VI - Fourth Stage - Depression

The world rushes on over the strings of the lingering heart making the music of sadness.

Tagore, from Stray Birds, XLIV

When the terminally ill patient can no longer deny his illness, when he is forced to undergo more surgery or hospitalization, when he begins to have more symptoms or becomes weaker and thinner, he cannot smile it off anymore. His numbness or stoicism, his anger and rage will soon be replaced with a sense of great loss. This loss may have many facets: a woman with a breast cancer may react to the loss of her figure; a woman with a cancer of the uterus may feel that she is no longer a woman. Our opera singer responded to the required surgery of her face and the removal of her teeth with shock, dismay, and the deepest depression. But this is only one of the many losses that such a patient has to endure.

With the extensive treatment and hospitalization, financial burdens are added; little luxuries at first and necessities later on nay not be afforded anymore. The immense sums that such treatments and hospitalizations cost in recent years have forced

any patients to sell the only possessions they had; they were unable to keep a house which they built for their old age, unable to send a child through college, and unable perhaps to make many dreams come true.

There may be We added loss of a job due to many absences or the inability to function, and mothers and wives may have to become the breadwinners, thus depriving the children of the attention they previously had. When mothers are sick, the little ones may have to be boarded out, adding to the sadness and guilt of the patient.

All these reasons for depressions are well known to everybody who deals with patients. What we often tend to forget, however, is the preparatory grief that the terminally ill patient has to undergo in order to prepare himself for his final separation from this world. If I were to attempt to differentiate these two kinds of depressions, I would regard the first one a reactive depression, the second one a preparatory depression. The first one is different in nature and should be dealt with quite differently from the latter.

An understanding person will have no difficulty in eliciting the cause of the depression and in alleviating some of the unrealistic guilt or shame which often accompanies the depression. A woman who is worried about no longer being a woman can be complimented for some especially feminine feature; she can be reassured that she is still as much a woman as she was before surgery. Breast prothesis has added much to the breast cancer patient's self-esteem. 

Social worker, physician, or chaplain may discuss the patient's concerns with the husband in order to obtain his help in supporting the patient's self-esteem. Social workers and chaplains can be of great help during this time in assisting in the reorganization of a household, especially when children or lonely old people are involved for whom eventual placement has to be considered. We are always impressed by how quickly a patient's depression is lifted when these vital issues are taken care of. The interview of Mrs. C. in Chapter X is a good example of a woman who was deeply depressed and felt unable to deal with her own illness and impending death because so many people had to be attended to and there seemed to be no help forthcoming. She lost her ability to function in her old role but there was no one to replace her.

The second type of depression is one which does not occur as a result of a past loss but is taking into account impending losses. Our initial reaction to sad people is usually to try to cheer them up, to tell them not to look at things so grimly or so hopelessly. We encourage them to look at the bright side of life, at all the colorful, positive things around them. This is often an expression of our own needs, our own inability to tolerate a long face over

any extended period of time. This can be a useful approach when dealing with the first type of depression in terminally ill patients. It will help such a mother to know that the children play quite happily in the neighbor's garden since they stay there while their father is at work. It may help a mother to know that they continue to laugh and joke, go to parties, and bring good report cards home from school-all expressions that they function in spite of mother's absence.

When the depression is a tool to prepare for the impending loss of all the love objects, in order to facilitate the state of acceptance, then encouragements and reassurances are not as meaningful. The patient should not be encouraged to look at the sunny side of things, as this would mean he should not contemplate his impending death. It would be contraindicated to tell him not to he sad, since all of us are tremendously sad when we lose one beloved person. The patient is in the process of losing everything and everybody he loves. If he is allowed to express his sorrow he will find a final acceptance much easier, and he will be grateful to those who can sit with him during this stage of depression; without constantly telling him not to be sad. 

This second type of depression is usually a silent one in contrast to the first type, during which the patient has much to share and requires many verbal interactions and often active interventions on the part of people in many disciplines. In the preparatory grief there is no or little need for words. It is much more a feeling that can be mutually expressed and is often done better with a touch of a hand, a stroking of the hair, or just a silent sitting together. This is the time when the patient may just ask for a prayer, when he begins to occupy himself with things ahead rather than behind. It is a time when too much interference from visitors who try to cheer him up hinders his emotional preparation rather than enhances it.

The example of Mr. H. will illustrate the stage of depression which worsened because of the lack of awareness and understanding of this patient's needs on part of those in his environment, especially his immediate family. He illustrates both types of depression as he expressed many regrets for his "failures" when he was well, for lost opportunities while there was still time to be with his family, and sorrow at being unable to provide more for them. His depression paralleled his increasing weakness and inability to function as a man and provider. A chance for additional promising treatment did not cheer him up. 

