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|Dying, Death and the Value of a Good Separation Deintegration and reintegration at the end of one’s life and in cases of separation|
|Congresses - 2004 Barcelona|
|Written by Elisabeth Adametz|
“I have often been asked what I believe about death, that unproblematical ending of individual existence … The question of the meaning and worth of life never becomes more urgent or more agonizing than when we see the final breath leave a body which a moment before was living. How different does the meaning of life seem to us when we see a young person striving for distant goals and shaping the future, and compare this with an incurable invalid, or with an old man who is sinking reluctantly and impotently into the grave!” With these words C.G. Jung began his paper, “The Soul and Death,” which he published in Berlin in 1934 (Jung, 1934).
I had my first encounter with death as a nine-year-old with mother at my side, as I saw my deceased grandmother laid out peacefully in her bedroom, as though she was sleeping. Flowers and candles stood in the dimly-lit room. Mother took us with her to the cemetery too, where she tended to the graves of her ancestors and her little sister, who drowned when she was one-and-a-half. Mother, who was three years older, recalled her sister laid out and beautiful, many people, a children’s choir, and that she wanted to go where her sister was. Later she didn’t think much of exotic images of paradise and knew she would be laid to rest in this cemetery.
I accompanied my mother for eight months in the time leading up to her death. I would like to depict some of my intimate experiences and observations. I also want to discuss the similarities and differences in the development of small children and the dying. Thirdly, I would like to explore how this understanding can help us in our analytical attitude and work, especially in cases of separation.
(In the following passages I will refer to her as M, which stands for “mother” but also for her first name, Marianne). M lived her entire life in one place. She lived alone but with support, and would have loved to have stayed in her house and garden to the end. When she was eighty-five she fell and broke her arm in the winter. She had a small inoperable brain tumor for two years which caused occasional seizures in her right arm and leg. This made her insecure and her vitality clearly diminished. It was not possible to care for her at home. So we brought her to a nearby nursing home, initially for four weeks, where she had registered herself a year earlier. Soon she could walk again with assistance, and many friends, relatives and old schoolmates, some of whom also lived in the nursing home, came to see her. She told of her experiences and was as always very interested to hear from us. After initial improvement she became weaker again, and realized she couldn’t return to her home any more – a painful disappointment for her.
– M wants her midday nap, I turn to go for a walk. She says, “Are you going alone?” I say, “Yes – would you like to come?” She answers thoughtfully, “I can’t anymore, and when I was still able to, I often didn’t want to.”
– We are sitting in the cafeteria. M is in a wheelchair. At the next table a man is playing with a six-month-old baby; he holds it up in the air and puts it on his lap again. Then the baby and M make eye contact. They look at one another steadfastly. It’s like an understanding without words in a state of consciousness, in which time and space have little meaning. Maybe this is like being asleep, when we are less conscious and our dreams come to us.
– She can still sit up, but is already quite weak, and repeatedly wants to go to the toilet. She clings to us and it is very difficult to hold her, although she is small and delicate. I fear that she will drag me into the abyss with her. I say, “It’s so hard to hold you, if you cling so tight we’ll both fall over. You’re pulling as if you were drowning!” “Yes,” she replies, “Maybe I feel like that, like a drowning person!” This clear statement gives me pause, and her situation becomes clearer.
– She is bed-ridden but we still talk a lot. I think we have exercised patience mostly outside the family until now. I say, “Maybe we are meant to, and have time to, learn to be patient with one another; until now, we’ve had few chances.” She says, “Well, that’s probably going to be more comfortable for you than me!” I didn’t mean it like that, but I feel patient and relaxed and M is also patient, grateful for our help, enjoys our company and is happy with us the way we are. It wasn’t always that way.
Time and Impatience
M’s sense of time deteriorates. She waits weeks for her granddaughter to return from a journey. “Is it tomorrow?” “When is she coming?” She forgets the answer and asks again until her granddaughter is finally back with her youthful love and warmth. She also asks about her sister’s golden anniversary. It’s a bitter disappointment for her that she can’t attend because of her illness. After that, time becomes meaningless. She could look out of her window into the springtime bloom, but says: “I don’t want to look anymore, I just want to close my eyes. I’m satisfied with that!”
