When the subject of death appears in the therapeutic context, dealing with it can be a complex task. Levinas proposed that there is no anxiety towards one's own death but rather that fear for death is fear for the Other's death, meaning that because of death's incomprehensibility, it can only be experienced when it happens to others. According to him, both death and the Other represent a way out of solitude for the subject. Death is thus intrinsically related to human encounter. The present work deals with the way the philosophy of ethics, by drawing our attention to our responsibility in the face of the Other, helps us understand and address the question of death in relational therapy.
"Everything in the world began with a yes. One molecule said yes to another molecule and life was born. But before prehistory there was the prehistory of the prehistory and there was the never and there was the yes…"
"The Hour of the Star" [1].
When the subject of death appears in the therapeutic context, dealing with it, specifically with death acceptance, can be a complex and challenging task. This subject has been examined in the past [2]. Rather than looking at death anxiety through the angle of terror management theory [3], we would like to propose here a philosophical and analytical approach to the question. Levinas wrote that there is no anxiety towards one's own death but rather that fear for death is fear for the Other's death. According to him, one's own death becomes graspable only because it happens to Others [4]. As the subject becomes worried for the Other's death despite the evidence of its own death, its only remaining role in the context of the encounter is the one of Responsibility [4]. As we will see further, Levinas's stance on alterity and death invites us to rethink the therapeutic relationship and processes in terms of human encounter and responsibility, in terms of Otherness.
We previously wrote about the importance of adequate and adaptive to and fro movements along the axis of Sameness and Otherness in therapy [5]. In the case we described, we showed the importance of Sameness in the therapeutic relationship. Indeed, the adoption of Sameness by the therapist enabled him to step outside and act from his position of Otherness [5]. To exemplify the importance of Otherness when dealing with the subject of death, we discuss the following case through Levinas's philosophy of ethics.
Mrs. B. was 71-years-old at the beginning of the therapeutic work. She described an increasing feeling of anxiety, irritability and cries. She told about her gastrointestinal cancer that was diagnosed when she was 65 and about going through surgery twice during the years that preceded our work. During the first months of our work, her fears about death remained mainly unspoken, until a change of attitude on the part of the therapist. This subject started then to unravel, becoming much more present and even dominant. Mrs. B. was born in northern France. From age 1 to 5, she grew up with a foster mother, with seldom visits of her biological mother who was often described by Mrs. B. as violent to her during childhood, and depressive. Only around age 15 did Mrs. B. discover that her stepfather was not her biological father. Mrs. B. grew up in France and moved to Israel at the age of 20, to work as a volunteer in a kibbutz. She described herself as very dedicated to her tasks and also wooed despite her lack of interest for intimacy. She became rapidly a regular member, resident and worker of the kibbutz, after she got married. She became mother of N., 47-years-old now, who was raised in the kibbutz by a community caregiver. In this model, the children and their parents used to live separately and see each other only at defined times. N. is married, has two children (age 19 and 15), and lives in Paris. Mrs. B. got divorced when she was 28 and married a second time at the age of 40. She has been living with her second husband since then.
During the first months of therapeutic work, Mrs. B. appeared anxious and stressed. Often dressed in black, she would spend most of the sessions verbalizing her difficulties in daily life and her struggle to carry out routine tasks. The subject of death was characteristically spoken in vague terms. She seemed to be confined to a pattern of inward preoccupations and investments which caused in return an increase of her suffering. The possibility of death may be viewed at this stage as experienced sensorically rather than symbolically: "It is so tough, I cannot distinguish between anxiety and pain".
