When a Patient Dies . . . Should the Therapist Attend the Funeral?

• Responding to a patient's death
• Should I go?
• Honoring . . . grieving

Unless we are treating medically ill or very elderly patients, we're not likely to think of our patients as being at imminent risk of death, at least not while they are under our care. Patients leave therapy for any number of reasons, but few clinicians are prepared for the possibility that termination would take place because a patient has died. I had been worried about Jim* for months, urging him to see a physician for his deteriorating health, particularly his strained breathing. The fact that Jim was similar to me in age (early fifties) made the issue all the more personal for me. When I began seeing Jim as a psychotherapy patient some nine years earlier, our expectation was that we would meet for only a few months. Jim had grown increasingly concerned about troubles in his marriage, and he wanted to figure out what he was doing wrong. The story that unfolded during the subsequent years was tragic in so many ways. Oddly, as matters got worse in Jim's life, the alliance between the two of us got stronger.

When I received the phone call from Peggy, one of Jim's friends, I sensed that I should rush to the hospital. The fact that Jim had actually, finally, gone for medical help led me to believe that he must have been in desperate pain. As I arrived at his bedside, he gave me a wry smile, so common in our exchanges, so much like the amused look that he would give in our sessions when he said something completely outlandish about the state of affairs in our world or our town. It was evident to me that Jim was at the threshold of death, a hunch confirmed by the nurse who entered the room during our chat.

During dinner at home that evening Peggy called from the hospital to tell me that Jim had passed away. I excused myself from the table, and went to my study where I reflected with deep sadness about the loss of such a precious person. A bit surprised by the depth of my grief, I felt caught off guard as I tried to discern the reasons that Jim had affected me so deeply. I reflected with fondness on the years of our work together, but also questioned what I might have done to help him obtain medical help before the point at which his body began to surrender. Over the course of Jim's nine-year therapy, Jim brought me some of the most difficult issues I had encountered in three decades of clinical work.

Soon after Jim had started therapy, his wife asked him for a divorce, causing him to become depressed and neglectful of his physical well-being. Jim began to drink heavily in his desperate attempts to alleviate the incapacitating emotions with which he struggled on a daily basis. In time, he lost his job as a salesman because of his increasing unreliability. Without work, Jim then was left without insurance coverage. His financial picture worsened on a daily basis, and he eventually became destitute as he found it necessary to allocate his minimal savings to cover the expenses of a protracted divorce and custody battle. As Jim's psychological, financial, and medical problems intensified, I found myself juggling several roles in my work with him. In psychotherapy, we focused on his emotional well-being, with particular attention to his worsening problem with alcoholism. Although Jim was responsive to therapeutic work focusing on abstinence, he periodically relapsed in response to stressors in his life. In the financial realm, Jim was able to turn to close friends to help him procure the basics of life, but he had nothing more than what was needed to sustain himself.

As for his deteriorating medical condition, I helped Jim connect with a public health nurse who agreed to consult with him as well as facilitate the process by which he could obtain basic medical care for critical physical conditions. As the months and years flew by, Jim was looking sicker and sicker each time I saw him. In one medical consultation the nurse became deeply concerned about Jim's strained breathing, and insisted that he proceed with her immediately to the emergency room so that he could be admitted to the hospital. The end would come only two days later, leaving me no time to process impending death with Jim, or for that matter gather my own thoughts in anticipation of the loss.

Responding to a patient's death

Although I had seen hundreds of patients over the years, and had supervised or consulted on thousands of cases, I had not yet dealt with the death of one of my patients. I had no script but I had many questions. Should I attend the funeral? How will I identify myself? Do I send a sympathy card or flowers to Jim's sister? If I attend the funeral, how should I interact with his son, or with his ex-wife who would probably accompany their son to the funeral? Jim's ex-wife and I had met once, at the very beginning of my work with Jim, to discuss their marriage; presumably, she would remember me. Certainly, she had heard quite a bit about my involvement over the course of the nine years, particularly in the form of the reports I had written relevant to the custody evaluations. In addition to the pragmatic concerns, what about the emotional issues? How would I process my own grief? With whom could I consult to deal with my questions, my concerns, my sadness?

I was also unprepared for the ethical issues that emerged. When Peggy called to inform me of his passing, she said that she hoped that she and I would have the opportunity to process our feelings about Jim, and our reaction to the loss. On several occasions Jim had given me permission to speak with Peggy regarding my concerns about him. Jim knew that she and I shared a commitment to his well-being. However, would it be ethical to disclose anything about my therapeutic work with Jim? I thought not, although I did feel that it was permissible to concur with statements about what an impressive man Jim was, and how he had touched each of our lives.

