Helping Therapy Clients Cope with the Reality of Death

Clinical Wisdom to Combat Fear, Anxiety, and Grief at the End of Life

Helping Therapy Clients Cope with the Reality of Death

The daughter fingers the small glass-beaded necklace around her mother’s neck and says, “Her granddaughter gave her this one.” Touching the delicate gold watch around her mother’s stiff wrist, she says, “This was an anniversary gift from my father years ago.” After attending a dozen such viewings of deceased clients in the last few years, I know what question will come next. “Doesn’t she look good?” the daughter asks me with a sidelong glance.

I look at her mother’s body in the crushed-velvet interior of the mahogany coffin, head uplifted by the satin pillow at what, if she were alive, would be a wrenching angle. She’s in her Sunday best, with her face powdered and rouged more than I’ve ever seen in the past 10 years. I respond with the requisite, “Yes, the undertaker did a great job.”

I suppose he did a great job of sorts, but I wouldn’t say she looks good. It seems to me she’s too much made up in all ways—a ruddy-cheeked object of her family members’ fantasy, rather than the depressive, often cranky, 70-year-old woman she was. This is her but not her, and the difference adds to the sadness I feel about losing the complex, feisty woman I’ve known.

As I step away from the casket after saying my own silent good-bye, my sadness quickly gives way to awkwardness as I get in the receiving line to greet the immediate family members. When one after another asks me, “How did you know Clare?” I respond, “We used to work together.” The answer isn’t false; just misleading. I offer the usual condolences, but have to be careful not to be too effusive or risk raising suspicions that we were more than just office chums.

Learning to Confront Death

For 17 years, I’ve specialized in medical family therapy, working in acute-care hospitals, nursing homes, primary care offices, and physical medicine rehab units to help clients and family caregivers adjust to such life-altering illnesses as stroke, traumatic brain injury, Parkinson’s disease, cancer, Alzheimer’s, congestive heart failure, multiple sclerosis, lupus, and advanced diabetes. Managing responses to death has become part of my work, whether originally my intention or not. I’ve aspired to helping families hang tough through medical crisis, but now spend some of my time hanging crepe.

During my own father’s last days in the hospital, though, I was enjoying my summer as a standout athlete and budding ladies’ man at an overnight camp 100 miles away. I wasn’t there with him at his end—didn’t talk with him about what he meant to me as a father, didn’t console my mother at his bedside, didn’t witness his life ebb away. I was at his funeral, but, following Jewish custom, we had a closed casket; I never laid eyes on him again after he died. As much as I’ve tried to put this out of my mind, my absence from his deathbed has been a persistent source of guilt, which accounts, in part, for my commitment to seeing psychotherapy clients through to their deaths—to be present for them in a way that I wasn’t for my own father.

Taking People as They Are

I’ve now accepted the variety of ways people react to their dying. There are those whose deaths are good, who can tolerate facing their fears and regrets, and impart a gift of thanks and even wisdom to the grieving relatives they leave behind. Then there are those who shut their eyes to the prospect of death until the instant they’re terror-stricken at the first glimpse of the white light. Or they expend their waning energies lashing out verbally or physically at those around them, as if trying to stave off the Grim Reaper. Mostly, though, people are neither noble nor horrid at the end. They’re anxious about the unknown, saying fearful things or wearing pained expressions that make their loved ones uncomfortable. If they’re in hospice care, they’re likely to be doped up on morphine and to pass in and out of agitated confusion. All of these ways of facing death are utterly ordinary and human.

For the occasional Clare, I’m all spiritual values and existential truths. For most others, though, I merely try to provide comfort. If they reject any consideration of the hereafter, I’m all in favor of focusing on the here-and-now. If they quail at deaths door, I’m willing to hold their hands to keep them on this side of the divide for even a moment longer. If, in their panic, they can’t help but lash out, I’m ready to absorb their frantic blows.

I try to apply these lessons to my own grief for the dead. I mourn my clients and miss them. I go to their funerals to be comforted as well as to comfort. As awkward as it sometimes is for me to be there, I get solace from knowing that my sadness is shared by others in attendance. I also get a richer sense of my client, the cast of characters in his world, and the drama of his life.

Recently, a middle-aged female client whose kidneys are failing asked me sheepishly if Ill attend her funeral one day. I heard in her query a request to be there for her because she anticipates that few of her estranged family members will attend, but I also detected a question about whether I care enough about her to remember her and mark her life. I said without hesitation, “Of course.” When I made the commitment to be her therapist, I agreed, in my mind, to see her through her illness to her final send-off, and to carry her memory with me afterward. Presuming I don’t die first, I’ve promised her that, in my casket-side prayers to her while staring down at her painted face, Ill fill her in on the details of her big event.


Barry Jacobs

Barry J. Jacobs, Psy.D. is a Philly area-based clinical psychologist, healthcare consultant, and coauthor (with his wife, Julia L. Mayer, Psy.D.) of AARP Meditations for Caregivers (Da Capo, 2016) and AARP Love and Meaning After 50 (Hachette, 2020). He writes a monthly self-help column for family caregivers on