Death first appeared in a symbolically-defined form only later, around the second year of our work: "I know that in some time my death will come, I have never talked about this with anyone... I would like to die with dignity". From an ontological point of view, death could only be experienced and spoken at this stage in accordance with what Heidegger described as small talk. According to him, the certitude of death is avoided (but also confirmed) by dailyness, and small talking is the mode of being that one uses. One signifies that one dies , not me, they. This they-self forbids the surge of awareness of finitude and that of an authentic self, which is the authentic form of Dasein. "The They forbids the courage of the anxiety of death to come to light" [6]. "Many people live and have to cope with medical conditions worse than mine." Mrs. B.'s anxious state could be viewed as a failed attempt to cope with Heidegger's possibility of death, i.e. the possibility of impossibility, and to reach authenticity. This failed attempt to reach an authentic form of Dasein was indeed accompanied by a similar feeling of inauthenticity during the sessions, an absence of true human encounter, maybe related to a resistance from both of us to engage in such a complex and possibly painful journey. As we will discuss later on, this positioning towards death can also be discussed in the light of the premature rupture between Mrs. B and her mother during the first years of life.
It is at this point important to start looking at the meaning of death also in psychodynamic terms. For Freud, the Unconscious does not know, nor recognize or understand anything about death. "In the unconscious, the meaning of our term - destruction of life - does not exist. Something similar to death has never been experienced" [7]. Freud, a few years earlier, even proposed that "no one believes in his own death, or, to put the same thing in another way, that in the unconscious every one of us is convinced of his own immortality" [8]. Thus, the unconscious does not speak the language of death. One can notice here an apparent resemblance between Heidegger's impossibility of death and Freud's denial of death. The authentic Dasein mode of being allows to live away from the possibility of death. In Freud's Beyond the Pleasure Principle [9], death, unknown and ununderstood by the unconscious, denied, manifests itself through death instinct (Thanatos) which is an "urge inherent in organic life to restore an earlier state of things". Freud even proposed that "the aim of all life is death" and that the function of life instinct (Eros) is merely to guarantee self-preservation [9].
Before showing how this strong assumption is alive in our case, it is important to recall its meaning in terms of relating and narcissism. Whereas Eros's preservative role consists of seeking object and investing in these bounds, Thanatos's natural function is dis-investment and un-bounding, away from objects [10]. Green's death narcissism is defined as active search for nothingness, a sort of psychic death to avoid despair. Masochism in its various forms, anesthesia, guilt and negative therapeutic reaction are, through a mechanism of repetition, its main expressions. This renouncement to desire, seen as a sacrifice to regain the love of the parents [10], was very present in Mrs. B.'s discourse, as she seemed to be constantly inhabited by a feeling of guilt and worthlessness causing masochistic patterns in her relations. We propose to view also her life-long incapacity to enjoy physical intimacy and the consequent feeling of being legitimately punished for that as an expression of death narcissism. This dominance of Thanatos over Eros, of conservation over procreation, would necessarily influence the way she apprehends the possibility of her own death.
Freud, in Beyond the Pleasure Principle [9], uses cellular division as a perfect metaphor to illustrate his concepts of life and death instincts. The germ-cells work against death by combining with other similar cells, allowing life through later differentiation. This is interesting to us in a double sense. First, because in this conceptualization, cells need one another to preserve life (i.e. struggle against death). One should keep this in mind when death through the perspective of Levinas and a shift toward Otherness are discussed. Also, because one of the mechanisms underlying malignant disease is the absence of differentiation, i.e. cells lose their capacity to be specifically different in their structure or function, which represents a movement away from Otherness.
The main mode of interaction during this stage of work was, in a schematic attempt to describe a plentitude of processes, that of an empathic listening to Mrs. B.'s discourse. Husserl used the idea of the Other as a basis for intersubjectivity and empathy, proposing that intersubjective experience plays a fundamental role in our inner comprehension of ourselves as objectively existing subjects, other experiencing subjects, and the world [11]. Kohut, defining empathy as a method, maintained a theoretical and therapeutic one-person psychology stance in which the therapist's subjectivity is irrelevant [12]. The empathic listening of Mrs. B. and the recognition of her emotional experience, related to events in the past or the present, whether in the context of expansive grandiose affect states or in the more prevalent context of painful affect states, seem to produce merely a transient calming effect on her.