Our interviews revealed his readiness to separate himself from this life. He was sad that he was forced to struggle for life when he was ready to prepare himself to die. It is this discrepancy between the patient's wish and readiness and the expectation of those in his environment which causes the greatest grief and turmoil in our patients. If the members of the helping professions could be made more

aware of the discrepancy or conflict between the patient and his environment, they could share their awareness with their patients' families and be of great assistance to them and to the patients. They should know that this type of depression is necessary and beneficial if the patient is to die in a stage of acceptance and peace. Only patients who have been able to work through their anguish and anxieties are able to achieve this stage. If this reassurance could be shared with their families, they too could be spared much unnecessary anguish.

Our first interview with Mr. H. follows:

PATIENT: Do I have to talk very loudly?

DOCTOR: No, that's all right. If we can't hear you then we'll say so. You speak as loud as you can as long as you are comfortable. Mr. H. said if I keep him up psychologically he will be having a good conversation because he has been studying communication.

PATIENT: The reason for that being that I am physically very dizzy and tired.

DOCTOR: What did you mean by "psychologically keeping you up"?

PATIENT: Well, it's possible to feel physically up to par even though you don't. Providing you have a kind of psychological lift. In a way you feel extra good, you know, like if you have good news or something like that, that's all I meant.

DOCTOR: What you are really saying is to talk about good things and not about bad things.

PATIENT: You say we are?

DOCTOR: Is that what you are saying?

PATIENT: Oh, no, not at all . . .

CHAPLAIN: I think he was just saying he wants a little moral support.

DOCTOR: Yes. Well, naturally.

PATIENT: What I mean is that if I sit here more than about five minutes I'm likely to collapse from sitting here because I'm so tired and I've been up so little.

DOCTOR: Okay, so why don't we get right into the matter that we want to talk about.

PATIENT: Fine.

DOCTOR: We know practically nothing about you. What we are trying to learn from the patients is how can we talk to them as human beings without going through the whole chart and all that first. So maybe, just to start, could you give us a very brief summary of how old you are, what your profession is, and how long you have been in the hospital.

PATIENT: Been here about two weeks and, roughly, and I'm a chemical engineer, by trade. And I have a graduate degree in chemical engineering and in addition to that I took courses at the University in communications.

DOCTOR: (Not clear)

PATIENT: Well, not really, because at the time that I was doing this they had a communications course and by the time I finished with it they dropped it.

DOCTOR: I see.

CHAPLAIN: What prompted you to get interested in communications? As a chemical engineer, was this part of your job or your own interest?

PATIENT: My own interest.

DOCTOR: What brought you to the hospital this time? Is this the first time you have been in a hospital?

PATIENT: First time I've been in this hospital.

DOCTOR: What brought you here?

PATIENT: Well, the fact that I needed more work on my cancer. I had had an operation in April

DOCTOR: April of this year?

PATIENT: -in a different hospital.

DOCTOR: Of this year? And then you were diagnosed as having cancer?

PATIENT: And then without any further diagnosis I requested admission to this hospital, and I got it.

DOCTOR: I see. How did you take it, this news? Were you told in April that you had cancer?

PATIENT: Yes.

DOCTOR: How did you take that, how was it told to you?

PATIENT: Well, naturally it was a blow.

DOCTOR: Um hm. But different people react very differently to blows.

PATIENT: Yes, well, it was more of a blow than it might be because they gave me no hope.

DOCTOR: Not a bit?

PATIENT: Not a bit. The doctor himself said that his father had had a similar operation, in the same hospital, with the same surgeon, and that he failed to recover and died within about a year and a half at the same age. And that all I could do was just to wait for the bitter end.

DOCTOR: That's pretty cruel. You know, one wonders if this doctor did that because it happened in his own family.

PATIENT: Yes, the end result was cruel but the cause was the fact that he had actually had this experience.

DOCTOR: Makes it excusable, you think. It makes it understandable.

PATIENT: Yes.

CHAPLAIN: How did you react when he did this, when he told you?

PATIENT: Well naturally I felt quite low and stayed at home as he requested and rested up rather than doing too much. But I did do too much, I did also get around quite a bit, you know, visiting, this and that and the other thing. But after I got here and found out that there was some hope for my condition and that my condition wasn't hopeless, then I found out that I had done the wrong thing, that I had exercised too much, and that if I had only known it at that time I would be in top-notch shape right now.

DOCTOR: It means you are blaming yourself now for doing almost too much.

PATIENT: No, I'm not saying this, I didn't know. There's no blame one way or the other. I don't blame the doctor because of his own experience, and I don't blame myself because of the fact that I had no knowledge.

DOCTOR: Yes. Before you went to that hospital, did you have any hunch? What kind of symptoms did you have? Did you have pain or did you have the feeling that there was something seriously wrong?

PATIENT: Well, I had been getting lower and lower, but one day I had this very bad condition of my bowels and I had a colostomy. That was the one operation I had.

DOCTOR: Yes. What I'm really asking is how much preparation did you have for this blow. Did you somehow have a hunch?

PATIENT: None at all.

