A Cure for Death Anxiety?
A Focused Review of the Yaloms’ Book: A Matter of Life and Death
Dr. Irvin Yalom is an American psychiatrist whose popularity as author and intellectual is unsurprising, but perhaps unexpected. His success is unsurprising because his ability to integrate ideas from philosophy into our understanding of psychology is rare and impressive. Indeed, I imagine few psychologists or psychiatrists practicing in North America possess the combination of philosophical knowledge, creativity and writing ability to create what Yalom has produced in his career.
The unexpected aspect of his success stems from the fact that much of his work has been dedicated to a topic that most would rather avoid thinking of (death) and that his treatment orientation (a type of existential psychotherapy with psychoanalytic and psychodynamic underpinnings) is uncommon in North America given the rise of Cognitive Behavioural Therapy (CBT) over almost the exact period of time he’s been publishing books.
As a practicing CBT psychologist who is open to multiple means and methods by which cognition can be changed — including the discussion of existential and philosophical concepts — I’ve enjoyed and benefitted from Dr. Yalom’s multiple works of fiction and nonfiction. That benefit has not been restricted to professional life alone.
Like most humans, I have death anxiety. Thoughts of the dying process, the loss of connections to loved ones, the severing of opportunity to experience pleasure and joy, and of course the extinguishing of consciousness (the most mysterious and valuable element of existence) are the typical, primary drivers of this anxiety for me and everyone else.
So like many other Yalom readers, I was drawn to his writings partly to explore the terrain of what philosophy and psychology have to offer those contemplating death. A key quality of Dr. Yalom and his writing is the degree to which he engages in self-revelation, which is not often seen among those practicing older methods of psychotherapy — I can still recall a psychodynamic training rotation where one was taught to be a “blank slate”. I’ve neither met nor read a practicing therapist who discloses as much personal material as Dr. Yalom. This is unfortunate because when used correctly it can be a valuable tool for teaching.
So, as someone who has enjoyed and benefited from his writings, and as a person interested in exploring the topics of death and death anxiety, I was excited to finally read Dr. Yalom’s latest book — A Matter of Life and Death, written with his wife Dr. Marilyn Yalom — herself a skilled thinker and professional writer (I will hereafter refer to the authors simply as Irvin and Marilyn).
The structure and premise of the book are unique: the Yaloms alternate chapters offering a first-person perspective on coping with Marilyn’s cancer diagnosis (Multiple Myeloma). I’ve never encountered a book structured in such a personal manner and the authors’ candid transparency is a central strength. The reader moves from Irvin’s experience tending to an ill partner and his personal thoughts coping in such a circumstance to the next chapter covering Marilyn’s experience of being ill and needing to rely on her husband and family.
There is much to be written about this excellent book, but for this review I want to focus on the changes in Irvin and Marilyn’s relationship to death as a consequence of their individual experiences [SPOILER ALERT: For those wanting to read the book completely ignorant of the outcome of Marilyn’s illness, I’m going to discuss it below).
The context is important here — both Irvin and Marilyn are open about their fear of death, and Irvin in particular has made it both a professional and personal point of emphasis and inquiry in his life. He is now having to experience his wife’s mortality and to face the impending nature of his own (he’s in his 80s and requires the use of a pacemaker).
There are two particularly interesting elements to reading Irvin’s attempt to cope with this state of affairs. First, he turns to his own professional work for solace and assistance — he rereads Staring at the Sun, his non-fiction self-help book that aims to help readers manage death anxiety, mostly through philosophical ideas and concepts. His deteriorating memory actually proves useful here as he’s forgotten much of his own writing and starts to benefit from the ideas therein — a sort of unexpected time travel therapy where the younger Irvin is offering support to the older one.
The second surprising aspect of watching Irvin cope through this ordeal is the impact of his wife’s illness and eventual death on his own death anxiety. This is a man who has pondered, struggled and worried about the eventual demise of his own consciousness; indeed, someone whose career focus has been to identify ways to assist those like him reduce their own anxiety.