The first two years of work did not seem to yield much change neither in Mrs. B's clinical symptoms and suffering from an external point of view, nor in the way she would relate to herself, speak about herself and her condition. Although Mrs. B. was struggling with objective illness with little chance of absolute cure, it became necessary at this point to look into the patient-therapist interaction, to ask whether the therapist's therapeutic stance allowed a subjective change to occur or not. We shall now describe how a change of therapeutic attitude will allow a new beginning, the appearance of life, i.e. the life instinct's (Eros) manifestations such as the investment in external bounds and activities.
Gradually and naturally, as the therapist started to feel closer and more attuned to Mrs. B.'s presence and narrative, less judgmental and more open regarding his own affective states, he would notice more diversity in her affects. She would smile and sometimes laugh, emphasizing that the sessions are her unique opportunity to feel joyful.
The therapist would gradually notice in particular more calmness in Mrs. B.'s voice and in her attitude, including in the way she would describe the conflictual relationship with her husband. He would also notice a change in the way she related to the external world in general. For instance, she would yet relate to her oncologist which she had earlier described as inhumane, in much warmer and respectful terms. This change would also be accompanied by a feeling of calm and confidence in the therapist's own self experience. He would feel less defensive and more confident about being able to explore Mrs. B.'s reactions to the expression of his "constant and pervasive subjectivity", and even "authorize her collaboration" while interpreting on her affective states, to use Renik's words [12]. "I think that the fact you can see your oncologist through this new perspective is really important. First, because she seems to behave more respectfully, and you deserve to be treated respectfully. Second, because being able to see that people have different facets can have a positive impact on you, for instance relating to yourself and your different facets with more tolerance".
As the therapist became more inclined and confident in disclosing his own subjective perceptions of her suffering and on how she could go on with life, he was, a posteriori, making a step away from Kohut's one-person psychology empathic stance, by consciously making available to Mrs. B. his subjectivity, generating more data that would participate in enriching Mrs. B's experience and understanding of herself [13]. He was no longer restricting himself to the function of self-object but yet Mrs. B. had in front of her an-Other, an object that shared with her his own experience. This change of therapeutic attitude, although it occurred naturally as the therapist and Mrs. B. got closer over time, was nevertheless a conscious one resulting also from the understanding that such a change may be required to cause progress in the therapy. Mrs. B. would learn now how to use this object and not only relate to it. Usage of object has the qualities of a relationship to the Other as an-Other. In Winnicott's words: "Object-relating can be described in terms of the experience of the subject. Description of object-usage involves consideration of the nature of the object. In my opinion a capacity to use an object is more sophisticated than a capacity to relate to objects; and relating may be to a subjective object, but usage implies that the object is part of external reality" [14].
Mrs. B. was learning a new mode, or rather a new quality of interaction with Otherness: "I have lately noticed that one cannot isolate oneself from the world, one cannot live on his own". Could this new quality of interaction and new insights also influence the way she experienced the possibility of her own death? While keeping in mind the resemblance between Heidegger's avoidance of death and Freud's denial of death, both of them related to the impossibility to grasp one's own death, let us yet postulate a major difference. It seems that, if one follows Freud's thoughts, the only existing death may in fact well be the death of the Other. Let us look at how he relates to the commandment: "Thou shalt not kill" (EXO. 20:13), before continuing and trying to understand this important question of the death of the Other through the case of Mrs. B. In Thoughts for the times on war and death, written six months after the beginning of World War I, Freud says: "What came into existence beside the dead body of the loved one was not only the doctrine of the soul, the belief in immortality and a powerful source of man's sense of guilt, but also the earliest ethical commandments. The first and most important prohibition made by the awakening conscience was: Thou shalt not kill. It was acquired in relation to dead people who were loved as a reaction against the satisfaction of the hatred hidden behind the grief for them; and it was gradually extended to strangers that were not loved, and finally even to enemies" [8]. Freud is bringing about Otherness in the question of death. Also, in this quote, one can see that Freud clearly separates the questions of guilt and morality. In Civilization and its discontents [15], Freud proposes that "We ought not to speak of a [moral] conscience until a super-ego is demonstrably present. As to a sense of guilt, we must admit that it is in existence before the super-ego, and therefore before [moral] conscience, too". By separating guilt and moral conscience, Freud invites us to think of something that could be named Guilt without Fault [16]. Freud says: "Before this [discovery of superego], the sense of guilt coincided with remorse. (We may remark, incidentally, that the term ‘remorse' should be reserved for the reaction after an act of aggression has actually been carried out)" [15]. Guilt without Fault is thus resulting from the encounter with the beloved Other's death and could also be called Guilt of the Survivor, or be the impossible response or obedience to "Thou shalt not kill".
