(1958). International Journal of Psycho-Analysis, 39:178-181
Fear of Death—Notes on the Analysis of an Old Man1
Hanna Segal
This communication is based on the analysis of a man who came to treatment at the age of 73½ and whose analysis was terminated just before his 75th birthday. He had suffered an acute psychotic breakdown when he was nearing the age of 72. Following the usual psychiatric treatments (electric shocks, etc.), he settled down to a chronic psychotic state characterized by depression, hypochondria, paranoid delusions, and attacks of insane rage. Nearly two years after the beginning of his overt illness, when no improvement occurred, and when the psychiatrists in Rhodesia, where he lived, gave a hopeless prognosis, his son, who resided in London, brought him for psycho-analytical treatment.
His treatment with me lasted eighteen months. It was not, of course, a completed analysis, but it dealt sufficiently with the patient's outstanding problems to enable him to resume normal life and activity and to achieve for the first time in his life a feeling of stability and maturity. At the moment this paper is going to press, the patient has been back in Rhodesia for 18 months, enjoying good health and having resumed his business.
In his analysis I came to the conclusion that the unconscious fear of death, increasing with old age, had led to his psychotic breakdown. I believe that the same problem underlies many breakdowns in old age.
In a paper of this length I cannot give a complete picture of the patient's history or psychopathology, and I shall mention only such points as are relevant to my theme.2 He came from a little Ukrainian village, of an extremely poor orthodox Jewish family. His childhood was marked by fear of starvation and freezing during the long, cold winters. He had seven siblings, with nearly all of whom he was on bad terms. His mother was, to begin with, portrayed as greatly favouring his older brother, while he himself was a favourite of the father. In contrast to the mother, who was felt as cold and rejecting, the father was idolized, but also greatly feared. Following his father's death the patient, then 17, fled from the Ukraine, and after a long hard struggle eventually established himself in Rhodesia as a middleman salesman. He had not tried to keep any contact with his family which remained in the Ukraine. He also largely broke away from Jewish orthodoxy. He married and had two daughters and one son. He idealized his family, but in his business relations he was suspicious and persecuted. For several years he had been addicted to secret drinking.
The circumstances of his breakdown are relevant to my theme. It became apparent early in his analysis that there were three precipitating factors of his illness. The first was his first visit to his son, who was studying medicine in London; the second was his meeting (during the same visit) his younger brother, from whom he learned that all the members of his family who had remained in Europe had perished in Hitler's camps during the war; the third and immediately precipitating factor was an incident which happened when he returned to Rhodesia. He had for several years given bribes to a man in order to get business from his firm. During the patient's absence this man had been caught in another dishonest deal. As soon as the patient heard this, he felt terrified that his own bribery would be discovered, and within a matter of hours he was in a state of acute psychosis with delusions of reference and persecution, centring, to begin with, on his fear of his deal being discovered, and his being punished and ridiculed. He believed, for instance, that newspapers contained articles about him, that radio broadcasts were being made, people laughed at him in the streets, etc.
I suggest that my patient was unconsciously terrified of old age and death, which he perceived as a persecution and punishment; that his main defences against this fear were splitting, idealization, and denial. His visit to London had shaken his defences. His idealization of his only son broke down. The news he received about his family had broken down his denial of his family's death and the resulting guilt and fear of retaliation. When he returned to Rhodesia he was faced with the fear of punishment, which to him at that point represented death.
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1 Paper read before the 20th Congress of the International Psycho-Analytical Association, Paris, July–August, 1957.
2 A fuller case history is now awaiting publication.
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From the point of view of the patient's anxiety about death, the analysis could be divided into three phases. The first was characterized by complete denial of ageing and fear of death. He described himself as having always been very young for his age, working and looking like a young man, etc., until the beginning of his illness, which he felt had robbed him of his youth and health. He unconsciously expected that his treatment would give him back his youthfulness. It soon became apparent that this denial was made possible by the patient's idealization of his son, who represented to him another self, young and ideal, into whom he had projected all his own unfulfilled hopes and ambitions. He used to send him parcels every week, and on these parcels all his interest and love centred. He put himself into these parcels sent to his son, in whom he lived, untouched by age. This relationship to his son was partly a repetition and partly a reversal of his relation to his own father. The father appeared early on in the analysis, particularly as a loving and feeding father. In relation to him the patient had developed an unconscious, intensely idealized, oral, homosexual relationship. He was the father's favourite, and he felt that so long as he had his father's love and could orally incorporate his penis, he would be protected from starvation and cold, ultimately from death. With his son he partly repeated and partly reversed this relationship. He identified himself with his father and projected himself, the favourite son, into his own son, thereby prolonging his own life. This projective identification of his young self into his son kept fears of persecution and death at bay. He also at times projected his idealfather into the son, and expected to be fed and kept alive by him for ever.