For all the books, essays and therapy accumulated throughout his life in the pursuit of his own and others well-being in this regard, it ultimately was the loss of another’s consciousness that proved most effective in eliminating anxiety. Since his wife’s death from cancer, Dr. Irvin Yalom is admittedly no longer afraid of death — an apparent cure.
Likewise, his wife also comes to lose her death anxiety, but for different reasons.
Marilyn has an excellent perspective on her life as the battle with cancer prolongs and worsens. She knows the quality of her life has been in the top 1% on both historical and modern levels of comparison with others — the beneficiary of the best life has to offer, including a fine education and meaningful career, a long marriage with a caring partner, many years with children and grandchildren, innumerable (it seemed) friends with depth of connection to many of them, beautiful home, strong finances, travels abroad, and the opportunity to live in one of the richest areas in the country.
But this life has been lost — her energy, focus and ability to enjoy life in general tends to be greatly diminished by the cancer and the cancer treatment. It’s both this loss of life quality and eventually the unthinkable physical suffering that allows death anxiety to recede, as the notion of being pain free forces a radical acceptance of death. Indeed, one of the most powerful and moving events is the description of her actual death and how the decision is made.
One of the prominent pieces of advice that Irvin has offered patients and readers over the years is to diminish regret to the greatest extent possible in one’s life, as it has been a predictor of mental suffering for those nearing death. Both he and his wife repeatedly make clear throughout the book that they’ve indeed lived lives with little regret, as a result of completing most experiences they wanted to achieve. The Yaloms are keenly aware of how blessed their lives have been.
Although the advice to live without regret is undoubtedly true to some extent, and may have helped the Yaloms, it’s worth noting that their regret-free, ultra high-quality lives did not prevent suffering from death anxiety. No matter how wonderful a life one has lived, it’s not sufficient to play a fully protective role.
The Yaloms are atheists, so there was no help from religion or spiritual beliefs. Irvin has written about the meaning attached to legacy — the “ripples” one creates in the world through professional and person actions. This too provided some solace at times — both Irvin and Marilyn wrote about the pride and satisfaction of their careers and relationships, but the healing effects of such thoughts were ephemeral.
Their connections with family and friends were also quite welcome, although these interactions can also be accompanied by the pain of being reminded that time with loved ones is nearing an end. This demonstrates a difficult truth — the more you love something, whether it be a person, a career or even a lifetime — the more pain and threat of pain from possibly losing it.
A Matter of Life and Death makes clear that there is no single or simple piece of advice or idea that could fully protect a person from death anxiety and the human condition. However, experience-based meaning seemed to emerge as potent tool.
As mentioned, it was the experience of Irvin losing his wife. For Marilyn, it was the pain and suffering from her illness. In both cases, it was a critical loss that made death more welcome. Whether it be the loss of a loved one or losing the ability to live with sufficient quality — in either case, there was a threshold reached that rendered the fear of death moot.
Irvin had experienced plenty of loss in his life and this was not the first time Marilyn had suffered. But the intensity of both losses was beyond what they’ve experienced previously and seemingly what they could anticipate.
If there’s a lesson here it’s that we can’t always predict what the experience of life and death will bring to bear. One could read all the great existential philosophers and spend a lifetime preparing for and imagining the experience of dying and death, and yet completely miss the mark of what will actually transpire. For some it will be worse and for others not as awful as imagined…and for some death and dying will be a spiritually positive experience.
Uncertainty is arguably the most reliable cause of worry and anxiety. Those who struggle to live with uncertainty often take steps to mitigate the emotional and cognitive toll by engaging in reassurance seeking, excessive planning, and avoidance via alcohol, drugs, work, etc. Death is the ultimate uncertainty event and many with death anxiety will spend many living hours trying to anticipate, imagine and emotionally prepare for its arrival. For some, this will take on a pathological course.