As the therapy progressed, Mrs. B. continued to appear gradually calmer, less preoccupied, more positive, showing more vitality and creativity. Mrs. B. started contemplating a separation from her husband with whom she did not get along for a long time, and a departure to France where she would be closer to her daughter and her grand-children, as well as to her roots. "After a certain age, one starts thinking about the past, one wants to go back to known places, or die in the village where one was born.", "I would prefer a funeral ceremony like my parents had".
We previously showed how Freud introduced death of the Other (the encounter with the Other's death), through "Thou shalt not kill". But who is this Other? We shall start looking at this Otherness in its radicality, away from the Sameness of another famous commandment "You shall love your neighbor as yourself" (LEV. 19:18) which commands the loving of oneself in the other, thus seeing the other as another oneself. Indeed, another important question that became especially relevant at this stage was the question of Autonomy. What should be the therapist's stand when, obviously, the therapeutic work has brought about and unmasked needs for major changes in life? Should the therapist intervene in the decision process in such a context, contrarily to what is usually done in traditional currents of psychotherapy where the therapist should absolutely abstain from intervening in the patient's decision process? In the philosophical tradition, autonomy [etymologically, having its own laws] is guarantor of freedom. In that sense, the subject aspiring to freedom should first follow its own moral law. "Now with the idea of freedom the concept of autonomy is inseparably bound up, but with the latter the universal principle of morality, which in the idea grounds all actions of rational beings just as the natural law grounds all appearances" [17]. Or, "Liberty is obedience to the law which one has laid down for oneself" [18]. "You shall love your neighbor as yourself" (LEV. 19:18) is thus understandable as an order to obey to oneself. The Other is another myself and by loving him I would be loving myself. Relation is ruled by Sameness. But according to Levinas, freedom is not dependent on autonomy but rather linked to Responsibility [4], contradicting the notion that autonomy and morality are closely paired.
How is this radical shift from traditional thinking reflected in the relational psychoanalytical stance on Autonomy? Aron proposed that [classical] "psychoanalysis was defined as that treatment which led to the greatest autonomy because it came about through intrapsychic structural change rather than through the relationship with the therapist", further saying that "Psychoanalysis traditionally is aligned with the goal of autonomy and psychotherapy is aligned with the dimension of relatedness" and that "any school of psychoanalysis or psychotherapy has to make use of both autonomy and relatedness, self-definition and dependency" [19]. According to Mitchell, in classical psychoanalysis, "the patient's autonomy was felt to be preserved by removing the analyst's personal impact" [20]. This justified the use of a neutral position on behalf of the therapist. Mitchell challenged and even refused that neutrality could serve the patient's autonomy: "The claim that equidistant neutrality protects the patient's autonomy from the analyst's influence actually masks and disclaims what is often the most powerful influence the analyst has - his impact on constructing the very terms in which the patient comes to think about and struggle with her conflicts" [20]. Greenberg defines neutrality from the perspective of the relational model with the following words: "Neutrality embodies the goal of establishing an optimal tension between the patient's tendency to see the analyst as an old object and his capacity to experience him as a new one […] it is thus not to be measured by the analyst's behaviors at any moment, but by the particular patient's ability to become aware of and tolerate his transference" [12]. In this sense, one could say that neutrality is co-created in the relationship. As one can see, the position of neutrality is not any longer viewed as an ideal (or even a possible) posture to guarantee the patient's autonomy, unless it is defined by relational terms. Hence, the therapist's subjectivity (i.e. the therapist's Otherness, its Alterity) is not anymore seen as a disturbing element of the therapeutic process but rather recognized as an important factor in therapy success [12,13]. Through these perspectives, one can see that therapeutic work is not seeking solely autonomy but also relatedness, through a redefined form of neutrality. In this sense, the therapeutic work moves away from Sameness which promotes the patient's autonomy through transferencial processes and working-through, toward Otherness which promotes relatedness through the sharing and acknowledging common human experience between the patient and the therapist.
