Discussing death is extremely frightening. This subject is taboo and places an overwhelming burden on everyone involved: the dying person and their loved ones. The dread of acknowledging the inevitable departure leads to silence, as if unspoken words could somehow magically alter what has already been predetermined.
Most cancer patients pass away alone, not due to a lack of support from their families. The inability to openly share their feelings and the grief of their loved ones results in emotional isolation, exacerbating depression and anxiety. Ultimately, instead of meaningful words and emotional closeness before saying farewell, there is an emotional rupture.
In this article, I want to openly discuss the process of dying and talk about the emotions experienced by a person with terminal cancer, how their loved ones should behave and what mistakes they should avoid. Additionally, I will explore what a psychotherapist goes through when losing a client after prolonged, in-depth therapy.
I’ve been reflecting on how to write this text for quite some time. It’s crucial not to breach ethical standards, not to disclose the client’s private life, not to trivialise or hurt the feelings of family members, and not to turn the story into a dry analysis of the case. I hope this text will come across as genuine and provide support to those who have received a cancer diagnosis. And in the process I will perhaps grieve a little more for the loss.
The Story of Therapy
The Meeting with L.
A year and a half ago, a young woman (let’s say her name is L.; the name has been changed) came to me with a diagnosis of triple-negative breast cancer with distant metastases. I had worked in various hospitals, developed recommendations for doctors to enhance patient adherence to treatment, and participated in projects related to hepatitis C, cancer and suicide, so I was well acquainted with the subject of death and severe emotional states.
L. initially reached out due to her resistance to treatment, but it was her relatives who felt the need for her to speak with a specialist rather than L. herself. She felt pressured, disagreed with her family, and shut down emotionally. L. was young — she hadn’t even turned 40. Active, bright, expressive, with notes of demonstrativeness and provocation, she immediately reminded me of the lead singer of the band Roxette, Marie Fredriksson, who also had a shocking endurance and confidence organically combined with tenderness and emotional fragility. L. had two small children, about nine and five years old, and a stable marriage.
At the time we met, she was no longer working full-time (though this wasn’t related to her illness). She led an active life, sang in a band, looked after her home, her children, and the numerous animals that were part of her large family. A woman with a strong inner force, and then suddenly a diagnosis of triple-negative breast cancer, which, despite all the advances in modern medicine, is unfortunately a one-way ticket. The doctors gave L. a year and a half to live, and she lived that time, falling short by just one and a half to two weeks.
The first meeting between a psychotherapist and a client is always about understanding the problem and learning about the person’s life story. I listen, ask direct but clarifying questions, inquire about their childhood, and after gathering the necessary information for understanding, I provide comprehensive feedback. That’s how our conversation with L. went. I won’t disclose the details of the client’s life, but I will mention the main nuances that highlighted the true request.
Refusal to Undergo Treatment
At the time of the consultation, L. had already undergone a complete mastectomy and a course of chemotherapy which showed positive results. Almost six months after the treatment, she faced the inevitable recurrence of the disease, emotionally unprepared to accept it. According to her relatives, her refusal of treatment was only evident in her unwillingness to consult with additional specialists beyond the primary ones at her place of residence.
She meticulously followed the second course of chemotherapy and all the prescriptions from the oncologist, chemotherapist, and other doctors. She arrived on time for her procedures, adhered to her diet, and took her medications as prescribed. Her reluctance to seek additional consultations with other doctors stemmed from her sense that these meetings were meaningless and that she was experiencing yet another crushing blow to her hopes. L. did not want to hear that perhaps her treatment had been inadequate, even though the treatment protocols for triple-negative cancer are the same in Russia and worldwide, and at this stage of modern medicine the doctors’ prognosis is always the same: there are no experimental methods available anywhere in the world at present.
The Desire for Control and the Fear of Death
We talked about how this perceived resistance to her relatives’ requests reflected her need for excessive control, despite fully acknowledging her approaching death. Faced with the inability to manage her own body and the collapse of an unconscious fantasy of omnipotence, the special strength of someone who had learned to survive on a mental level, she instinctively tried to control only those aspects that she could still influence.
The familiar faces of a seasoned chemotherapist and a genuinely empathetic, down-to-earth oncologist, plans with her children and spouse, and doing a bit of remote work gave her a sense of stability. She stood on a firm patch of ground amid the boiling lava around her and felt secure only there.
After the operation and the first “chemo,” L. believed that there was hope and subconsciously convinced herself that she was able to cope with cancer. But the disease only lay low for a while, gathered resources for an attack, and returned to L.’s life, destroying the myth of omnipotence over the body. At the same time, L. acknowledged death. She did not isolate herself from the world and maintained her previous lifestyle, so some detachment from thoughts of illness, combined with hypercontrol, seemed adequate to her current life situation. Sometimes “normal” is not what seems natural at first glance.