Accompanying this idealization there was a great deal of split-off persecution. Parallel to his ideal son there was a son-in-law like a black twin, his main persecutor. In the past the father had been perceived mainly as loving, while the brothers were remembered for bullying and terrifying him. Any feeling of persecution that appertained to his father was immediately split off and projected onto his older brothers. In the background there was a picture of an unloving and cold mother. The feeling of persecution that he experienced in relation to her has been mainly transferred by him on to the various countries he lived in, which he completely personified, and invariably described to me as treating him badly, exploiting him, and refusing to give him a livelihood. None of this split-off persecution could, to begin with, be mobilized in the transference. I represented mainly his idealfather and son, occasionally merging with an ideal feeding mother. He had projected into me all the ideal figures, including his ideal self, in projective identification. His bad feelings and figures he had projected on to remote persecutors. So long as he could maintain this idealization of me, I would protect him from persecutors and he would be safe.
The second phase of the analysis was ushered in by the first holiday, which the patient acutely resented; when he came back it was more possible to make him aware of his feelings of deprivation. The splitting lessened; the persecution came nearer to the transference. The bad countries of the past stopped playing such a rôle in his analysis, and the persecution now centred on the very cold English winter which was going to kill him. Death was no longer denied, it seemed to be there, round the corner. The split between his son-in-law and his son also narrowed. To begin with, he could maintain quite simultaneously that his son brought him to London where he was going to be made completely well again because he had his wonderful analysis, and at the same time that his son-in-law sent him to London to die of cold. Gradually it was possible to point out to him how much his son-in-law was the other aspect of his son, and how much the cold climate and country that was going to kill him was the other aspect of the analytical treatment and of myself. At that point his disappointment in his son during his first visit to London came to the fore. He had admitted that his son had not lived up to his expectations. He kept repeating: 'It wasn't the same Harry, it wasn't what I meant for Harry.' He admitted that he had felt completely robbed, that he had put his potency, his life, his love into his son and then that in losing the son he was losing his own potency and life and was left to face death alone. Having to face that his son, though devoted to him, led in fact a life of his own, was felt by him as losing his greatest hope, namely that his son would give him a new lease of life.
At this point it became clear to the patient that his ideal and his persecutory object were one and the same person. In the past he had split off his fear of his father on to his brothers. Now he saw clearly that it was his father's retaliation that he was afraid of. He feared that his son would leave him to his persecutors and to death and disown him, as he had left and disowned his family. Earlier on in the treatment he said that before he left the Ukraine he had to put a stone on his father, and worked very hard to earn the few shillings to purchase this stone for the grave. To begin with it appeared as an act of mourning and piety; now it became clearer that he had to keep under the stone a very frightening and revengeful ghost of his father. In the transference it also became clear how much he had either to placate me or to control me in order to prevent me from becoming a persecutor. The persecution by his mother also came vividly to the fore: it was experienced as cold and starvation and as being abandoned or actively poisoned. He remembered that his younger brother was fed by a Christian wet nurse. One day this girl squirted some milk in his face, and he fled terrified, feeling
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soiled and poisoned. Being burnt up or broken inside (a frequent description of his hypochondrical symptoms) was also felt by him as somehow connected with his mother. As his experiences of persecution were becoming more explicit and more connected with the real objects—myself in the transference, his son, and finally his experiences with his early family—it was also becoming clearer that these persecutions which he was either expecting or currently experiencing were felt by him as punishments. With his admission of these fears of persecution and punishment, he could overtly admit his fear of death. He felt that his idealization of me was his only protection against death. I was the source of food, love, and warmth, but equally I was the killer, since I could bring him death by withdrawing them. Idealization and placation of me alternated with only thinly veiled persecutory fears.
