Death and Dying

by Sudhir Kakar

  After a series of talks with the psycho-oncologist, the patient agrees to a palliative-medical consult. A couple of weeks later, she decides against continuative arrangements, which would slow down the progress of the illness. She asks to be transferred to the palliative ward. She is relieved that she has found another way than to have her husband take care of her in the end of her life. In the very comfortable atmosphere of the palliative ward, which is free from the hectic and hustle of a university clinic, she can allow her children to visit her. She experiences that her children are not scared of the hospital, but actually ask questions about the future. In the last days of her life, Mrs P wishes to ‘plan ahead’ for her children and wants to leave them with memories. She dictates letters to the children, fills ‘memory boxes’ and keeps talking with and about her children continuously. It is important to her that her husband is present and part of this until the end.

  In light of the above, it would be highly desirable that oncology, psycho-oncology and Palliative Medicine were not merely separate disciplines with considerable friction in an interdisciplinary context. Rather, we should aim at an oncological system directed towards the patients that would include thought and action from Palliative Medicine as well as from the psychosocial approach, as basal understanding of medicine. For the overwhelming majority of our patients this would be a supportive system of care that has to be complemented to accommodate the needs of a small group of patients with special problems and questions by specific and detailed professional competence.

  Objectives of Psychosocial Support in Oncology and Palliative Medicine

  The moment in which we face the existential threat of certain death (sooner or later), often causes a deep existential crisis, in which fears and uncertainties are pervasive.

  What professional staff can do, however, is to create a situation in which questions can be answered and perspectives can be transformed. Above all, this means to provide an emerging space that creates a new awareness for life and individual answers can develop. This emergence requires time, attention and openness. All those involved in the process of treating oncological patients are called upon to face the needs of the patient: autonomy, respect, dignity, relationship and authenticity with their ethic attitude. With this, professionals can support the patients in their coping efforts with the disease or the crisis.

  The needs of the affected differ: Besides the determinants of their primary personality and the socio-cultural circumstances of their life, the real situation of the disease and its prognosis are of importance as well. In a therapeutic or medical conversation, it is therefore necessary to compare the subjective notion of the patient with the real situation of the current phase of the disease. After a definitive diagnosis of the disease, it is necessary to clarify which trajectory the disease is most likely to take, which changes of normality have been going on so far and, hence, which individual needs for treatment and support will be the result. Special attention has to be given to the question whether all people involved in the process have a shared perspective of the situation the disease has brought about; whether there is a need for clarification and information, even if it is repeatedly necessary to inform. This component is not about confronting the patients with their frequent mechanisms of resistance, like repression and denial at all costs. It is, however, important that patients and those closest to them have a shared perception of reality, if they want to master the situation together.

  Denial (actually a ‘healthy’ mechanism of resistance against a threatening reality) that is sustained with good intentions for some of those concerned, has the potential to lead to communication barriers and, thus, inevitably to (partial) isolation and failed adaptation.

  In addition, the changing social situation, induced by the disease, leads to conflict for many of those involved, which is caused by lost role behaviours and patterns, as well as the limited ability to provide for oneself or the dependent family members. The psychosocial stress symptoms that are caused by the adaptation efforts (imposed upon the subjects by the reality of life) have sufficiently been examined and described in the literature: In 25–30 per cent of cases, people who find themselves in the range of a transitional crisis to a chronic overstrain show the ‘big’ psychological co-morbidities: fear, depression and adjustment disorder. Frequently overlooked or less registered, somatizations and deliria occur as well. A classification by time or the predictability of psychological symptoms in the course of the disease does not exist. While we cannot go further into the discussion of the specific methodology here, the broad range of symptoms leads to the necessity for a therapeutic groundwork in order to identify or even strengthen individual needs and resources for the patients:

  Integrating and enduring fears

  Providing a space for despair, shame and guilt

  Revising relationship patterns

  Providing a space for hope and consolation

  Fostering and restoring personal autonomy

  The overall objective is to improve the quality of life in its physical, psychological, social and spiritual dimensions, as well as the prevention, control or mitigation of psychosomatic symptoms and, furthermore, to facilitate a reorientation in a situation characterized by a temporary or final loss of structure and order.