L. resisted the pressure of her relatives not because she did not want to be treated. She was looking for empathy, not being able to accept it. She was looking for someone who would say “I will be with you until the end,” and perceived the understandable need of her family to seek other treatment options as a denial of her feelings. She suffered from self-disappointment, knowing that she was just unlucky. And most importantly, L. was consumed by a sense of guilt, characteristic of many people with a similar personality type, as if cancer were her own oversight. The harsh Soviet upbringing, in which children did not learn to experience emotions through adults, some nuances of fighting for themselves in childhood, natural strength of character, temperament: all of this threw L. into the feeling that she was to blame for her illness and deserved cancer, having overlooked something in herself.
At the end of our conversation, L. informed me of the need for regular meetings. And what attracted her was not the fact that we began to clearly understand her current situation, but the lack of fear in me: neither of her character (since people of her type cause quite strong emotions in others), nor of the fatal outcome of the disease.
Contact
I talked to her gently, but without the lisping and infantilisation that often turns out to be a protective reaction of loved ones when they don’t want to face the true grief of a dying person. My attitude was reminiscent of the situation from the French film “1+1,” when the main character, a disabled man, appreciated his assistant Driss for treating him like a completely healthy person and creating a natural atmosphere without a clinical feel, simply accepting the limitations of his employer. And this is very important: to see a normal person in a dying man and not to humiliate his human dignity with condescending care in a white doctor’s coat.
L.’s request at the end of the session came unexpectedly: to understand the psychological causes of cancer. And it reflected just two aspects of the client’s personality.
Firstly, the manifestation of the need for control. It is easier for a person to blame themselves for some kind of flaw than to admit the irrationality, randomness, and unpredictability of such a difficult fact of reality as a deadly disease that came out of nowhere. Self-blame gives you a sense of logic and control. Secondly, people are often scared to hear a refusal from the therapist at the first meeting, so they make a request that seems to be acceptable to the psychologist. L. lured my professional ego with such a request, fearing to be left alone with her feelings. This was compounded by L.’s frequent encounters with the lack of empathy among medical staff, so she exposed herself as an object for my potential research.
Thus, based on the results of the first meeting, we formulated the main strategies for therapy: working through hypercontrol and guilt for “bodily imperfection,” developing the ability to experience emotions without breaking down into aggression or emotional isolation, and improving the ability to build secure attachment despite a fatal prognosis, since reducing anxiety towards people significantly improves the quality of life, which was especially important in conditions of constant communication with various doctors. She knew how to love and take care of her loved ones, but she treated herself rather poorly and judged herself for her emotions, so we also decided to focus on this.
I asked directly: “How much time do we have ahead of us?” and didn’t get a clear answer. In the future, I never got to hear an accurate prognosis, despite the fact that doctors tell the patient how long they have left. This zone of avoiding the truth also became the focus of therapy.
In the case of a fatal outcome of the disease, some denial of death in the patient (in Russian clinical psychology this is called “hyponosognosia”) is normal, but only when it doesn’t turn into a refusal to comply with prescriptions and regimens. At the beginning of our sessions I also followed this approach: with an adequate attitude to treatment, not much could be changed. I had to intuitively combine a clear contact with reality and a non-directive discussion of the inevitable.
Accepting the Meaninglessness of What Happened
L. was a very active person. Neither the total mastectomy nor the first blocks of chemotherapy in any way affected the client’s lifestyle. Without knowing about the diagnosis, I would never have thought that in front of me was a person doomed to death. Even alopecia (hair loss) after chemotherapy didn’t mark the disease in her and was very organically combined with the image of a rock singer on stage.
I will not talk about the course of therapy and the details of L.’s life; I will only say that the therapy followed a standard course. We worked through both what we had planned and what inevitably arises in the field of therapeutic relationships and the life of the client themselves. This therapy lasted for almost a year, with a frequency of meetings twice a week, and of course it brought results.
We worked through the client’s request. L. stopped perceiving herself as omnipotent and accepted the fact that she was an ordinary, normal person. The feeling of guilt from not having watched over something irrational was replaced by sadness from the fact that it was simply bad luck. L. learned to accept her emotions without trying to process them through active actions, and just before her death, being in a rather weakened physical condition, she did not try to create unnecessary activity and simply said goodbye to her family. She stopped looking for a higher meaning in the disease and lived the life that remained, just as covertly denying the countdown.
The chemotherapy courses during our therapy, one after the other, didn’t lead to anything and L. felt worse. The last, strong course severely damaged her health. L. could no longer be as active as before, she needed the physical help of her loved ones, but thanks to psychotherapy and herself she could already cope with the limitations of reality, ask for help, and accept her fate.