Then a phase of impatience begins. She tosses and turns in bed, appears strained, she groans and can’t move the way she wants to. We help her move her arms and legs and to lay in a more comfortable position, which gives her relief. She says repeatedly for a few days, “I can’t stand it anymore!” “It has to get better some time!” I summon up my courage, I feel unsure, but then I dare to say, “Do you sometimes think that it might not get better, and you might have to die?” She says, “I think about it all the time!” I say, “If we both think about it and are sitting here together, we might as well say it.” The rest of the weekend is quiet. I remain unsure whether or not I said the right thing, earlier we spoke a lot about death, she prepared herself for it, but now that it’s so close it’s different. As I leave she says, “That was good, we talked about many things.” I say, “I wasn’t sure if it was maybe too much for you?” She answers, “No, not at all.” She tells her sister that we have talked about important things.
In the early weeks we go to the home’s restaurant. She eats on her own, but slowly starts to need help. When she is bed-ridden and can’t eat unassisted, she lets us feed her. We look at each other, I speak to her, and later I notice that I intuitively make the corresponding facial gestures when she eats. Sometimes she brings her hands to her mouth, the way small children do. When she has finished eating she closes her mouth and turns her head to the side. As long as she is still looking we show her things which might whet her appetite. Later I can still touch her lips gently, to see if she wants to eat more. There’s a short timeframe where she has good appetite, but her eyes are closed and she only opens them in certain moments. For me that has a disconcerting character – how can she be hungry, but not want to see anything? A nurse says, “At the moment it’s still okay, but when she doesn’t want to eat anymore it’s depressing.” That’s true, I’m somewhat surprised, consider it a rejection and sad that she doesn’t want to take in anything from the world. I need to process this, so that I can accept it without a heavy heart. Her granddaughter asks, “Don’t you reprimand her, when she doesn’t eat?” “No, I don’t.” “I think she has to eat, otherwise she’ll become weaker and eat even less!” “Yes, she’ll get weaker. She doesn’t have to do anything she doesn’t want to anymore.” But sometimes she wants a sip to drink, something soft or sweet, sometimes a piece of fruit. Her son asks her when she doesn’t want to eat anymore, “Are you on strike?” She replies, surprisingly clear, “Yes, I’m striking. I’m packing it in completely!” In her last days she doesn’t drink out of a cup anymore, she keeps her lips closed and doesn’t want a spoon in her mouth. If she’s thirsty she takes a small sip from a syringe.
Speaking and Breathing
In her last weeks she speaks less and less, sometimes she says a few words out of the depths. I play harmonica quietly, she looks at me astonished and joyfully, but this lasts only a few days. She likes it, though, when I sing for her. At night I sing her the songs she used to sing us, which she learned as a child. Then I tell her I’ll come early tomorrow. She sleeps peacefully and is happy that I live a few minutes away like a deputy in her house. In the morning I bring her flowers from her garden. She looks at them and me attentively and delighted. When she is awake I sit close to her. Sometimes I talk to her or stroke her when her breathing becomes uneven. The pauses between breaths are irregular and sometimes quite long. Often we don’t know if she will breath in again.
Eight days before her death we hold a small prayer with communion in her room with her young and friendly pastor. M is sleeping, then she opens her eyes and looks at us all one after the other very attentively. Then her gaze wanders back in the other direction, as if she would greet us individually, or wants to commit this view to memory, or bless us. She takes a teaspoon of grapejuice, she is aware and content and remains awake until the end of the ceremony. We both spend the afternoon calm and relaxed together.
The next morning her neurologist causes her pain while examining her. I see now for the last time – and I haven’t seen her like this for a long time – her fixing the doctor with a scornful glare with her otherwise calm and clear eyes, full of indignance about this unnecessary torture. It takes some time until she can calm down.
