Do you remember the moment when you decided to write this book?

I think the book was percolating in my mind forever, really. I first started thinking about death as a child, and how people never talk about it but it’s really such a big worry for all of us. I remember when my grandparents died, I asked my mother what happens after death and she said “nothing.” So, that turns you into an existentialist pretty quickly [laughs]. More immediately, the idea of writing this book became real to me after I had an experience with a patient who told me that he had been in treatment with a therapist in Philadelphia who had been actively dying, and despite his inquiries he was told “everything’s fine.” Then one day the patient went to the therapist’s office, and the door was locked. The therapist had died and the patient had not been notified. I was just shocked. Part of my work with this patient was to help him process the fact that his therapist had not been honest with him, first, and second to help him mourn the loss of this therapist, to whom he did not have the chance to say goodbye.

Then I myself had a heart attack, and I perpetuated the same experience! I had a patient who came to my office and sat in the waiting room and sat, and sat, and sat. It was the day after I had a heart attack, so I was in the intensive care unit, and eventually someone did notify all my patients but this particular patient had not yet been notified. So the fact that I myself had not made arrangements in the event of my own sudden illness or death made feel irresponsible, and also motivated me to write this book.

You mention Ernest Becker in your essay in the book. If you remember, when did you first encounter Becker’s work?

I first read Becker during my psychoanalytic training when a supervisor of mine was talking about the denial of death in regards to a particular patient I was seeing, and he said, “Oh there is a book you have to read!” So he gave me his copy, and I am embarrassed to say I still have that book 35 years later! I immediately connected Becker’s ideas to my own life and my own thoughts, and they have been extremely relevant during my professional career. I keep referring back to it, re-reading portions, and using it for papers I’m writing. My old supervisor is probably still wondering who took his book!

We have to have access to and awareness of our own terror, our own anxiety and vulnerability, in order to identify with our patients.

Speaking of the denial of death, in what ways can an analyst’s own death denial impede their ability to be optimally effective with patients?

It is my experience that many psychoanalysts and psychotherapists are hindered when it comes to fully discussing patients’ anxieties around death, and to making adequate preparation for their own deaths. I found this to be true in my own analysis; I spoke at length about my experiences with death and loss, my fear of death, etc. and my analyst remained silent through much of this. If we analysts or therapists are cut off from certain feelings, whatever they may be—in this case feelings about the fear of death—then there is a risk that when we listen to patients, we will fail to respond or won’t be fully available to the patient and the material. We have to have access to and awareness of our own terror, our own anxiety and vulnerability, in order to identify with our patients. We must relate to our patients as fellow human beings and realize that we have more common experiences with each other than we have dissimilar experiences.

Becker (among others) alludes to the idea that denial is somewhat necessary to function normally. Do you agree, or does there exist a happy medium between denial and terror?

I think there is a happy medium. We all need some denial. If we went through every minute of every day saying “I’m going to die,” we wouldn’t have any time or emotions left to work, be productive, love our children, love others—we would just be terrified messes. So we can’t be constantly in touch with our anxiety about death. But what we can do is to try our best in one way or another to come to terms with the reality. That might take working through some anxiety and terror for ourselves. If we can come to terms with our own feelings about death, reduce our terror, and keep in our awareness the fact that that someday life is going to come to an end, and if we keep that awareness present without keeping the terror fully present, then we will be able to live more fully and be more fully available to help our patients. In a sense, we need a fluctuating, flexible denial.

And for those of us who go into the helping professions, we have a responsibility to our patients to engage with this.

Do you think Americans have an especially hard time with mortality? If so, why?

Absolutely, I think Americans are especially denying of death. We’re such a can-do society. We were founded by people who came here to have freedom, to take control over their own lives. So I think that sort of person in particular does not want to think about times when they’re not going to be in control. And death is the ultimate loss of control. So I think there has been a long history in this country of denying death and wanting to shield children from death, meanwhile amassing possessions, and attaining pleasure, all of which is a covert form of denying death, as you are well aware.

In your personal experience, has confronting mortality benefited your practice?

It has definitely improved my ability to be a good therapist, and to be able to talk with people about death. But it has also improved my ability to listen, and to know when people are bringing death up, even in a covert way. And I think that’s the difference between psychoanalysts and other therapists—as psychoanalysts we’re trained to listen to the unconscious. I am able to say to patients, “Even though you haven’t used the word, I wonder if you’re thinking about death, or the fact that your life is finite, and I wonder if this is something that’s troubling you.” I can bring it to consciousness for the patient, and I don’t hesitate to do so. In fact, as a psychotherapist I think it’s pretty much my job to bring things up to people even though it may be difficult for them—and sometimes for me as well. And it’s a very good environment in which to bring up difficult matters because they’ve got me to talk about it with, and to process it. So I think I’ve been able to be much more proactive perhaps than some other therapists in this regard.

What do you think needs to happen to improve your field’s ability to have dialogues around mortality?

Part of the taboo is just even around speaking. Let’s talk about it. Let’s have courses on it. How do we think about death and our tendency to stay in denial about our finite existence, how do we talk about it? And for those of us who go into the helping professions, we have a responsibility to our patients to engage with this.

Denial is something we erect for good reason. If there is something that we can’t deal with because it produces too much anxiety, then we erect a defense against it. I try to help people gradually deconstruct their defenses so they can experience their feelings more directly. But for those of us who aren’t interested in getting rid of some of our denial, it reigns supreme.