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On Death and Dying: What the Dying Have to Teach Doctors, Nursers, Clergy, and Their Own Familiesby Elisabeth Kubler-Ross
On the Fear of Death
Let me not pray to be sheltered from dangers but to be fearless in facing them.
Epidemics have taken a great toll of lives in past generations. Death in infancy and early childhood was frequent and there were few families who didn't lose a member of the family at an early age. Medicine has changed greatly in the last decades. Widespread vaccinations have practically eradicated many illnesses, at least in western Europe and the United States. The use of chemotherapy, especially the antibiotics, has contributed to an ever decreasing number of fatalities in infectious diseases. Better child care and education has effected a low morbidity and mortality among children. The many diseases that have taken an impressive toll among the young and middle-aged have been conquered. The number of old people is on the rise, and with this fact come the number of people with malignancies and chronic diseases associated more with old age.
Pediatricians have less work with acute and life-threatening situations as they have an ever increasing number of patients with psychosomatic disturbances and adjustment and behavior problems. Physicians have more people in their waiting rooms with emotional problems than they have ever had before, but they also have more elderly patients who not only try to live with their decreased physical abilities and limitations but who also face loneliness and isolation with all its pains and anguish. The majority of these people are not seen by a psychiatrist. Their needs have to be elicited and gratified by other professional people, for instance, chaplains and social workers. It is for them that I am trying to outline the changes that have taken place in the last few decades, changes that are ultimately responsible for the increased fear of death, the rising number of emotional problems, and the greater need for understanding of and coping with the problems of death and dying.
When we look back in time and study old cultures and people, we are impressed that death has always been distasteful to man and will probably always be. From a psychiatrist's point of view this is very understandable and can perhaps best be explained by our basic knowledge that, in our unconscious, death is never possible in regard to ourselves. It is inconceivable for our unconscious to imagine an actual ending of our own life here on earth, and if this life of ours has to end, the ending is always attributed to a malicious intervention from the outside by someone else. In simple terms, in our unconscious mind we can only be killed; it is inconceivable to die of a natural cause or of old age. Therefore death in itself is associated with a bad act, a frightening happening, something that in itself calls for retribution and punishment.
One is wise to remember these fundamental facts as they are essential in understanding some of the most important, otherwise unintelligible communications of our patients.
The second fact that we have to comprehend is that in our unconscious mind we cannot distinguish between a wish and a deed. We are all aware of some of our illogical dreams in which two completely opposite statements can exist side by side — very acceptable in our dreams but unthinkable and illogical in our wakening state. Just as our unconscious mind cannot differentiate between the wish to kill somebody in anger and the act of having done so, the young child is unable to make this distinction. The child who angrily wishes his mother to drop dead for not having gratified his needs will be traumatized greatly by the actual death of his mother — even if this event is not linked closely in time with his destructive wishes. He will always take part or the whole blame for the loss of his mother. He will always say to himself — rarely to others — "I did it, I am responsible, I was bad, therefore Mommy left me." It is well to remember that the child will react in the same manner if he loses a parent by divorce, separation, or desertion. Death is often seen by a child as an impermanent thing and has therefore little distinction from a divorce in which he may have an opportunity to see a parent again.
Many a parent will remember remarks of their children such as, "I will bury my doggy now and next spring when the flowers come up again, he will get up." Maybe it was the same wish that motivated the ancient Egyptians to supply their dead with food and goods to keep them happy and the old American Indians to bury their relatives with their belongings.
When we grow older and begin to realize that our omnipotence is really not so omnipotent, that our strongest wishes are not powerful enough to make the impossible possible, the fear that we have contributed to the death of a loved one diminishes — and with it the guilt. The fear remains diminished, however, only so long as it is not challenged too strongly. Its vestiges can be seen daily in hospital corridors and in people associated with the bereaved.
A husband and wife may have been fighting for years, but when the partner dies, the survivor will pull his hair, whine and cry louder and beat his chest in regret, fear and anguish, and will hence fear his own death more than before, still believing in the law of talion — an eye for an eye, a tooth for a tooth — "I am responsible for her death, I will have to die a pitiful death in retribution."
Maybe this knowledge will help us understand many of the old customs and rituals which have lasted over the centuries and whose purpose is to diminish the anger of the gods or the people as the case may be, thus decreasing the anticipated punishment. I am thinking of the ashes, the torn clothes, the veil, the Klage Weiber of the old days — they are all means to ask you to take pity on them, the mourners, and are expressions of sorrow, grief, and shame. If someone grieves, beats his chest, tears his hair, or refuses to eat, it is an attempt at self-punishment to avoid or reduce the anticipated punishment for the blame that he takes on the death of a loved one.
This grief, shame, and guilt are not very far removed from feelings of anger and rage. The process of grief always includes some qualities of anger. Since none of us likes to admit anger at a deceased person, these emotions are often disguised or repressed and prolong the period of grief or show up in other ways. It is well to remember that it is not up to us to judge such feelings as bad or shameful but to understand their true meaning and origin as something very human. In order to illustrate this I will again use the example of the child — and the child in us. The five-year-old who loses his mother is both blaming himself for her disappearance and being angry at her for having deserted him and for no longer gratifying his needs. The dead person then turns into something the child loves and wants very much but also hates with equal intensity for this severe deprivation.
The ancient Hebrews regarded the body of a dead person as something unclean and not to be touched. The early American Indians talked about the evil spirits and shot arrows in the air to drive the spirits away. Many other cultures have rituals to take care of the "bad" dead person, and they all originate in this feeling of anger which still exists in all of us, though we dislike admitting it. The tradition of the tombstone may originate in this wish to keep the bad spirit
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