One can postulate that Mrs. B., by experiencing adaptive to and for movements on the axis of the Same and the Other in a therapeutic context which gave emphasis to relatedness and allowed these movements, especially those toward Otherness, could start experiencing Thanatos and Eros in a more balanced manner. She became more capable of freeing herself from Thanatos's hold and investing in object love, i.e. experiencing life through the Other. She could listen to what she aspired to, being closer to her beloved ones, those that she had once created in a moment of Otherness which created life.
In Levinas's view of alterity, the Other has no relation to myself. Levinas proposes to see the relation with the Other as a mystery, defined by its absolute alterity: "The relation with the other is a relation with a Mystery. It is the other's exteriority, or rather his alterity, for exteriority is a property of space, and brings the subject back to himself through the light which constitutes his entire being" [21]. In other words, the relation with the Other is rather to be considered as a non-relation, because we are talking here about its exteriority rather than its essence. The subject's sovereignty is thus challenged and, according to Levinas, as the subject becomes worried for the Other's death despite the evidence of its own death, its only remaining role in the context of the encounter is the one of Responsibility [4]. Hence, Levinas is taking us a step further in understanding Death through Otherness, in continuation with Freud's previously discussed positions. One's own death becomes graspable only because it happens to Others: "We encounter death in the face of the other" [4]. One sees now how the remarkable sentence of Freud that was previously quoted pointed in toward Death and Otherness as well as Responsibility (Guilt without Fault), already at the beginning of the 20th century: "What came into existence beside the dead body of the loved one was not only the doctrine of the soul, the belief in immortality and a powerful source of man's sense of guilt, but also the earliest ethical commandments. The first and most important prohibition made by the awakening conscience was: Thou shalt not kill. It was acquired in relation to dead people who were loved as a reaction against the satisfaction of the hatred hidden behind the grief for them; and it was gradually extended to strangers that were not loved, and finally even to enemies" [8].
This extraordinary encounter between the theories of Freud and Levinas questions whether there is or not any other position before death than the one of total responsibility for the Other. The awakening before one's own death could along these lines result from the absolute alterity of the Other. "In my analysis, the face is definitely not a plastic form like a portrait. The relation to the face is a relation to the absolutely weak, to what is absolutely exposed, naked, and destitute. It is a relation with destitution and consequently with what is alone and can undergo the supreme isolation we call death. There is, consequently, in the face of the other always the death of the other and thus, in some way, an incitement to murder, the temptation to go to the extreme, to completely neglect the other. At the same time (and this is the paradoxical thing) the face is also thou shalt not kill. This explanation can be taken much further. Thou shalt not kill is also the fact that I cannot let the other die alone. There is, as it were, an appeal to me" [22].
Finally, let's pay attention to how Levinas defines Love and the tremendous proximity to Freud's notion of ambivalence: "However, it is not my nonbeing that causes anxiety, but that of the loved one or of the other, more beloved than my being. What we call, by a somewhat corrupted term, love, is par excellence the fact that the death of the other affects me more than my own. The love of the other is the emotion of the others death. It is my receiving the other - and not the anxiety of death awaiting me - that is the reference to death. We encounter death in the face of the other" [4].
We would like to conclude this part with the last sentence Mrs. B. said at the end of our last session: "One has to live the life of one's desires, I am leaving to France in order to be close to my daughter and find back an identity".
Levinas's alternative to traditional approaches is a philosophy that made personal ethical responsibility to others the starting point and primary focus for philosophy, including when death is in question. "Ethics precedes ontology" is a phrase often used to sum up his stance. Knowledge, according to him, must be preceded by an ethical relationship. In Levinas's philosophy of ethics, the emphasis is on a relationship of respect and responsibility for the other person. Levinas insisted on the absence of reciprocity in inter-human realm, or asymmetry, called by him "a curvature of intersubjective space" [23]. "The intersubjective relation is an asymmetrical relation" [24].