DOCTOR: Not at all. You were well, you were a healthy man until when?

PATIENT: Until I went into the hospital.

DOCTOR: And why did you go into the hospital?

PATIENT: Well, merely to have him look at it because I was having such constipation and diarrhea alternating.

DOCTOR: Um hm. What you are really saying is that you were unprepared.

PATIENT: Entirely. Not only that but they sent me over to the hospital within a couple of hours of the time I arrived in his office and within a week or so he operated.

DOCTOR: So there was a sense of urgency. And then they did the colostomy or what?

PATIENT: Yes.

DOCTOR: Yes, and that's difficult to take too, isn't it?

PATIENT: Hm?

DOCTOR: That is difficult to take.

PATIENT: Oh, no, the colostomy is easy.

DOCTOR: Is easy to take?

PATIENT: It was the idea that was only part of it; in other words the colostomy supposedly reveals all sorts of other things, but the things they revealed apparently weren't right.

DOCTOR: How everything becomes relative. Hm, I thought the colostomy caused pain to endure but when it is a question of life and death then the colostomy is the smallest of the bad things.

PATIENT: Sure, that would be nothing if the person is going to live.

DOCTOR: Yes. After you had this news you must have been thinking about how Is going to be when you die. How long are you going to live. How does a man like you deal with those questions?

PATIENT: Ah-actually I had had so many personal griefs in the meantime in my own life that it didn't seem like much. That's about it.

DOCTOR: Really?

CHAPLAIN: Personal griefs?

PATIENT: A series of them over a period of time.

CHAPLAIN: Do you feel like talking about it?

PATIENT: Oh yes, that's all right.

DOCTOR: Does that mean that you had a lot of personal losses?

PATIENT: Yes, my father and my mother died, brother died, a twenty-eight-year-old daughter died, leaving two small children which we cook care of for three years, up until last December. And that was the worst blow of all because it was a constant reminder of her death.

CHAPLAIN: The children in the house. What did she die of?

PATIENT: She died of rigorous climate in Persia.

CHAPLAIN: While she was overseas?

PATIENT: A hundred and twenty degrees in the shade most of the year.

CHAPLAIN: She was away from home then.

PATIENT: She wasn't the kind that could take rigorous life.

DOCTOR: Do you have other children? Was this your only child? 

PATIENT: Oh, no, we have three others.

DOCTOR: You have three others. How are they doing?

PATIENT: Fine.

DOCTOR: They are all right? You know what I don't understand? You are a man of middle-age-I don't know how old you are yet-but a middle-aged man often has lost a father and a mother. The daughter naturally is the most painful, a child is always more painful. Why do you say that because you had so many losses your own life seemed kind of insignificant?

PATIENT: I can't answer that question.

DOCTOR: It's paradoxical, isn't it? Because if your life would be insignificant it would be very easy to lose it wouldn't it? Do you see what I don't understand?

CHAPLAIN: I just was wondering if this was what he was trying to say. Is this what you were trying to communicate? I wasn't sure, what I heard you saying was that the news that you had cancer came as a different blow because of the losses you had.

PATIENT: No, oh no, I didn't mean that. I mean that in addition to the cancer I had these other blows. However, I will say, ah, I was just trying to think of a little idea I had there, that was important. You brought up the question of why I would be interested more in death than in life since I had three other children.

DOCTOR: I brought this more up to look at the sunny side too.

PATIENT: Yes, well, ah, I don't know whether you realize it but, ah, when these blows come they not only have an impact on the father but the entire family. See?

DOCTOR: Yes, that's true.

CHAPLAIN: So your wife has had a pretty hard time too?

PATIENT: My wife and all the children, all the children. And so here I was, living in a morgue you might say.

DOCTOR: For a while. Yes. (Mixed conversation)

PATIENT: It kept on going and I look upon it as a matter of unresolved grief.

DOCTOR: Yes. What Mr. H. is really saying is there was so much grief that it is very hard to take more grief now.

PATIENT: That's right.

DOCTOR: How can we help you? Who can help you? Is there anybody that can help with this?

PATIENT: I think so.

DOCTOR: (Not clear) Has anybody helped you?

PATIENT: I've never asked anybody except you.

DOCTOR: Has anybody talked with you like we are talking now?

PATIENT: No.

CHAPLAIN: Well, how about these other losses. When your daughter died, was there anyone then that you talked with? Or that your wife talked with? Was this something that was left for the two of you to hold inside? Would you ever talk to each other?

PATIENT: Not very much.

CHAPLAIN: You had to hold it inside?

DOCTOR: Is your wife as grief-stricken now as she was then? Or has she kind of recuperated from this?

PATIENT: You can never tell.

DOCTOR: Is she a person who doesn't communicate?

PATIENT: She doesn't communicate about that. She, she's a good communicator, she's a teacher.

DOCTOR: What kind of a woman is she?

