Ruth Garfield, MSW, MD, is a child and adult psychiatrist, and adult psychoanalyst. She graduated from the Medical College of Pennsylvania in 1989, followed by a psychiatric residency. She has been in practice for 30 years and is on the faculty of the Psychoanalytic Center of Philadelphia. She wrote a chapter in Flirting with Death: Psychoanalysts Consider Mortality.
Can you tell us about your history and experience with serious illness?
After working as a social worker for nine years in various settings, I decided to pursue medicine. About two years before I went to medical school, I discovered that I had breast cancer. That was my first experience with cancer. Medical school got delayed by about a year because I had to get treatment. I was a somewhat older student, 36 when I started. I graduated in ‘89 and then did a psychiatric residency until ‘93. Also during that time, in my late 30’s, I was diagnosed with a recurrence of breast cancer. Then almost seven years ago, I was diagnosed with leukemia, for which I had a bone marrow transplant.
In your chapter of Flirting With Death, you talk about your colleagues not being able to engage with you and talk about your illness. Can you tell me about that, and your interpretation of it?
It has been hard. With my close inner circle it wasn’t like this, but many colleagues had a distancing response. I understand the practical aspects of this. When I first got back to practicing, colleagues may have worried that I wasn’t going to live too long and that they couldn’t refer patients. I have received referrals, but not at the level that I used to. I think I am seen differently. When I see colleagues, they often comment, “Oh, you look great.” Sure, maybe they would have said it anyhow [laughs], but I think it’s also a way of asking, “Are you really ok?” and perhaps of distancing, of saying, she’s the sick one and I’m not the sick one. I don’t think these are conscious thoughts but they’re in our minds When you have a serious illness, death is on people’s minds when you’re in proximity to them, and it makes them uncomfortable. But I don’t think people are consciously aware of their own fears of being sick or of dying.
In medical school or social work school, did you receive any training about approaching death and mortality?
It was the time of Elizabeth Kubler Ross, so people talked about stages of grieving and dealing with the death of a loved one, so in that sense there was some acknowledgment. But it was not about an individual’s confrontation with their own mortality or impending death. I think as the field of psychoanalysis is shrinking—no pun intended—the practitioners are getting older, and I have to assume are dealing more with their own death. But I don’t think that’s talked about a whole lot.
When you have a serious illness, death is on people’s minds when you’re in proximity to them, and it makes them uncomfortable.
Do you feel that it is beneficial to address death, or that analysts should bring up death more, even with younger patients?
That’s an interesting question. The psychoanalytic therapy in which I was trained is a very life-focused therapy. We talk about living a fuller life, a richer life, but without the question of what life means in the context of death. In general I would wait for somebody to bring something up before I would introduce it. If I think that if they’re sort of dancing around it, I would probably bring it up, and I have. With younger patients, sometimes people talk in a more theoretical way about their fears about mortality, and then I can pick up on it and open up the subject. But I think you raise an interesting question about whether it should be more infused into our clinical literature and training, and talked about more.
Is there anything you would like to see changed in psychotherapy to improve our ability to have dialogue around mortality?
The need to have a “will” for professional purposes so that someone calls your patients in the event of the unexpected is important and has become more common, but not universal. At the very least people are thinking in a practical way and making provisions for their patients. But I think that if therapists could talk more with each other and the professional community about dealing with death on a more existential level, it would be beneficial.
Someone I quote in my chapter, Carl Whitaker, has rules to “help keep the therapist alive.” One of them is to practice dying every day. I remember being so taken by reading this, maybe 40 years ago. It doesn’t have to be the total focus of your day, but I think it’s in my head somewhere every day. But I love that phrase, and what I think he meant by it is to be aware of the finitude of life in terms of what we can and can’t do, and to appreciate what we have for today. Also, if you practice something, you get more familiar with it, you learn it better, and maybe it won’t be so frightening.
I want to mention that there is a lack of self-care taught to us in our training, and I think that this contributes to the denial of death.
Finally, I want to mention that there is a lack of self-care taught to us in our training, and I think that this contributes to the denial of death. When you’re so busy, you don’t have to really think about anything, but this can actually be counterproductive. So just in general I think Carl Whitaker’s advice, to practice dying, should be one of those things that we are much more aware of.