As I enter her room on this sunny summer morning, she is breathing very heavily. Her skin is red and hot, sweat beads. She is straining and restless, she looks to me for help. Her mouth is dry, she sips tea and water thirstily. She continues to breathe heavily. I wipe the sweat away with a moist cloth, wet her lips, stroke her back, sides and belly, so that her breathing can calm down. Both of us are clear that the end has come. I sit quietly with her, hold her hand and say that she is going where her little sister, her parents and her husband have gone before, where we will follow her one day. That it’s sad she has to leave now. That she shouldn’t worry about us, that we will be thinking of her. I sing her old songs very softly – a chant about the fleeting character of life and songs which she had chosen for her funeral, her death. Then she becomes calm and breathes easily. I am very still, sit very close to her, she lies facing me. Her eyes begin to move rapidly back and forth. I think that she sees her whole life flash before her eyes. Although I am open and very close to her and experience this moment as a common engrossment, we are separated at the same time. Then the rapid eye movement ceases. She looks attentively and calmly at me, which also lasts some time. Then she closes her eyes softly but emphatically and then breathes out for the last time.
My mental image in this situation is somewhat prosaic: a person is standing on a high springboard, the water below, the person decides and jumps. I remain seated by her for some time before I get the nurse. We light candles, the nurse places some flowers in M’s hands. Later we put a fresh nightdress on her; she has neither urinated nor emptied her bowl. Her eyes remain closed, her mouth is relaxed and closed. She is lying on her back now, with her hands on her chest. She looks peaceful and tender as if sleeping. At the same time I feel her presence in the room. We hold a wake until late in the evening.
In 1931 C.G. Jung writes in his paper entitled, “Stages of Life:” “The 180 degrees of the arc of life are divisible into four parts … Conscious problems fill out the second and third quarters … Childhood and extreme old age are, of course, utterly different, and yet they have one thing in common: submersion in unconscious psychic happenings. Since the mind of a child grows out of the unconscious its psychic processes … are not as difficult to discern as those of a very old person who is sinking again into the unconscious … Childhood and old age are the stages of life without any conscious problems …” (Jung 1931)
I believe we perceive our problems very clearly during the far reaching developmental steps in early childhood and old age near death, but are unable to solve them unassisted. While caring for my mother shortly before her death I noticed many parallels to caring for an infant. Winnicott tells of “a live adaption to the … needs” and of the necessary “holding.” “It includes the whole routine of care throughout the day and night, and it is not the same with any two … and no two … are alike. Also it follows the minute day to day changes … both physical and psychological.” (Winnicott, 1960, p. 54, p. 49) He refers to infants, but this also applies to those in need of care, who require physical and mental “holding” too. Up until the end mother expressed, like a newborn child already can, hunger and thirst, whether something tasted good or disgusting, whether she was satisfied or not, in gestures. When she only ate sparingly, she reminded me of a weakly-drinking baby whose lips can be brought to the nipple or teat so that it drinks and thrives. It helps when we make eye contact possible and open our eyes to the baby, but we should also allow it to turn away and not pursue it intrusively. In the same way it torments and hinders a dying person, if they are needed too much.
Deintegration and Reintegration
Michael Fordham, who was the first Jungian to explore early childhood, postulates a primal self, which exists from the very beginning. He says, “I conceived it to be a psychosomatic entity containing within it the inherited potential for forming the experience of a body and a psyche.” (Fordham, 1995, p. 70) The self opens itself from the start with archetypal, innate and unconscious expectations when it needs something. Put simply: The baby is very active and knows how to attract the attention and affection of the mother – perhaps it has hunger and cries. The attentive mother hears the child and gives it “good milk.” A child can, if the contact between the child’s self and the mother’s self is good, drink the milk, go to sleep full and satisfied, digest and grow. According to Fordham we call the process of opening up deintegration and the process of taking in and digesting reintegration.
Reintegration requires “repose,” which is, at life’s beginning and end, sleep or a half-conscious dreamlike state. I consider these processes concerning the self, body and ego as follows: “Taking in” predominates in the baby. Ego fragments grow together via de- and reintegrative processes to form a structured ego and the consciousness grows accordingly. Time and space become meaningful. The ego seizes the body, which is also growing, and helps it to acquire motor skills, but can retreat thereafter and focus on other interests. “Giving away” predominates in the dying. It seems that fragments of the ego are given away via deintegration. This applies to the ego function of the body and the consciousness, when the development runs as slowly and clearly as I have described. Time and space lose their meaning. The loss or relinquishing must be processed in the reintegration. Development at life’s beginning runs in the opposite direction to the development at life’s end, but de- and reintegration are always close to each other and can occur simultaneously. An old person has acquired through life-experience an incomparably large wealth of memories and archetypal images, in which they can live. The newborn opens its mouth and eyes, its first breath is breathing in and it wants to grasp the world, at first in the form of its mother. The dying person closes mouth and eyes and with the last breath, a breathing out, the body is given back to the world.