PATIENT: Well, she's a heavy-set woman, full of good spirits, the kind of person that gets a standing ovation at the beginning of every class period and gets a very valuable gift at the end.

DOCTOR: That means something, you know.

CHAPLAIN: Those are hard to come by.

PATIENT: That's right.

DOCTOR: Yes.

PATIENT: She's also a person that goes all out for me and the family.

DOCTOR: She sounds to me like a person who could talk about those things with a little additional help.

PATIENT: Yes, you would think so, wouldn't you.

DOCTOR: Are you afraid to talk about it or is she inhibited to do it?

PATIENT: Say that again.

DOCTOR: Which one of the two of you prevents such a conversation?

PATIENT: Well, we actually did have conversations. And her answer was to go overseas and raise the children. So she went over two years in a row in the summer, including this past summer. And, of course, naturally our son-in-law paid the way.

The grandchildren were with us until December and then they went back. And then Mrs. H. went over there in December for the holidays, then she went back this summer for a month. She was going to stay two months but on account of me she stayed only one month, because it was during the period of my convalescence.

CHAPLAIN: I was wondering how much conversation that you want to have about your condition with this other on your wife's mind and her concern about her responsibility for the grandchildren. Whether this had had an effect then on your ability to share or maybe your feeling that you shouldn't share and burden her with anything else. Has there been any of that feeling?

PATIENT: Well, there are other problems between her and me. Although, as I say, she is one of these very outgoing people, well, still I'm concerned, she feels that I have not done a good enough job myself.

DOCTOR: In terms of what?

PATIENT: Well, I had not earned enough money. And naturally with four children, why, she would feel that way. She feels that I ought to be like the son-in-law, you know. She also feels that I was responsible for not bringing up my youngest son well enough. Because of the fact that he has a known hereditary trait. And yet even till now she blames me.

DOCTOR: She blames you for that?

PATIENT: Blames me for that.

DOCTOR: What is he doing?

PATIENT: He was in the Marines but they discharged him.

DOCTOR: What is he doing now?

PATIENT: Well, he was supposed to be applying for a job, his old job as a stockboy.

CHAPLAIN: And your other two children?

PATIENT: Well, my second son, she blames me for him too. Because he's a little slow in school. She felt that if somebody would get in there and pitch, you know, she's just a dynamo of energy, that he would have been right on top of the heap. Of course I think that sooner or later she will realize that he wouldn't be. It's just a matter of heredity. The first son is doing fairly well because she's pushing him and he's just finishing his degree in electronics.

CHAPLAIN: Because she's pushing him?

PATIENT: Well, no, he's very brilliant, he's the only bright one, you might say, outside of the daughter.

CHAPLAIN: Well, you mentioned too the heredity. Which side do you think the weakness comes from? You gave me the impression you think it comes from your side. Or your wife suggests it's from your side.

PATIENT: Well, I don't know what she suggests on that score. I don't think she feels it's heredity. I think she feels it's just not a matter of me getting in there and doing enough work. In my spare time I should do that. I should not only be earning more money, which has been the theme of our lives. She will help me to any extent, but she will always blame me for not producing my part. I should be earning fifteen thousand a year minimum.

DOCTOR: I have a feeling what Mr. H. is really saying is that his wife is such a peppy and energetic woman she kind of wants you and her children to be the same way.

PATIENT: Exactly.

DOCTOR: And that she can't really take it well when you are not like she is

PATIENT: Right.

DOCTOR: And that means peppy and energetic. And then she says look at my son-in-law, he makes a lot of money and he's probably very peppy and energetic.

PATIENT: Not only the son-in-law but everybody else she knows.

DOCTOR: Which would, I think, be relevant for Mr. H., the patient, because when he's sick and when he gets more weak

PATIENT: Beg your pardon?

DOCTOR: When you are sick and you are getting weaker you will be less peppy and less energetic and make less money.

PATIENT: In fact, that's what I told her at one point. When I, when I got about forty, you know, I was slowing down a little bit and I said to myself, boy, if things are this way now imagine what it will be then because she gets peppier.

DOCTOR: It will be terrible, huh?

PATIENT: Because she gets peppier and peppier.

DOCTOR: What this means, though, for you is that this is going to be harder. Is she kind of intolerant of people who would have to sit in a wheelchair?

PATIENT: She's extremely intolerant of people who aren't brilliant enough.

DOCTOR: Well-when you are physically weak you can still be brilliant, you know

PATIENT: Yes.

DOCTOR: But is she intolerant of people who are physically unable to do things

PATIENT: Yes.

DOCTOR: Because you can always be brilliant.

PATIENT: Well, when we say brilliant, we mean, ah, applying brilliance in action. That's what she wants.

CHAPLAIN: I hear you saying successful.

PATIENT: Successful, that's it.

DOCTOR: Um hm.

CHAPLAIN: That they not only have the capacity but that they have done something with it. But what comes through to me here is how with this kind of thing going on it kind of pushes aside any right or opportunity you might have to actually talk about yourself and your ills.