Now I’m not talking about the absence of heavy emotions, but just about the ability to be sad and grieve without feeling guilty for these emotions. The ability to recognise reality without running away is a very important result of working with a therapist and, in general, is a sign of inner strength and psychological health. We can’t control events, but we can pass through them adequately.
The Approach of Death
L. didn’t terminate our therapy, but in the last month of her life it became clear that the hour of separation was here. New tumours and metastases appeared, L. began to lose the ability to care for herself. Nature is really wise, and I saw the changes in L.’s eyes. It was as if she had become elderly, not outwardly, but on an elusive level in interaction. L. began to call me “Tanusha,” “Tanechka” (affectionate short forms of Tatiana) and gently thank me for the conversation. Like an old lady overjoyed by a sudden conversation with her granddaughter.
Fear for the Children
L. was worried about the children. At one of the sessions she asked how to soften the experience for her two kids. I honestly didn’t know what to suggest, and a therapist doesn’t have the right to give advice. Therefore, after thinking it over, I simply said that we do not have the power to save a child’s psyche from the inevitable loss of their mother. Such young children are unable to understand and deal with a loss, unlike an adult or teenager, and any attempts to talk will only lead to horror and anxiety. I suggested finding a child psychologist in her city, not online, who would work with the children for several years and help them live through such a terrible loss.
Often loved ones protect young children from facing reality and the death of their mother, and try to hide difficult feelings within the family. As a result, children face the loss without experiencing their emotions and begin to believe that they themselves provoked their mother to leave. This is fraught with serious mental problems in adulthood. Therefore the best thing in such a situation is to find someone who will professionally address the problem. Fear for the children is natural and understandable, but an adult also has natural and understandable limitations.
L. was afraid of her family’s emotions and complained. It was as if she was forced to process their experiences against the background of her own emotional burden. She just wanted to discuss her reality, share her fear of death, and say goodbye to her relatives and friends. She perceived sharp reactions, defensive silence, and attempts to change the subject as a denial of her own feelings.
We also discussed this situation as an adequate part of reality: everyone grieves in their own way, and there is no “beautiful” picture of a “beautiful” death. There are no ideal people, so everyone is only able to provide their partner with the support that their own psyche is capable of. Such conversations were not merely social in nature. Renouncing the existence of an ideal object that will relieve you of the hardships of existence is an important part of psychotherapeutic work.
Anxiety During Therapy Breaks
There was also some complexity in working through L.’s individual reactions to our therapeutic relationship, for example regarding my vacations and absences. In standard work with a client, we look for the causes of anxiety that occurs during a break. They can be hidden in the fear of losing control over the therapist, in the fantasy that the person is so bad and unpleasant that I will not return to them, or in anger at the autonomy of the other. These unconscious reactions are perfectly worked through in therapy, but L.’s emotions were also associated with her literal fear that we might not see each other again and that she would die during my absence.
Exhaustion
And at some moments I felt tired from contact with L. Usually such exhaustion from a client can be based on the influence of their destructive side, aggression, and the need for constant attention. For L., I was the only person she leaned on at death’s door, and it was a huge burden for both of us.
She was jealous that I would stay here. And it was quite difficult to work through this reaction. I really wasn’t going to go with her to a place where no one had ever returned from. The conscious connected with the unconscious and I intuitively formulated interpretations based on what was happening between us in reality. I have never seen anything like this in my practice. In normal situations there have never been such experiences after completing therapy with a client. I didn’t hide from the truth or from the strong emotions of L. Probably it was a personal trait of mine that helped us both cope with the unfolding tragedy in the soul of a dying woman.
The Last Conversation
At one appointment, L. did not show up for the call. Sensing the inevitable, I dialled her myself. She was in the palliative care centre and barely spoke, trying to maintain her typical enthusiasm. She said she was looking for a private place to call and sincerely apologised for not being able to, but had simply lost track of time. She also said that the conversation was not the last and that she would transfer money for the missed session. Paying for an untimely cancelled appointment is a standard part of the therapeutic contract, but in this situation I couldn’t hold to the boundaries and said that there was no need to cover the session. L. didn’t agree, she promised to make a transfer soon, and didn’t appear again.
She died two and a half weeks later. And after that I grieved for a very long time, violating some of the rules of a therapist’s work and breaking the general idea that a relationship with a client is a rigid form of interaction devoid of human background.
The Therapist’s Story
My Experience
Next I would like to share some of the experiences I encountered after L.’s death. In the paradigm I practise, a therapist should never open up to a client personally. No additions on social media, no correspondence, except for the discussion of organisational questions. On the evening of the news of L.’s death, I found her on social media and cried over photos from many years ago. I wanted to reach into the past to the girl captured on trips and shout to her that she needed to take a genetic test. Maybe she would have had a radical mastectomy earlier and could have saved her life. It was very hard to realise that it was impossible to touch a person who would never be there again.