  Contributors

  Edward F. Kelly is a professor in the Division of Perceptual Studies, a unit of the Department of Psychiatry at the University of Virginia. He received his PhD in psycholinguistics and cognitive science from Harvard in 1971, and spent the next fifteen-plus years working in parapsychology (initially with J.B. Rhine in Durham, North Carolina, then through the Electrical Engineering Department at Duke, and finally through Spring Creek Institute, a Chapel Hill non-profit), publishing papers on a variety of topics in parapsychology, and a book, Computer Recognition of English Word Senses. Between 1988 and 2002 he worked with a large neuroscience group at UNC-Chapel Hill, conducting and publishing EEG and fMRI studies of human somatosensory cortex. He returned to psychical research in 2002, serving first as lead author of Irreducible Mind (2007), and has now begun working on functional neuroimaging studies of altered states of consciousness and psi in exceptional subjects.

  Emily Williams Kelly is currently research assistant professor in the Department of Psychiatric Medicine at the University of Virginia. She received her undergraduate degree in English Literature from Duke University and a PhD from Edinburgh University. She has been associated with the Department of Psychiatric Medicine since 1978, working primarily with Dr Ian Stevenson in research on cases of the reincarnation type and near-death experiences. In recent years her research has focused on other kinds of phenomena suggestive of survival after death, including apparitions, deathbed visions and mediumship. She is the co-author of Irreducible Mind (2007).

  Michael Grosso studied classics and received his PhD in philosophy from Columbia University. He has taught philosophy and humanities at Marymount College, New Jersey City University, and City University of New York, and is now an independent scholar affiliated with the Division of Perceptual Studies of the University of Virginia. His most recent two books were Experiencing the Next World Now and Irreducible Mind (which he co-authored).

  He is working on a book that grew out of a long research and theory seminar at Esalen—temporarily titled Transcendent Brain: Entrances into a Greater Life.

  Ronald A. Sharp is professor of English at Vassar College, where he was dean of the faculty from 2003 to 2008. Before he came to Vassar he was acting president, John Crowe Ransom Professor of English, and provost of Kenyon College, where he was also editor of The Kenyon Review. His special interests include romanticism, contemporary poetry, Australian literature, and the literature of friendship. Sharp is the author/editor of six books including Keats, Skepticism, and the Religion of Beauty; Friendship and Literature: Spirit and Form; Reading George Steiner (with Nathan A. Scott, Jr.); The Persistence of Poetry: Bicentennial Essays on John Keats (with Robert M. Ryan); and Selected Poems of Michae
l S. Harper. With the late novelist and short-story writer Eudora Welty, he edited The Norton Book of Friendship.

  Sudhir Kakar, a psychoanalyst and writer, has been lecturer at Harvard University, research fellow at Harvard Business School, professor at Indian Institute of Management, Ahmedabad, and head of the Department of Humanities and Social Sciences at Indian Institute of Technology, Delhi. He has been the fortieth-anniversary Senior Fellow at the Center for the Study of World Religions at Harvard as well as the visiting professor at the universities of Chicago (1989-92), Harvard, McGill, Melbourne, Hawaii and Vienna. Since 1994, he is adjunct professor of Leadership at INSEAD in Fontainbleau, France, and lives in Goa.

  Dr Kakar’s many honours include the Kardiner Award of Columbia University, Boyer Prize of the American Anthropological Association, Germany’s Goethe Medal, Rockefeller Residency, Fulbright Scholar, MacArthur Fellowship, Distinguished Service Award of Indo-American Psychiatric Association, Fellowships of the Institutes of Advanced Study, Princeton and Wissenschaftskolleg, Berlin, the Bhabha, Nehru and ICSSR National Fellowships in India. In 2012 he was given the Order of Merit of the Federal Republic of Germany, the country’s highest civilian order.

  Kakar is the author of eighteen books of non-fiction and four novels, of which the latest is Young Tagore: The Makings of a Genius. His books have been translated into twenty-two languages around the world.