PATIENT: That's right, and the children too.

CHAPLAIN: This is a concern that I have.

PATIENT: The children are definitely held down, I feel, by the overriding demands of their mother. She's a brilliant seamstress, for instance, in addition to being a teacher. She can tailor-make a man's suit over the weekend from the cloth. And it will be better looking than any suit you'll see, it will be like a two-hundred-and-fifty-dollar suit.

DOCTOR: But how does all that make you feel?

PATIENT: Well, it makes me feel this way, that it wouldn't make any difference to me how great she is because I admire her like-I don't know how you would say it-but like an idol, you know. It wouldn't make any difference if she didn't insist upon me being the same.

DOCTOR: Yes. How can you take your illness then?

PATIENT: This is the main thing really.

DOCTOR: That's what we are really trying to find out, how to help you

PATIENT: This is really the main thing-Because you see if you have an illness, and you have the pain, and you have the grief that's unresolved, and you have a person that you are living with who meets every aspect on the grief business, you know, you say, well, I don't know how I'm going to live through this business of our daughter dying and that sort of thing, the answer comes right back, "Keep your chin up, positive thinking," in fact she's a fan of positive thinking.

CHAPLAIN: You keep going fast enough and you won't have to stop and think about it.

PATIENT: That's right.

DOCTOR: But he is ready to think and talk about it. You should talk about it; you have to have somebody to talk about it.

PATIENT: Your wife stops you right in the middle of a sentence. No possibility to talk to her about any of these things.

CHAPLAIN: I gather you've got a lot of faith within yourself.

PATIENT: I've done a lot of thinking within myself on how to resolve these problems. Because I'm really a very hard worker just like she would like me to be. I've always been, I've always been a very brilliant student. In the course I took at the University I got A's and B's in all the courses.

CHAPLAIN: But I hear you saying you have the capacity for it but you are aware that hard work isn't going to resolve the kind of conflicts that life has created at this point. You made a distinction between thinking of life and thinking of death, remember?

DOCTOR: Do you ever think about dying?

PATIENT: Yes. What were you going to say about it?

CHAPLAIN: I just wondered what thoughts you had about life in relationship to death and vice versa.

PATIENT: Well, ah, we'll have to admit it, I've never thought of death so much as a thing, per se, but I have thought of the worthlessness of life under such situations. "

CHAPLAIN: The worthlessness?

PATIENT: That if I were to die tomorrow, my wife would go on perfectly normal.

DOCTOR: just like nothing happened?

PATIENT: That's the way I feeL She wouldn't miss a beat.

CHAPLAIN: just as she did with the other deaths? Or a little differently?

PATIENT: After the death of my daughter, why, she worked on her children. But if I didn't leave any children her life wouldn't change at all.

CHAPLAIN: What gives you the strength to make a comment that one of the exciting things about coming here was that they gave you a sense of hope. They said there are some things they can do for you and they are doing them. What hit you inside in your own desire to live? In spite of the worthlessness of your feelings, there is something inside you that has found satisfaction and desire to go on. Is this faith?

PATIENT: Well, it's a kind of a blind hope more than anything else, I would say, and also my church group has sustained me a great deal. I've been active in Presbyterian church work for years and years and years. The fact that I could do a little bit which my wife didn't like, of course, like sing in the choir and teaching Sunday school and things like that. Well, the fact that I was able to do a few-things like that which I felt were worthwhile in the community and the work like that helped me. But every ounce of work I did along that line was considered to be worthless because of the fact that it didn't contribute to making a lot of money.

DOCTOR: But that's her concept. Your concept is still that it was worthwhile?

PATIENT: I think it's worthwhile, very worthwhile.

DOCTOR: You see, I think this is the important thing. That you still have a sense of worth. This is why I think hope is meaningful to you. You still want to live. You don't really want to die, do you? That's why you came to this hospital.

PATIENT: Right.

DOCTOR: What does death mean to you? It's a difficult question but maybe you can answer it.

PATIENT: What does death mean to me?

DOCTOR: What does death mean to you?

PATIENT: Death. It means a cessation of valuable activity. By valuable in my case I don't feel the same way as my wife. I don't mean money-making activities.

CHAPLAIN: You're talking about singing in the choir and teaching Sunday school. Being with people, this kind of thing.

DOCTOR: Yes.

PATIENT: I've always been active in community work, all sorts of different activities. That one thing that makes life worthless right now is the fact that I looked upon myself from the other doctor's point of view as not ever being able to go back to these things.

DOCTOR: And what are you doing right now in here?

PATIENT: Hm?

DOCTOR: What are you doing right now, here?

PATIENT: What I'm doing right now is exchanging views which might help.

DOCTOR: Which is a valuable activity. It may be helpful to you but it's certainly helpful to us.

CHAPLAIN: A valuable activity in his sense, not his wife's.