I never discuss clients with family and friends, only exclusively in the supervision space. After L.’s death I shared my experiences with people who were important to me, without revealing the personal details of the client. The need for support that arose was perceived by me as contrary to ethical professional standards.
For several months I couldn’t take on other clients during the time that L. and I used to meet, which was two hours of sessions per week. Professional interest, financial considerations, everything receded into the background, and it seemed to me that meeting another person in those hours would be a betrayal of the relationship with L. I didn’t seem to have done anything prejudicial, but still every single act resonated in my heart as a betrayal of the work ethic built up over decades.
What to Do in Such a Situation
I would also like to share some professional recommendations for those who have learned about a fatal diagnosis.
Let’s be honest. No amount of exhortation about the joy of the blue sky should bring peace to the soul of a dying person. There really won’t be any. And the well-known stages of grief (denial, anger, bargaining, depression, and acceptance) will not change anything in life. It’s always frightening to die. In psychological publications the topic of death is carefully skirted, with an emphasis on a certain hope, and all recommendations sound quite vague.
The One Who Leaves
So there is a certain announced deadline ahead. Various reactions to this fact are possible: hypernosognosia, an overestimation of the severity of the condition with hysterical, panicked perception; hyponosognosia, an underestimation or diminished sense of danger; anosognosia, a lack of critical attitude and denial. In a situation of finite prospects, any condition is absolutely normal and the psyche itself will find an opportunity to adapt.
I think the most important thing is to focus on solving tasks, because action is good at coping with anxiety. To formalise an inheritance, to think about the future of life for children, professional goals. This is not just a responsibility, but also something that will create a sense of certainty, because in a situation of uncertainty a person experiences much more horror and helplessness. It’s important to take control of what is available in order to feel alive and meaningful, and not to dissolve into a state of meaninglessness and worthlessness.
Cancer patients are often forced to decide whether to undergo severe chemotherapy, which will damage the body but prolong life for a short time, or to spend the rest of their days as they are. I think there really is no right answer, and it’s worth choosing what you want to do now. Every decision will turn out to be wrong in some sense, so you need to rely solely on your instincts. Your loved ones and doctors will insist on treatment, but your body belongs exclusively to you. Choose only yourself.
By the way, it’s also very hard to withstand the grief of relatives. You’re not a therapist and you don’t have to work through their experiences, but everyone grieves in the way they can. The fear of losing your family is understandable, so try to perceive it without guilt, although it is very, very difficult. Do not sacrifice your needs for the sake of their distress. If you want to spend a last holiday in the sun, that is entirely acceptable. Your emotional comfort comes first right now.
It helps a great deal to cope with feelings through psychological help groups. Emotional isolation is exhausting and leads to the build-up of negative emotions and a dissolution into a negative attitude towards oneself. But if a person encounters others in an emotionally identical situation, they receive tremendous confirmation of their own normality. And this is the main thing for you now: feeling like a whole person even against the background of a dying body.
The main thing is that you are not to blame for anything, even if you smoked while sunbathing in the sun every day. Life is unpredictable and you never know what to invest in, or what will happen to our lives tomorrow.
Close People
It’s also very difficult for loved ones. The most difficult thing is to admit the fear of losing a dying relative. Talk to them about all their experiences. In our society there is a misconception that emotions need to be eliminated, although recognising and accepting reactions to a situation is absolutely normal. It often seems that if you distract a person and switch their attention, the emotion will resolve on its own. As a result, a dying person finds themselves trapped in their experiences and is forced to cope with their grief alone. Say words like “I’ll be with you until the end,” “tell me about your feelings.” Show that you are on the side of your loved one’s emotions.
And there is nothing shameful about taking emotional care of yourself, although it will feel as though you are betraying a relative in this way. Think about what will help you cope with the loss. Maybe it will be a psychological help group and, or, relatives and friends.
Don’t be afraid to worry about yourself because after the death of a loved one you will be left alone with your suffering. Think about your financial and emotional prospects: what you will be left with after, and how you can help yourself. There are no correct answers in this situation either. Taking care of yourself also falls on your shoulders. No one chooses to face cancer, and all that is possible is to choose your own mental comfort in what has happened.
Afterword
And as for me, I grieved L.’s death as best I could. Time and inner work heal, whether we like it or not. Thank you, L., for choosing me to complete your journey. I learned a different facet of life and got to know myself in a new way, realised that I could withstand death emotionally.
There are a lot of numbers stored in my phone and I try to delete contacts of people with whom there will be no further intersections. But I decided to keep L.’s number. We will not meet again, but I keep this relationship in my heart and I will never forget it. This article is my best way to say goodbye.
Tatiana Poddubnaya is a psychodynamic psychotherapist with extensive experience working in clinical and hospital settings, including oncology and palliative care contexts. She works with individuals facing severe illness, grief, and complex emotional states. Find Tatiana on It’s Complicated.
