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A Brief History of Death and American Psychiatry

Martinovic, Jelena PhD

Section Editor(s): Lunbeck, Elizabeth PhD; Editor

doi: 10.1097/HRP.0000000000000216
History
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From the University College London, Health Humanities Center/Institute of Advanced Studies; Department of History, Goldsmiths, University of London; Centre Hospitalier Universitaire Vaudois and University of Lausanne, Institut des humanités en médecine. Email: j.martinovic@ucl.ac.uk

The history of psychiatry and death remains to be written. Traditionally, psychiatrists have not been concerned with death. Rather, they have dealt with it in indirect ways; through suicide prevention, forensic psychiatry, and, most notably, the study of individual attitudes toward death. Thus, before the advent of modern palliative care, commentaries on death were predominantly written in a psychoanalytical fashion. Sigmund Freud published his famous commentary on war, terror, and destruction, introducing the idea that death is unimaginable to humans and that they therefore do whatever they can to deny it. In the 1930s, studies examined individuals’ suicidal tendencies from a comparative perspective or analyzed soldiers’ reports on imminent death to advance the semiology of trauma disorders. Empirical studies conducted in the immediate post–World War II period focused on survivors of the Holocaust and, in particular, on their experience of prolonged exposure to the threat of death, thereby laying the groundwork for humanistic psychotherapy.1

In the second half of the twentieth century, however, psychiatrists in the United States assumed a leading role in evaluating the cultural, ethical, and psychological aspects of death and dying. In the 1960s, psychiatrists developed their skills in the nascent field of end-of-life care and debated the dying experience publicly. During the same decade, while palliative care and medicine were being institutionalized and professionalized, criticism of psychiatry’s role in managing dying also mounted. Despite those criticisms, post–World War II psychiatric commentaries on death remain influential today. For example, we still think of dying as a psychological experience or of denial of death as a typically Western phenomenon.

In what follows, I discuss how psychiatrists focused on becoming experts on death in the period from 1950 through 1980. I argue that American psychiatrists—both clinicians and scholars—were instrumental in framing the mid-twentieth-century debate on the “taboo of death.” This debate concentrated on the argument that death had been silenced as a consequence of advances in biomedicine—in particular, intensive care medicine—and its quest to prolong life. Psychiatrists’ contribution to that discussion was to explain dying as a psychological process, or “psychic event.”2 Furthermore, the “experience of dying” became a key topic for mental health professionals. More broadly then, American psychiatrists in the mid-twentieth century pooled insights about death and dying from different fields and epochs—as far back as antiquity—to make their main claim: dying should happen consciously and without agony. To demonstrate this development, I first provide contextual elements to explain how and why psychiatry played a central role in the American “rediscovery of death.”3 I then focus on two examples to illustrate ways in which psychiatrists, based on their observations of terminally ill patients and survivors, described dying processes: first, pain management with LSD, and second, investigations of near-death experiences. Finally, I examine how psychiatrists linked these clinical insights to historical notions of an “easy” and “good death.” In conclusion, I reflect on the legacy of psychiatrists’ contributions to the study of death, and question their relevance today.

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AN AMERICAN “REDISCOVERY OF DEATH”

The intellectual debate on death in the mid-twentieth century was an important moment for the development of bioethics. It concentrated on ethical issues that arose in intensive care units and focused on the conditions of critically and terminally ill patients. In Europe, the debate surrounding death was predominantly led by the social and human sciences, whereas in the United States, psychologists and psychiatrists brought it to the attention of the broader readership. It is therefore possible to talk about a specifically “American” rediscovery of death in which psychiatrists played a leading role: they defined death in a psychological manner and talked publicly about the experiences of their patients. One prominent example of this public development are the Death and Dying Seminars, organized by Swiss-American psychiatrist Elisabeth Kübler-Ross and her colleague, the pastor Carl Nighswonger, at the Billings Hospital (1965–69).4 The goal of their educational program was to teach staff how to communicate with, and take care of, patients who suffered from incurable illnesses. Yet, the seminars were also opened to lay people who wanted to learn more about dying in the hospital and the coping strategies of patients. The seminars were extremely well attended and covered by Life Magazine.5