DOCTOR: Yes, (laughter) that's why I wanted to clarify it. What you are really saying is that life is worthwhile living as long as you can be of some value and do something worthwhile.

PATIENT: But you know, it is also a nice thing to have somebody else appreciate it. If you love them.

DOCTOR: Do you really believe that nobody else appreciates you?

PATIENT: I don't believe my wife does.

CHAPLAIN: That's what I thought he was referring to,

DOCTOR: Yes, what about your children?

PATIENT: I think they do. But the wife is the big thing you know, a man's wife. Especially if he admires her quite a bit, you know. And she's so, you might say, lovable. Because she's so full of sparkling energy and all that sort of thing. 

CHAPLAIN: Has this been consistent with your marriage? Or has this been more noticeable after your periods of grief? And loss?

PATIENT: No different. Actually it's been better after the griefs and loss. Well, right now, for instance, she has been very nice to me for a while. Since I've been in the hospital, but ah, it's always been that way. When I was sick or something like that, why, she would act real nice to me for a while. But then she couldn't get rid of this fact that here was a loafer who didn't make any money.

CHAPLAIN: Well, how do you account for the things that have happened in your life? You mentioned going to church. How do you account for the things that happened to you? In terms of your attitude toward life, what some people would call your faith in life. Does God play a part of this?

PATIENT: Oh yes. Well, in the first place, as a Christian, Christ acts as an intermediator. It's very simple. When I keep the vision in view things work out pretty well. And I get relief from my- I get solutions to problems which concern people.

CHAPLAIN: The very thing he's been talking about between his wife and himself is a need for a mediator, and you mentioned Christ as a mediator in your other problems. Have you thought of this in terms of your wife and your relationship?

PATIENT: I have, but unfortunately or not, my wife is such a dynamic person.

CHAPLAIN: What I hear you saying is your wife is so dynamic and active that there is no room for an active God in her life. There would be no room for a mediator.

PATIENT: Well, that's what it amounts to in her case.

DOCTOR: Do you think she would be willing to talk to one of us?

PATIENT: I certainly would, yes.

DOCTOR: If you would ask her? Would that be okay with you?

PATIENT: My wife would never think of going to a psychiatrist, especially with me.

DOCTOR: Um hm. What's so scary about a psychiatrist?

PATIENT: The very things we have been talking about. I think she sort of covers them up.

DOCTOR: Well, let's see how that interview goes. It might be helpful. And if it's okay with you we will drop in once in a while. Okay?

PATIENT: You are going to drop in, you say?

DOCTOR: And visit you.

PATIENT: At my bed?

DOCTOR AND CHAPLAIN: Yes.

PATIENT: I'll be leaving Saturday.

DOCTOR: I see. So we don't have much time.

CHAPLAIN: Well, if you are coming back to the clinics anytime, you might be coming back to see the doctor?

PATIENT: I doubt it but might be. It's a long, long trip.

CHAPLAIN: Oh, I see.

DOCTOR: Well, if this is our last meeting, maybe you have some questions that you would like to ask.

PATIENT: Well, I think that one of the biggest advantages of what this interview is that lots of questions have been brought out that I wouldn't have thought of.

DOCTOR: It has helped us too.

PATIENT: I think that Dr. R. has made some very good suggestions and you have made good ones too. But I do know one thing, unless I make radical improvement, why, I will not be cured physically.

DOCTOR: Is this scary?

PATIENT: Scary?

DOCTOR: I don't sense any fear in you.

PATIENT: No, it wouldn't scare me, for two reasons. One, I have fairly well grounded religion which has been grounded in the fact that I have passed it on to other people.

DOCTOR: So you can say of yourself that you are a man who does not fear death and who accepts it when it comes, just like that.

PATIENT: Yes, I don't fear death but I do more or less fear the opportunity to continue my former activities. Because, you see, I didn't really like engineering as well as working with people.

CHAPLAIN: This is where your interest in communications came in.

PATIENT: Part of it, yes.

CHAPLAIN: What strikes me is not the absence of fear but also the concern, sense of regret in terms of your relationship with your wife.

PATIENT: I have regretted that all my life, that I couldn't communicate with her. You might say really, if you wanted to go down under the mat, in my study of communication was, I don't really know, but it probably might have been ninety percent trying to get together with my wife.

DOCTOR: Trying to communicate with her, no? You never got any professional help for that? You know, I have a feeling that this could be helped, it still can be helped.

CHAPLAIN: That's why tomorrow's meeting is so important.

DOCTOR: Yes, yes . . . So I don't feel really helpless, this is not irrepairable, you know. You still have the time to do that.

PATIENT: Well, I would say that as long as I am actually alive there is hope for life.

DOCTOR: That's right.

PATIENT: But life isn't the whole thing in the world. The quality of life, why you live it.

CHAPLAIN: Well, I appreciate having had the chance to visit with you. I'd like to drop in on you this evening before I go home tonight.

PATIENT: Well, I would like to do that ... Oh ... (patient does not want to leave) ... You were going to ask me some questions you didn't ask.

