide end of life care for those living with a life limiting illness. I often assist my client in setting out their wishes for the final days in a death plan, which includes what sort of funeral they would like, how and where they want to spend their ending days along with anything else that gives them a sense of closure before passing on.

As death is a process that involves mind, body and spirit, there are additions to talking therapy that can soften the final weeks, days and hours. Some clients have places they would like to see and things they would like to do. One last walk on a beach, to visit a church, gallery, restaurant or garden. If physically able these moments create tender memories that can soothe clients as they become less able to leave their bed. As time draws near, breathing techniques, along with a mixture of music, singing, singing bowls, poetry and toning can help ease anxiety and pain. Windows can be covered with coloured fabrics of choice that can offer soft light and a soothing environment. Favourite smells, white sage, juniper, sandalwood along with frankincense and myrrh can be used to still the mind and fill the air. If open to physical touch, massage is a beautiful reminder that they are not alone. Soothing touch in all different forms using essential oils, or not. A favourite of mine is to put a clients foot on my heart and gently sit there either with music, singing, toning or simple silence. Allowing the calmness of my soul to merge with theirs offering companionship in a very sacred moment.

Having witnessed clients at all stages of the dying process, I offer them my full presence by remaining open to the mystery of what is happening for them and between us. I am conscious that for most I am not part of their inner circle, but for a few, I am their only comfort. As a result, I tread respectfully and mindfully through the dying process offering my assistance as, how and when needed, without wanting to intrude. Whether clients have viewed death as an uninvited stranger or a welcome guest there comes a moment when death comes beckoning. Whether I am there or not I hold the hope that with their last breath they know that they are loved and that that love remains their companion, along with tranquility and trust, as they take their leave.

Kubler-Ross, E. (1969) On death and dying. New York: Macmillan.

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