Self-Hatred in a Dying Patient
March 5th, 2011 adminHope you’ll check out the “Special Events” section at the top of this page (it’s not up on my website yet) and join Jon Frederickson, MSW, (amazing clinician and teacher!) and myself in Virginia at the Washington School of Psychiatry’s 6th Annual Summer Immersion Course in Intensive Short Term Dynamic Psychotherapy from June 5 -10, 2011. Last time I did this with Jon a couple years ago, it was a breathtaking experience. Also, there’s still room in my intimate supervision/training group, “Monthly Mondays,” from 12:30-2:30 p.m. in my Woodland Hills office.
I had a recent email exchange with a therapist that I repeat here with her permission. She has the most heart-wrenching task of trying to help a young woman in her 20’s to find some internal peace as she faces death from cancer. The patient asks, “How can I not feel that I did something to deserve this?” The therapist says that in probing a little further it almost seems that this self contemptuous stance is defensive albeit masochistic as she said to me, “I cannot love myself…it would be harder to feel weak and accept death.”
This young woman, who I understand has felt self-hatred for a long time, lets her therapist know that she has anger/rage inside of her (see below). However, her terrible suffering is increased not by her rage but by rejected rage that is forced to turn against the self rather than have it’s natural trajectory, directed outwards. She is in fact “attached to anger” (see Dr. Clayton’s comment below) because she will not permit herself to experience it towards anyone or anything but herself, and once she opens that door, she fears or feels guilt about the feelings that would follow. It would also seem that her perpetrator has defined self-hatred as a source of strength and perhaps necessary for survival.
Were she to unleash her feelings, we can only imagine the grief to follow the rage involved in facing her death as well as other feelings towards significant others. I’m imagining that like many people, she has come to associate painful feelings with weakness and is not recognizing the great courage and strength involved in facing them. But I would want to ask her how it is that she associates acceptance of death with weakness? I will admit that my own fears and grief over death have never been worked through enough to arrive at the state of acceptance that Kubler-Ross describes as the final stage of grief…a state that I would see as a triumph…but I do believe it’s possible.
My husband, Donn Warshow, Ph.D., said to me, “Her self-hatred is a form of cancer.” My comments in the email exchange with her therapist are italicized below:
2/16 Th: “So I just had a very sad session with ____ who has relapsed with four new tumors in her pelvis (this is her fourth relapse.) She says something to me repeatedly which leaves me speechless. What she says is that she feels angry, but can’t focus the anger outside of her because the cancer is inside, so how can she not be angry toward her body/herself? Any thoughts?”
Susan: I’d ask, “Might you turn your anger on the cancer and hate it rather than yourself, your essence, your core? Your self-hatred is tragic as it inflicts more suffering upon yourself than you’re already enduring. I feel deep pain as I witness this lifelong rejection of yourself. Do you not want to have the experience of compassion and love for yourself while you live and sit here with me? For once in your life??” Also: “How do you experience that I feel towards you?” “Are you aware how profoundly affected I am by your pain? How deeply I feel compassion for you? How much I despise the part that withholds love from you?” If she does: “How is it for you to see that compassion in my eyes? What do you feel as you see my caring for you?” If she does not: “So, you need to push my caring away from you and to also withhold it from yourself? If it were your sister (or someone she loves), what would you say to her if she spoke to you of her self-hatred, especially at such a time as this?”
2/28 Th: “Thanks for letting me vent about …my cancer patient. She starts big guns chemo tomorrow and is filled with dread. She still can’t give herself any slack. I asked her if she could feel and take in my compassion. She said she was terrified that if she did that, I would find out something bad about her and reject her. I asked her what that might be and she had no response. My heart is breaking for her as I dont think she is going to come out of this alive (not according to her doctor.) Interesting side note; I spoke to her psychiatrist who is prescribing her anti-depressants. Her response to this relapse was to up the dosage of her meds and her words to me were, ‘Don’t get too close to her.’ Too late for that…”
Susan: I would suggest telling her something like, “Of course there is a risk that if you begin to treat yourself more compassionately and become freer to share yourself with me, there would be a possibility of experiencing feelings that I could reject. On the other hand, it is far more likely that you would reject yourself than I would…could we look at the track record? At your own experience with me? Nevertheless, you may choose to keep yourself at a distance from me, which I have no choice but to accept, but at the same time, you will tragically be inflicting even more pain and isolation upon yourself as well as a life not fully lived. I empathize with the struggle this involves for you and with the fear you’d have to face. But it is also possible that you might let me stand alongside you in facing your fears, that I will not reject you and that you will feel more at peace with yourself than ever before in you life. But of course, only you can make the choice to take that risk.”