DOCTOR: I did?

PATIENT: Um hm.

DOCTOR: What did I forget?

PATIENT: I understood from what you said that she was in charge not only of this seminar but- Well, what are you in charge of, let's put it that way. Somebody was interested in the relationship between religion and psychiatry.

DOCTOR: Yes, I'm beginning to understand. You see, a lot of people have different concepts of what we are doing here. What I am most interested in is to talk with sick people or dying patients. To get to understand them a little bit more. To teach the hospital personnel how we can help them better, and the only way we can teach it is to have the patient be our teacher, you know.

CHAPLAIN: Were there questions you had about relationships of religion

PATIENT: Yes, I had some. For instance, one of the things was that the average patient is only going to call a chaplain, he's not going to call the psychiatrist if he happens to feel bad.

DOCTOR: That's right.

PATIENT: All right. Then the question was asked me before by you or someone, ah, how do I feel about the service of the chaplains. And I would say that I was dumbfounded to find that I requested a chaplain in the middle of the night and there was no night chaplain. I mean this is just unbelievable to me, unbelievable. Because when does a man need a chaplain? Only at night, believe me. That's the time when you get down with those boxing gloves and have it out with yourself. That's the time when you need a chaplain. I would say mostly between twelve and so on

DOCTOR: The early morning hours.

PATIENT: And if you were to show a chart it would probably have a peak at about three o'clock. And it should be just like that. You call the buzzer, the nurse comes, "I'd like to have a chaplain," within five minutes the chaplain shows up and you are on the road to, ah

DOCTOR: To really communicate.

PATIENT: Yes.

DOCTOR: This is the question you wanted me to ask, how you are satisfied with the services of the chaplain. I see, I asked this question perhaps indirectly when I asked you who helped you, was there anybody who was helpful to you. You didn't mention the chaplain at that time

PATIENT: That's the trouble with the church itself. When does a man need a minister.

DOCTOR: Yes.

PATIENT: He needs him about three o'clock ordinarily.

DOCTOR: Well, Chaplain N. can answer this because he was up all night last night seeing patients.

CHAPLAIN: I don't feel as guilty as I would have, I only had two hours sleep last night. I can appreciate this though, I think there is a lot more being said that is felt.

PATIENT: And I don't think that anything else should take precedence over that.

CHAPLAIN: The genuine concern of somebody reaching out for help.

PATIENT: Sure, the minister, the Presbyterian minister that married my father and mother, was that kind of a man. It didn't hurt him at all. I met him at ninety-five, his hearing was just as good as ever, his seeing was just as good as ever, his handshake was like a man of twenty-five.

CHAPLAIN: This again symbolizes some of the disappointments that you've experienced.

DOCTOR: This is part of the seminar, to find out those things, so we may become more effective.

PATIENT: That's right. And in the case of ministers I would imagine you'd have less chance of consultation when you needed it than you would in the case of a psychiatrist-this is a peculiar thing-because a minister is supposed to be no moneymaking, and a psychiatrist is supposed to be out for a minimum amount of money. So, here you have a fellow making money, he could make money in the daytime, at night or anytime he wants to, but yet you could make an arrangement with a therapist to come at night, but try and get a minister out of bed at night.

CHAPLAIN: Seems like you have had some experiences with clergy.

PATIENT: My own clergyman right now is very good but the trouble with it is he is settled with a whole flock of children. At least four. Well, when is he gonna get out? Then they tell me about how they, ah, have young fellows in the seminary and things like that. Not a lot of them, fact we even had trouble getting some for Christian Education work. But I think if they had a going church they wouldn't have any trouble getting the young people.

CHAPLAIN: I think we've got some things to talk about that aren't part of the seminar. He and I will get together sometime and we'll revise the church. I'm in agreement with a part of what he says.

DOCTOR: Yes, but I'm glad he brought this up here. This is an important part. How was the nursing service?

PATIENT: Here?

DOCTOR: Yes.

PATIENT: Well, practically every night that I needed a chaplain, it was because that I had to deal with a wrong kind of a nurse, during the daytime. There are some nurses here that are efficient but they rub the patient the wrong way. Fact, my roommate said, you get better twice as fast if you didn't have that nurse. She fights every minute, you know what I mean? You come in and you say, well, would you give me a little help and start on eating because I have an ulcer and liver trouble and this and that and the other thing. She says, well, we are very busy, it's up to you to do that. If you want to eat you can eat, if you don't want to, you don't have to. Then there is another nurse who is pretty nice and in the way she helps you, but she never smiles one bit. And for a person like me who ordinarily, you know, smiles and takes on the badge of goodwill, why, it seems sad to look at her. Every night she comes in and not a trace of a smile.

DOCTOR: How is your roommate?

PATIENT: Well, I haven't been able to talk to him since he started these breathing treatments, but otherwise I imagine he would get along pretty well because he doesn't have so many different ailments as I have.