There are parallels between the intimacy of the shared but also different experiences of mother and myself and psychoanalytical work. This applies to anxieties in the beginning of treatment, but also deeply regressive phases, mostly in analytic segments with three or more sessions per week. Patients lie on the couch, which assumes a part of the holding function. I sit close to the patient as if we are at the beach and look out to sea together. Through the shared perspective or looking at each other simultaneously we can experience intimacy. Winnicott (1958, p. 36) says, “The basis of the capacity to be alone is the experience of being alone in the presence of someone. In this way an infant with weak ego organisation may be alone because of reliable ego support.” The baby can explore itself or fall asleep, if it knows that the caretaker is present. Mother also slept and was awake in her own rhythm in her last weeks. I have the impression she could do this so peacefully because she knew we were there. Patients learn by coming repeatedly, remaining in the session and having to leave at the end – coming, staying and taking leave. They come with a past, experience the present with de- and reintegration processes with us and we release them into the future; this is the cycle of every session. What we are waiting for in deintegration we can perceive as a good or bad object by taking in and reintegrating. An object which isn’t there is a special kind of bad object. If our ego and our frustration-tolerance are strong enough, an absent object can induce thinking.
Fordham says, “If (after deintegration) the integrative process does not follow, then the term splitting becomes appropriate … objects become not just good and bad but persistently persecuting.” He describes a baby observation: “When N. was about one year old, his mother started to subject him to a sequence of teasing about her going away; then quite suddenly she went out for some hours … N. was inconsolable … Eventually, in a persecution despair, he cried himself to sleep.” (Fordham 1985, p. 60)
This state of desperation is called disintegration, and leads to exhaustion that doesn’t serve the child’s growth. Babies can fall asleep and people can die in a state of disintegration, and patients can take leave from us in a state of incomplete reintegration or disintegration. If we allow ourselves to be disturbed regularly at the end of a session, or regularly leave the room before the patient, they don’t learn to close the door and leave us behind. We can only learn to take our leave when somebody is there to take leave from. If we are alone we can’t take leave and instead have to stray around.
It’s also important with a view to the termination of an analysis to devote enough time and significance to the individual separation in itself. When separation is not successful this can lead to destructive inner attachments to the person we have lost which are very difficult to resolve. I would like to examine closely this separation-paradox not by seeing a new beginning in the end, but by being able to experience something special by taking pause in this borderline situation. We must be present in order to take leave. All attempts to find “meaning” or to skip over the present in our desire for finality disrupt the necessary “being there” considerably. Maybe our goal should be to perceive and experience the present while also being open to the past and future. Bion calls this state “O”, “… that aspect of the human personality that is concerned with the unknown and the ultimately unknowable”, “… in brief, I use O to represent this central feature of every situation that the psycho-analyst has to meet.” I think that these are very seldom and unusual moments of fulfillment, in which we are removed from the outer world but not in a state of diffusion or unity and can experience this complete “not-knowing” calmly and in devotion. He also says, “It (psychoanalysis) must be a science of at-one-ment, … not identification.” (Bion, 1970, p. 88, 89) In my mother’s last hours, as described earlier, I had the impression that we both were very near to “at-one-ment” as well as to “O.”
Individuation in life begins with the conception/birth and ends with death. Although deintegrative and reintegrative processes take place throughout life, they are most striking in early childhood and, in my opinion, at life’s end and in separation, and often require support. Fordham also describes the relinquishing of acquired abilities as disintegration (cf. 1993). I have attempted to portray that we also can give away abilities de- and reintegratively and that not even death has to take place in disintegration.
Translation from German into English by Karl Meaney and Elisabeth Adametz