Re. the psychiatrist’s comment:
Susan to therapist: “So, we should try to be close in life but not in death? Or perhaps never be close?” It is indeed an overwhelming prospect to allow all the torrential feelings to which we are exposed on a daily basis to resonate through our bodies. I used to wonder myself if I’d “make it” with this degree of exposure to emotion. Is this psychiatrist right that we do need defenses against closeness as we are exposed to so much human pain? (Another question for another time: Should we limit our caring feelings towards someone who may never let them in?).
Scroll down to the reference to an article written by forensic psychologist F. Barton Evans III, Bethesda, Maryland and Department of XX George Washington University Medical School on 10/13/10 that eloquently addresses this issue. My answer is that we need boundaries but not defenses, self-care and self-compassion, intermittent breaks like walks around the block and lunch with a friend. Behaviorists would say this is an exposure (to feelings) therapy and desensitization is part of the cure…for patient and therapist alike. Seems to me that there’s something magical inborn within us that makes this closeness thing seemingly boundless and infinite.
I was just rereading a wonderful comment to my blog from Dr. Rob Clayton in which he says, “We can also see how attachment to anger is counterproductive from both a Buddhist and a psychological perspective. We have all encountered clients who seem to be a seething mass of anger, with almost no ability to experience the pain of the (psychological) attachment wound that underlies it. The (dharmic)attachment to anger here is a defensive use of affect.” Along this line, McCullough (1991) tells us that “borderline rage…hides enormous sorrow over unmet, and natural, longings for validation of experience.” So, do we say that rage is a defense against grief and the experience of loss or do we say that rage is potentially a pathway to grief and subsequent empowerment? It is my perspective that we cannot arrive at the underlying attachment wound except THROUGH THE TUNNEL of rage, but at that point, there is generally fear and guilt that prevent curative processing. In other words, it is resistance to rage that blocks underlying grief over the attachment wound.
I believe it is fear and guilt over rage that is defensive, not anger itself, and that fear and guilt can cause us to become stuck in anger (i.e. “attached to anger.”) There are those who hold the belief that anger is a destructive, negative force to be gotten rid of as soon as possible. Rather I find that the shared experience of anger/rage, with an awareness of its physiological (bodily) manifestations, and also releasing guilt and fear about the emotion of anger, almost invariably leads to calmness, inner peace and greater capacity for relationship. And very importantly, it can lead to insight into old wounds; empowerment/newfound strength to defeat that which abuses and neglects in order to protect self and others in healthy ways; and more clarity in the decision-making process.
It is certainly vital to pay attention to our anger in a timely way, which does involve not only registering the degree of its internal intensity, i.e. “How great is the force of this rage?” but also sitting with it in order to become additionally aware of the following: “To whom is it directed?” and “Are these feelings in any way familiar and who comes to mind?” and finally “What other feelings follow upon it?”
A woman says, “I ran into Carol and Tom today and they’re going to the Getty museum with friends. But I don’t care because I don’t enjoy their friends anyway.” She cannot permit herself to experience anger…therefore she is unconsciously attached to it because there is no path for release. As she self-reflects, she becomes aware of disappointment, feeling left out. “Why did they tell me without inviting me?” Eventually anger comes to awareness…disappointment almost always having components of anger…then memories of being excluded from other groups as a child come to mind. I ask, “Who is it that has been excluding you, really?” “Who is it that bypasses your angry feelings instantly and drives them out of awareness?” “If these friends do in fact exclude you regularly, shall we look at the self-hurting part within you that has ignored your anger and remained attached to them for years?” Or “You tell me they often spend time with you, which is clearly inclusive, so what is the cruel part that will not allow you to take in their caring and uses the Getty comment to clobber you (anger turned against self)?” “But now that you are thankfully aware, certainly an achievement, that the anger is present… shall we follow it’s true course and see what it feels like inside your body?” Etc. Bottom line, I believe in embracing all emotions, trusting we have access to them for a purpose.