DOCTOR: You know originally you planned only about five or ten minutes and then you said you would get very, very tired. Can you still sit comfortably?

PATIENT: Well, it so happens that I'm all right. DOCTOR: Do you know for how long we talked? One hour.

PATIENT: I never would have imagined I could have lasted an hour.

CHAPLAIN: We are getting very conscious of it in not wanting to tire you here.

DOCTOR: Yes, I really think we should stop it now. PATIENT: I think we have talked about most of the things.

CHAPLAIN: I'll drop by around dinnertime before I go home, to see you again.

PATIENT: Ah, six o'clock? '2
CHAPLAIN: Five thirty to six, somewhere along there. `

PATIENT: That's very good. You can help me eat because I have a bad nurse. 

CHAPLAIN: Okay. DOCTOR: Thank you for coming. I appreciate it.

Mr. H.'s interview is a good example of what we called the "door-opening interview."

He was regarded as a grim, noncommunicating man by the hospital staff, and their prediction was that he would not agree to talking with us. At the beginning of the session, he warned us that he was likely to collapse if he sat for more than five minutes -yet, after a full hour of conversation he had difficulty leaving and felt perfectly all right physically as well as emotionally. He was preoccupied with many personal losses, the most serious one the death of a daughter far away. What grieved him most, however, was the loss of hope. It was related at first as the doctor's presentation of his illness: ". . . they gave me no hope. The doctor himself said that his father had had a similar operation, in the same hospital, with the same surgeon, and that he failed to recover and died within about a year and a half at the same age. And that all I could do was just to wait for the bitter end . . ."

Mr. H. did not give up and admitted himself to another hospital, where hope was offered.

Later in the interview he expresses another sense of hopelessness, namely, his inability to have his wife share some of his interests and values in life. She often made him feel like a failure, he was blamed for the children's lack of achievements, he did not bring enough money home, and he was fully aware that it was too late to satisfy her demands and ever meet her expectations. As he felt weaker and unable to work, looking back at his life, he became even more aware of the discrepancy between her values and his own. The gap seemed to be so great that communication became almost impossible. All this happened to this man during the mourning process for his daughter and reawakened the sadness he experienced after his parents' deaths. As he describes it, we had the feeling that he had so much grief, he was unable to add more sorrow to it-thus leaving the most vital dialogue unspoken, which would have, we hope, given him a sense of peace. In all this depression there was a sense of pride, a feeling of worth in spite of his family's lack of appreciation. So we could not help but wish to be instrumental in a final communication between the patient and his wife.

We finally understood why the hospital staff was unable to tell how much Mr. H. was aware of his illness. He was not thinking of his cancer as much as he was reviewing the meaning of his life and searching for ways to share this with the most significant person-his wife. He was deeply depressed not because of his terminal illness but because he had not finished his own mourning for the dead parents and child. When there is so much pain already, some added pain is not experienced as much as when it hits a healthy pain-free body. Yet we felt that this pain could be eliminated if we could find means to communicate all this to Mrs. H.

The following morning we met with her, a strong, powerful, healthy woman, energetic as he had described. She confirmed almost verbatim what he had said the day before: "Life will go on much the same when he has ceased to be." He was weak, he could not even cut the lawn or else he might faint. Men on the farm were different kind of people, they had muscles and were, strong. They worked from sunrise to sundown and he was not much interested in making money either . . . Yes, she knew he had not long to live, but she was unable to take him home. She had made plans to bring him to a nursing home and she would visit him there ... Mrs. H. said this all in a tone of a busy woman who had a lot of other things to attend to and could not be bothered. 

Maybe at that time I felt impatient or had a sense of Mr. H.'s hopelessness, but I repeated in my own words once more the essence of her communications. I summarized briefly that Mr. H. had not fulfilled her expectations, he was not very good in many things really, and would not be mourned when he ceased to be. Looking back at his life, one might wonder if there was anything memorable in it .... Mrs. H. suddenly looked at me, and with feeling in her voice she almost yelled: "What do you mean, he was the most honest and the most faithful man in the world ...."

We sat for another few minutes during which time I shared with her some of the things that we had heard in the interview. Mrs. H. admitted that she had never thought of him in these terms and was quite willing to give him credit for these assets. We returned to the patient's room together and Mrs. H. repeated on her own what we exchanged in our office. I shall riot forge the patient's paleface deep in his pillows, the expectant look oil his face, the wonderment in his expression at whether we were able to communicate. And then his eyes lit up when he heard his, own wife say, "... and I told her that you were the most honest and most faithful man in the world, and that's hard to find these days. And on the way home we would pass by the church anti pick up some of your church work that was so meaningful to you It will keep you busy for the next few days ...."

There was some genuine warmth in her voice when she talked with him and prepared him to leave the hospital. "I shall never forget you as long as I live," he said when I left the room both of us knowing that this would not be long, but it mattered little at this point.

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