Popular interest in dying and the active role of psychiatrists in encouraging such interest led practitioners to reflect on the meaning and timing of this development. The retired Bellevue psychiatrist Walter Bromberg noted that his 1930s study on “mental reactions” to death garnered no interest at the time but was suddenly widely cited in the 1960s.6 Likewise, Herman Feifel argued in 2012 that before the publication of The Meaning of Death, a seminal book of essays he had edited in 1959, “academic attention to death was no more than a few flashlights from a lighthouse.”7

What helped leverage the discussion on death in the 1960s? What drew readers to these authors, and others like them, at that time? A number of historical factors led to the development of psychiatric expertise in, and the American rediscovery of, death. First, post–World War II psychiatry gained prominence both in medicine and in society. In the wake of the National Mental Health Act of 1946, psychiatrists received increasingly significant financial support to allow them to diversify preventive skills and engage with other specialists, such as pastoral caretakers, counselors, psychologists, and community workers.8,9 This, in turn, opened up new avenues of research in hitherto unexplored fields, such as cancer research and end-of-life care. Second, the newly dominant role of oncology in biomedical research increasingly shifted the focus in psychiatry toward evaluating the emotional reactions of patients suffering from cancer and, more generally, critical illnesses. Third, suicide prevention became increasingly concerned with the motivations of survivors of suicide attempts and the impact of this experience on their personalities. Fourth, at a time prior to the classification of mental disorders in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), psychiatrists were studying experiences of near-death in connection with survivor studies. Fifth, an aging society and the growing field of geriatrics gave additional impetus to research on death and dying,10 including studies in which attitudes toward death “among the aged”11 were compared to those of children and adolescents.12 Sixth, the development of palliative care and medicine, an increasingly institutionalized field in the late 1960s, allowed psychiatrists to consider pain, emotional distress, and depression of the dying within a broad range of psychiatric literature, from grief to depression, as well as to develop specific psychotherapeutic support for terminally ill patients and their families.

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THE PALLIATIVE TURN

Palliation was the main impetus behind the modern hospice movement: easing the severity of pain and offering care for patients who cannot be cured. Hence, in the 1950s, palliation was predominantly discussed in relation to the use of narcotics and analgesics.13,14 Psychiatrists (together with nurses and anesthetists) started to examine the emotional suffering of patients in end-of-life care, and of those who were receiving acute treatment, more carefully. The first seminal text that offered psychiatric expertise in end-of-life care was Kurt Eissler’s The Psychiatrist and the Dying Patient,2 published in 1955. In that book Eissler primarily focused on patients suffering from neurosis and revisited different strands of thanatology, the “science of death.”15 He brought together insights from across different periods, from Sigmund Freud to Martin Heidegger, to highlight the importance of psychiatrists in their role as caretakers of the dying. Eissler’s immediate successors dealt more specifically with the mental distress and anxiety observed in patients diagnosed with severe illnesses. Daniel Cappon,16 for example, described suicidal, paranoid, and schizoid ideation as tendencies among critically ill patients. By contrast, Arnold Hutschnecker,17 a specialist in psychosomatic illnesses and former psychotherapist to Richard M. Nixon, distinguished between different personality syndromes in “patients dying from different diseases” (e.g., cancer, coronary thrombosis). Based on Thomas Szasz’s approach to carcinogenesis,18 Hutschnecker17 claimed that psychological factors influence the growth of cancer cells. In the following decade, publications on life-death problems in psychiatry multiplied, with studies on “the predilection to death”19 or the “responsibility” of psychiatrists20 in delivering care to terminally ill patients.