A lesson from A Matter of Life and Death is that humility is required by all. Not only can we not predict our deaths, but we can never truly know how our beliefs and anxiety will change — through the multitude of life experiences, including the witnessing and experiencing of death and dying in others, and perhaps through a personal experience of pain that is simply too complex and severe to even be imagined.
The meaning of living and dying is what changes. It’s terrifying to imagine death when you’re young, happy and healthy. In this state of life, death is often only considered a senseless loss. Conversely, it can be equally terrifying to imagine living when there is immense suffering and that suffering is no longer attached to meaning. This is a concept developed by the psychiatrist Viktor Frankl in Man’s Search for Meaning. Suffering can offer a sense of purpose and meaning and stoke a desire to live, so long as one can find meaning in its course.
In a podcast interview following the release of the book and his wife’s death, Irvin Yalom admitted to looking forward to joining his wife, even though he believes intellectually that he won’t be consciously joining her anywhere. It appears he now finds a particular form of meaning in death that was not present prior to her death.
Perhaps this is ultimately the best remedy we can hope for — finding a purpose or sense of meaning in death. That meaning might directly relate to one’s death, for example “I’ll no longer have to suffer” or “I’ll be reunited with my loved ones.”
Alternatively, the meaning of death may come from the life you’ve lived — finding a way of comprehending existence in a manner that allows for not just an acceptance of death, but perhaps even appreciation for its meaning in the grand scheme of things. To this end, I’ll share two very powerful quotes that I believe can create a particular form of meaning — one of gratitude.
I’ll start with this quote from Richard Dawkins:
“We are going to die, and that makes us the lucky ones. Most people are never going to die because they are never going to be born. The potential people who could have been here in my place but will in fact never see the light of day outnumber the sand grains of Arabia. Certainly those unborn ghosts include greater poets than Keats, scientists greater than Newton. We know this because the set of possible people allowed by our DNA so massively exceeds the set of actual people. In the teeth of these stupefying odds it is you and I, in our ordinariness, that are here. We privileged few, who won the lottery of birth against all odds, how dare we whine at our inevitable return to that prior state from which the vast majority have never stirred?” — Unweaving the Rainbow: Science, Delusion and the Appetite for Wonder
It’s rare to discover a passage that so powerfully quantifies and articulates the preciousness of our brief existence, something worthy of deep gratitude — even gratitude for the opportunity to die!
Next, I’ll offer a quote that I believe complements Dawkins’ belief and adds something extra. It comes from one of my favourite philosophers, William James. In his lecture titled Is Life Worth Living (printed in the Principles of Psychology), James imagines what could be said to someone contemplating suicide, or as he put it — “What reasons can we plead that may render such a brother (or sister) willing to take up the burden again?”
I cannot review here the reasons and logic offered by James, but I will share the ending of the essayed lecture:
“These, then, are my last words to you: Be not afraid of life. Believe that life is worth living, and your belief will help create the fact. The ‘scientific proof’ that you are right may not be clear before the day of judgment (or some stage of being which that expression may serve to symbolize) is reached. But the faithful fighters of this hour, or the beings that then and there will represent them, may then turn to the faint-hearted, who here decline to go on, with words like those with which Henry IV, greeted the tardy Crillon after a great victory had been gained: “Hang yourself, brave Crillon! We fought at Arques, and you were not there.”
To be clear, I’m not quoting this section to criticize those who end their lives, but rather because I was moved by the sense of pride that I believe is available to all who’ve lived this life. I believe both the aforementioned quotes lend themselves to the following, justified belief -
There is something very special about arriving at the end of a life — not only the “stupefying” odds that it even exists, but that there is an honour in counting oneself among those who endured the pain of existence, to know not just semantically, but experientially what it means to have lived a human life.
Like Dr. Irvin Yalom, by chance or by design, I hope to discover more such meaning along the way. And I hope you do as well.