Levinas invites us to rethink the therapeutic relationship and processes in terms of human encounter and responsibility. From a psychodynamic point of view, it seems that asymmetry has remained a consensual cornerstone of the therapeutic paradigm, despite the changing landscape with regard to neutrality as previously discussed, and mutuality: "I advocate mutual data generation in contrast to unilateral data generation as a general principle of the psychoanalytical method. Nevertheless, I think of the analytical situation as asymmetrical […] My use of the term asymmetry is meant to preserve a space within relational psychoanalytical theorizing, amidst the various dimensions of mutuality, for acknowledgment of and attention to differences in power and responsibility between patient and analyst" [13]. While retaining Aron's theoretical stance on mutuality and asymmetry, we would like to propose to view Responsibility as a mutual element of psychoanalytical work in its essence, yet asymmetrical in its meaning and aims: A positive clinical change of the patient's condition, which is and remains at the center of attention and efforts under the therapist's responsibility, is made possible by an authentic human encounter which necessarily involves the awareness of a shared mortality and the "impossibility of abandoning the other to his aloneness" [25]. Hence, psychodynamic change is allowed by this profound form of human relatedness and shared recognition of common finitude.
In this therapeutic work, a change of approach allowed Mrs. B. to experience Alterity. According to Levinas, both death and the Other represent a way out of solitude for the subject. "But the death thus announced as other, as the alienation of my existence, is it still my death? If it opens a way out of solitude, does it not simply come to crush this solitude, to crush subjectivity itself?" [21]. Hence, Mrs. B.'s encounter with Alterity allowed her to relate to and better cope with her own death. Indeed, this movement from Sameness toward Otherness on the axis of the Same and the Other was accompanied by a clinical improvement as Mrs. B. could relate to the possibility of her own Death with less despair. An increased feeling of autonomy (Sameness) was made possible by neutrality which was co-created and redefined by relatedness (Otherness). But yet, this new quality of interaction with external Alterity would also favor change in her relation with the Others within herself, allowing, to a certain extent, a correction of the premature rupture she experienced early in her life and later reproduced with her daughter. Mrs. B. eventually decided to return to her roots and live close to her daughter and grand-children. Her new relation to Otherness allowed this rapprochement to the Others who originated from within, echoed in Levinas's: "The Other is in me and in the midst of my very identification" [26].
Clarice Lispector, the Brazilian writer, died of cancer at the age of fifty-six in 1977. The Hour of the Star, her last novel, was published on that same year. Lispector dedicated her novel "to all those prophets of our age who have revealed me to myself and made explode into: me. This me that is you, for I cannot bear to be simply me, I need others in order to stand up, giddy and awkward as I am…" [1]. The Hour of the Star is a brief, strange, and haunting tale about Macabea, one of life unfortunates. Macabea, like Lispector herself, came to Rio de Janeiro from the North-eastern poor provinces of Brazil. Like Mrs. B., although for different reasons, she was separated from her parents at an early age and born anew to herself and her future at the moment of her death: "Macabea stood there in bewilderment, uncertain whether she should cross the street now that her life had been transformed. Transformed, moreover, by words - since the time of Moses the word had been acknowledged as being divine. Even when it came to crossing the street, Macabea was already a new person. A person enriched with the future… The moment she stepped off the pavement, destiny (bang) swift and greedy, whispered: Now, quickly, for my hour has come! And a yellow Mercedes, as huge as an ocean liner, knocked her down… Macabea, lying on the ground, seemed to become more and more transformed into Macabea, as if she were arriving at herself" [1]. Finally, just as Mrs. B. who wondered back to her childhood sceneries in France as her disease aggravated, Lispector, shortly before she became ill, began to experience an almost obsessive nostalgia for Recife in the North-eastern State of Pernambuco, where she had spent her childhood. This nostalgia resulted in a sentimental journey to renew contact with scenes and locations associated with her earliest perceptions.