As this split in his perception of me lessened, so did the projection, and gradually he was able to admit his aggression in relation to me. This ushers in the third phase of his analysis, during which the persecution and idealizations gradually gave place to ambivalence, a sense of psychic reality and depressive anxieties. Slowly he was beginning to realize that if his symptoms now appeared only during breaks and weekends it was not simply because I, the ideal object, abandoned him to his persecutors; he was beginning to realize that everything I had given him—interpretations representing the good breast and food or the good penis—turned in my absence to bad burning, poisonous, and persecutory substances, because when he was away from me, hatred welled up in him and turned everything bad. He began to admit more freely how greedy he was for the analysis and for my presence, and how impatient and angry he was when away from me. His son and I were becoming more and more in his eyes the oedipal couple, always together when we were not with him, his son representing now the father, now his younger brother—a partner of myself standing for his mother. He recalled vividly the birth of his younger brother and the absolute fury he experienced not only in relation to the baby and the mother, but also to the father who gave mother this new baby. We reconstructed that he was weaned at the birth of this brother when he was about two. He remembered soon after that there was a fire which destroyed nearly the whole village, after which his family had been practically homeless, living in one room in an inn. It became clear that this fire was felt by him to be a result of his own urinary attacks. These were relived with such intensity that for a few nights he actually became incontinent.
We could now trace the beginning of his secret drinking to the beginning of the war in 1939, which produced in him a severe unconsciousdepression which he controlled by drinking. The beginning of the war unconsciously meant to him the destruction of his family. He admitted that, had he thought of it, he might have brought his family over to Rhodesia and saved their lives. He felt that he had had all the luck; he took the father's penis and then he turned against his family in anger, superiority, and contempt, and left them behind to be burnt and destroyed. He unconsciously internalized them and carried inside himself the concentration camp with its burning and breaking up. But, unable to bear his depression and guilt, he split off and denied it, and turned to drink as in the past he had turned to an ideal homosexual relationship with his father. When in his analysis he began to face what the beginning of the 1939 war meant to him, he experienced a great deal of guilt in relation to his family and particularly to his mother. His previous valuation of her had become very altered. He realized what a hard struggle she had had to keep the family alive, and that the bad relations that existed between himself and her were at least partly due to the way in which he treated her, turning from her with anger and contempt to the idealized homosexual relation with his father, thereby robbing her both of himself and the father. He then experienced mourning about his family and particularly about his mother, and with it relived his early weaning situations with her, his deprivation, jealousy, envy, his urinary attacks on her which he felt had left her empty and bad, so that she was unable to feed his younger brother. Together with this changed relation to his mother and family came a very altered relation to the idea of his own death. The end of the treatment had then been already fixed, and symbolized for him his approaching death, of which he now spoke very freely. It appeared to him as a repetition of weaning, but now not so much as a retaliation and persecution, but as a reason for sorrow and mourning about the loss of something that he deeply appreciated and could now enjoy, which was life. He was mourning his life that he was going to lose, together with his analysis that was ending, and for the first time he was mourning fully the mother, and the breast that he had lost in the past. He also felt some longing for death, expressed mostly in his wish to go back to Rhodesia to meet his old friends again, which symbolized his wish to die and to meet his dead parents of whom he was no longer frightened. But the mourning and sadness were not a clinical depression and seemed not to interfere with his enjoyment of life. In fact, he began to feel that if this life, this life-giving breast was something that he was going to mourn for so much, then, as he told me, he might as well enjoy it and do his best with it whilst he could.
In the last weeks, particularly in the last days of his analysis, he repeated some main themes in his associations, but not in symptoms, and I here select a few associations from the last week. The first day he spoke angrily about somebody who behaves like a cow; he gives one a bucket of milk and then kicks it. I interpreted that I was the cow who
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gave him the analysis, like the mother who gave him the breast, but by sending him away was kicking it and spoiling it all, and was myself responsible for kicking the bucket, that is my own and his death. The next day he came back to this association and said in a dejected way that it was he, in relation to his mother, who often behaved like the cow that kicked the bucket. Later he said that she was the cow and he kicked the bucket that fed him; and he accepted my interpretation that his anxiety was that when he has to leave me he will be so angry that he will kick me inside him and spoil and spill out all the good analysis, as he felt he had done with his mother's breast, and that he would be responsible for my death inside him and for his own death. On the third day he spoke about a jug; he said that one must not judge a drink by the jug it is carried in, and he associated that he was the jug; old and unprepossessing, but the stuff that he contained could be good; it could be beer, he said, or milk. In associations it became quite clear that the beer and milk represented the good breast and the good penis, the mother and father, and myself in both rôles, inside him. He felt that he had re-established his good internal objects.