Therapy in the Shadow of Death and Its Remarkable Privileges By Tom Medlar, LMHC on 1/31/23 - 1:11 PM

Concerns Converging on Loss

“So, the doctor told me that it is cancer, and that there's nothing they can do. I just hope I have a little more time; my biggest hope is that my sons will reconcile with each other.”

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

“The doctor came to my room to see me. He held my hand and said, 'I'm sorry you have cancer, and I'll do everything I can to keep you comfortable.' And he said, 'From everything you've told me about who you expect to meet when you leave, I think that should be the best comfort for you,' and the doctor was right, my faith is a comfort to me.”

“My daughter, my beautiful daughter killed herself. There's just no answer to explain it.”

“Don't say goodbye, I'll see you in heaven; I've been there before (near-death experience) and it's beautiful.”

“Oh, Tom, can you see this client today, her son just died; they think it was a drug overdose.”

“They're all gone, my parents, my wife, my children, everyone; I'm the last one left. I don't know why, but I'm still here.”

“This is the third time my mother is in hospice. I wish she would die, but then I feel so guilty for wishing that. Then I wish she would get better, but I don't think she will; it's all just so difficult and confusing.”

Walking with My Clients

Over four decades, I’ve provided psychotherapy to residents in nursing facilities. I have worked with many thousands of clients, most of whom have died. I have been privileged to accompany so many on the last steps of their journey through this world. All persons die, and virtually all persons have lost someone, or many others dear to them. I have likewise been privileged to provide companionship to so many amid of their grieving. Speaking with someone with a terminal illness or someone grieving is a weekly, if not daily, or even several-times daily part of psychotherapy in a nursing facility.

Sometimes I know in advance, and can have sessions in which to work reflectively with the client as they approach the end. Other times I come to the room of a resident and their belongings are gone, and inquire of the nurse and am told they died. Sometimes, I receive an email telling me the sad news before I arrive, and sometimes a staff person will console me, “I know how close you were to her.”

For many clients who have a terminal illness, it is a comfort and relief to speak frankly in psychotherapy about matters of death and dying. The person's family members, and even some caregivers, might tend to avoid the topic, perhaps due to personal discomfort.

Staff persons might encourage continued socialization, yet the dying individual may be occupied with the internal work of preparation. A nurse asked me to “talk to” a dying resident because she thought her TV show was inappropriate. The resident was sitting up in bed while a television show for toddlers was quietly playing. While the resident sat facing the TV, she was clearly looking inwardly.

As I quietly kept her company between brief bits of conversation, I noticed how the TV show in the background provided a soothing backdrop. This particular resident, like others close to death, needed to pull away from the ordinary things of this world and reflect on their life, their relationships, and their eternal future. My father was lucky to die at home. As I visited him weekly towards the end, he would each time give me a book or another item of his. I thought of how I pack up when I am preparing for a journey. He was unpacking as preparation for his journey.

Sometime around 12 to 15 years into my 40-year career, I started to experience burnout; a result of too much trauma and human suffering. For me, it was a deepening of religious faith that allowed me to once again fall in love with psychotherapy and learn to practice without being harmed by it.

Of Greeting and Bidding Farewell

Some dying individuals are comforted by their faith, and some struggle with doubts. Everyone will have some fear of death, yet I notice how each person has their own kind of fear as they near it. For many of my clients, the fear is of God's judgment. Clients often voice worries about their mistakes and misdeeds in life — yet I regularly see how narrowly a person might look at their life experiences and influences, and how harsh and disproportionate is their judgment of themselves.

Many of my clients have been rejected by so many in life, they doubt there is a God, or let alone a God awaiting them with kindness and understanding. I feel a tenderness for each of my clients, yet often in therapy, sometimes as a client most severely chastises themselves, I feel a loving kindness in me that does not seem to begin in me. I notice a gentle feeling of wanting to reach out and touch their cheek, or a reassuring largeness of understanding that surrounds all the good and the bad of that person’s life, and I simply hold those ideas or sensations as aspects of my bringing a therapeutic presence to their suffering.

I have worked for many years in particular facilities; maybe 10 years in one, or 18 years in another. As I walk through the halls, I often think of the individuals who previously stayed in those different rooms, recalling their personalities and the challenges of their life.

Psychotherapy in nursing facilities is often a process of greeting, uplifting, supporting, and of saying goodbye. It can encapsulate and intensify the general experiences of life and death one might encounter in other settings or ordinary living. I am grateful for this work. When the time comes to retire, I will continue to see in my mind's eye the many people I have worked with and to thank them for their trust when they were most vulnerable.


File under: The Art of Psychotherapy, Musings and Reflections