The ethical quandaries continued when I received a call from Jim's sister, who phoned to thank me for all that I had done for Jim and to invite me to the funeral, saying that she knew it would mean so very much to Jim if I were present. She had known that Jim had been unable to pay for his sessions during the past several years, and expressed her deep appreciation for my kindness in continuing to see her brother. Although she offered to pay his debt, I explained that I couldn't accept the offer. I was well aware of the fact that his sister had minimal financial resources, and that there would certainly be no estate in Jim's name.

Should I go?

Should I attend the funeral? How could I not go? After reflecting on the words of Jim's sister about how much it would mean to him, the decision became clear that I should be present at the celebration of Jim's life. As I pulled up in front of the stately church, I fretted about when I should enter and where I should sit. I sat inconspicuously in the middle of the congregation, attending to the eulogies, and quietly grieving the loss of such a special man. Following the ceremony, Jim was buried in an adjacent cemetery while additional prayers were read. To exit the burial area it was necessary to pass through a receiving line consisting of Jim's sister, his son, and his ex-wife, all three of whom were aware of who I was and the nature of my relationship with Jim. I offered the customary expression of sympathy, all the while feeling constricted in terms of what or how much I could say.

Somehow I expected that the story of my relationship with Jim would not end on the day of his funeral. I anticipated a call from his sister, another from Peggy, perhaps from his ex-wife, and possibly from his son. I was relieved that I wasn't contacted by any of these individuals, or anyone else for that matter. In the years since his passing, I've wondered why I had even anticipated such a contact. At the risk of sounding egocentric, I had come to realize that Jim's son, his friend Peggy, and I—his psychotherapist—were the most important people in Jim's life. Wouldn't family members, or close friends, want to extend condolences to me? Obviously, such a wish had more to do with my needs than with the reality of the situation. However important the therapist may be, in the eyes of others, the therapist may or may not be all that different from the accountant, or even the auto mechanic, for that matter.

Many people might wonder why a therapist would experience grief at the loss of a patient. Unlike a planned termination with a long-term patient, Jim's death left me feeling a sadness for a life cut short, frustration about clinical work abruptly terminated, and an aching feeling of emptiness resulting from the loss of someone I cherished. To process my grief, in the week following the funeral I turned to a colleague who guided me through a cathartic discussion about my reaction to the death of this special patient. We spoke about the grief evoked by the death of Jim, and also about the reactivation of grief associated with previous losses of significant people in my life. Specifically, I found myself becoming stirred by thoughts and memories pertaining to the death of my parents. In so many ways, memories of being nurtured by caring parents as a child evoked associations regarding the ways in which Jim relied on me for help, support, and kindness. The cycle of life and death continued.

Honoring . . . grieving

There's no question in my mind that adhering to the highest standards of ethical and professional behavior is essential, irrespective of the situation. My patient's privacy must be protected, dead or alive; the secrets I hold must go with me to my grave. At the same time, I cherish the wonderful relationships I have had with many of my patients. Just as I have become a compelling voice in their lives, they have also become part of me. Out of respect for this valued alliance, we need to grieve. We need to find ethically informed ways to participate in the rites of death and the process of mourning.

There are, however, circumstances in which attending a deceased patient's funeral may not be appropriate. Many patients are not as open about being in therapy as Jim, who had talked to me often about his discussions of our clinical work with his sister, his friend, his son, and even his ex-wife. However, for patients who are secretive about their therapy, the presence of the clinician at a funeral, especially a small gathering, might be problematic because mourners might infer or ask about the relationship with the deceased. Risking such a confidentiality breach must be avoided, necessitating that the clinician grieve in private rather than at the funeral. Or, had there been ongoing legal problems or animosity involving relatives and significant others, the presence of the therapist at the funeral might be provocative, and therefore inadvisable. If and when such events recur, I will again consider the dilemmas, seek out consultation, and strive to make choices that are ethically and clinically grounded, yet informed by caring attitudes.

I feel at peace regarding my choice to attend Jim's funeral. I know that I would have felt terrible pangs had I chosen to stay away due to a rigid, unfeeling worry about professional boundaries. The decision was less complicated due to the fact that Jim was so open about his therapy under my care, and also by the fact that the funeral was well publicized and drew a large crowd. I was touched by the fact that several people came up to me to say, "You must be the Richard" whom Jim so often mentioned. If I had not been a known character in the play, I still would have attended, but with the demeanor of a saddened distant acquaintance at a large ceremonial gathering, rather than as a person in whom Jim had invested the stories of his life.

I also felt that I had benefited in many ways by my relationship with Jim through the positive energy, the intelligent dialogue, and the profound humanity he brought to each of our interactions. Jim left me with intangible gifts that continue to enrich me professionally and personally in many ways. Honoring Jim, and grieving with others who cared deeply about him, felt important and right.

* Note: All names have been altered to pseudonyms.

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