  John Dourley is professor emeritus, Department of Religion, Carleton University, Ottawa, Canada. He is also a practising Jungian analyst in Ottawa, and a graduate of the C.G. Jung Institute, Zurich/Kusnacht, Switzerland, 1980. He is a Catholic priest and member of a religious order, the Oblates of Mary Immaculate, ordained in 1964. He has written widely on Jung and religion/mysticism. His most recent works are Paul Tillich, Carl Jung and the Recovery of Religion (Routledge, 2008), and On Behalf of the Mystical Fool; Jung on the Religious Situation (Routledge, 2010).

  Patrick Mahony is professor emeritus of the Université de Montréal, where he taught English Renaissance literature, literary theory and comparative literature. He is also a supervising and training analyst of both the International and Canadian Societies of Psychoanalysis. His publications include studies in clinical theory and technique, the roles of discourse in psychoanalysis, the history of psychoanalysis, the life of Freud, and applied psychoanalysis. He is a member in the Royal Society of Canada, Fulbright scholar, resident in the Guggenheim Foundation, and recipient of the Carlson Award (Cornell University), the Mary Signourney Award (International Society of Psychoanalysis), and the Killam Award (government of Canada).

  Eckhard Frick is a psychiatrist and psychoanalyst, who also holds MA degrees in philosophy and theology. A member of the Society of Jesus since 1986, he is a didactic analyst at the C.G. Jung Institute, Munich, professor of anthropolgy at Munich Jesuit School of Philosophy, and professor of spiritual care in the School of Medicine at the University of Munich. He has worked in the area of suicide prevention since 1991, and has psycho-oncology as his special research interest.

  He is the author/co-author of several books of which the more recent ones are: Auf Unendliches bezogen: Spirituelle Entdeckungen bei C.G. Jung. Kösel, München, Spiritualität und Medizin. Gemeinsame Sorge für den kranken Menschen. Kohlhammer, Stuttgart and Schöpferisch im Spiel vor Gott. Bibliodrama und Exerzitien. Echter, Würzburg.

  Katharina Poggendorf-Kakar is the founder of the NGO Tara Trust, and gives a lot of her time to work with deprived children in India. She studied comparative religion, Indian art, and anthropology at the Free University of Berlin. She has taught at the University of Berlin and the College of Protestant Theology, Berlin, and was a fellow at the Centre of the Study of World Religions at Harvard University. She has published several articles and contributed to chapters in books on Indian women, society and religion. She is the author of the books, Hindu-Frauen zwischen Tradition und Moderne: Religiöse Veränderungen der indischen Mittelschicht im städtischen Umfeld and Der Gottmensch aus Puttaparthi. Eine Analyse der Sathya-Sai-Baba-Bewegung und ihrer Westlichen Anhänger, Moving to Goa, and the co-author of The Indians: Portrait of a People. She is currently writing a book on death in the Indic traditions.

  Pia Heußner is a medical doctor specializing in oncology and psychotherapy. Starting in Hannover, Rostock and Augsburg as an oncologist, she has worked in the field of psycho-oncology and palliative care as a psychotherapist and trainer for more than ten years. She is the chair of the Munich Psycho-Oncology Academy (APOM). Her main research interest has been in the field of psycho-oncology, and she has published a number of papers, especially on the quality of life and psychosocial distress of cancer patients and their families.

  Almuth Sellschopp is a training analyst of the German Psychoanalytic Society (DPV), and currently the chair of the visitors’ program at Munich Psychoanalytic Institute. She has been a professor of psychosomatic medicine at the university clinics of Freiburg, Heidelberg and Munich for many years. Her main research interest has been in the field of psycho-oncology, and she has published a number of papers, especially on the care of seriously ill cancer patients. In 2004, she received the German Cancer-Help Prize. Her current research and clinical work concerns personality disorders and gender topics, with a growing concentration on the boundary situations of psychological experience, particularly in cases of severe bodily illness. She is a curator of the Breuninger Foundation, with particular involvement in the Wasan Academy and research projects concerned with promoting female leadership in business.

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