The growth of oncology in post–World War II American medicine21 provided an unprecedented opportunity for psychiatric and psychological studies on large numbers of patients suffering from cancer and other incurable illnesses. This period also fostered collaborations between psychiatrists and oncologists: observations on patients from cancer wards or intensive care units gathered by psychiatrists were published in specialized oncology journals.22,23 In 1965, the Group for the Advancement of Psychiatry meeting dealt predominantly with malignant disease. Entitled “Death and Dying: Attitudes of Patient and Doctor,” the meeting focused on communication skills (how to announce impending death to patients) and examined patients’ attitudes and affective reactions to advanced malignancy.

More generally, focusing on mental health problems in patients dealing with fatal diagnoses allowed psychiatrists to introduce expertise, such as that related to grief. In fact, psychological conceptions of dying were significantly shaped by grief studies.24 For example, Erich Lindemann’s 1944 study of the adaptive strategies of survivors of the Cocoanut Grove fire (a nightclub fire in which nearly 500 perished)25 was used to characterize patients’ reactions to fatal diagnoses. Knight Aldrich developed the concept of anticipatory grief reaction26 in relation to Lindemann’s study. This notion was subsequently taken up to assess a dying patient’s adaptation to separation and loss.10

Denial was another key theme of the psychological approach to dying at the time. Avery Weisman,27 for example, characterized the course of a life-threatening illness as a battle of two contrasting forces—denial and acceptance—against time. In a study conducted in 1967, the physician compared the “denial reactions” of 20 patients hospitalized with acute myocardial infarction to 20 patients dying of cancer, observing that a “conspiracy of silence surrounds the dying cancer patient.”28 Yet the study also showed that the patients were aware of their fatal outcome and developed strategies to cope with it, whereas professionals sometimes lacked the courage to address the critical issue of dying. Another important contribution came from the work of Kübler-Ross. The psychiatrist and therapist coined the term death and dying and, while examining the conditions of the incurably ill, also developed the five stages of dying/grief. In her theory, denial is the first stage in a learning process that leads to acceptance. Kübler-Ross’s model echoes humanistic principles: it suggests that a person “dies well” if she or he knows how to overcome negative life experiences and transform them into a positive source of personal growth. More specifically, Kübler-Ross considered the incurably ill as “teachers” whose experience should be used to reduce fears of death in Western societies.

Further contextualization is needed with regard to psychiatrists’ engagement in portraying dying as a positive experience. Interest in illness narratives and in death and dying studies increased significantly in the 1960s because of ethical debates about biomedical definitions of death and life. These debates were triggered by advances in treating cardiovascular diseases, by developments in emergency medicine and life-sustaining treatment, and by the newly introduced definition of irreversible coma in 1968 by the Harvard Ad Hoc Committee. Patients’ rights, doctors’ duties, and ethical concerns about organ transplants were being discussed, and psychiatrists participated in the debate. They criticized biomedicine for “dehumanizing” and “silencing” death. For example, in her personally written account in On Death and Dying, Kübler-Ross located the origins of the modern “taboo of death” in biomedical progress. Kübler-Ross and many others at the time expressed their support for treating the incurably ill without the use of medication. Others, however, came to see their role specifically as one of physical pain alleviation. Psychedelic therapists sought to test whether psychopharmacology could alter pain perception and, by ultimately reducing the patient’s fears, lead to a change in attitude toward life and death.

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PAIN MANAGEMENT WITH LSD

Pain management, like oncology, was one of the most significant post–World War II developments in biomedicine and experimental research.29 The establishment of pain clinics after World War II, concomitant with an increase in the administration of narcotics during end-of-life care, led to a series of models (such as gate control) that considered pain perception as a psychological phenomenon, dependent on individual, cultural, and religious factors.30 A range of new, often interdisciplinary experiments and treatments led to a major shift in medicine: a person-centered approach.29

Today, as in the past, psychoactive substances are seen as potentially powerful agents that open access to psychological material. Psilocybin is at present administered in low doses to patients who deal with death-related anxieties; in the past, physicians focused on LSD. Although the use of lysergic acid diethylamide had tapered off in official research laboratories and treatments by the mid-1960s—largely as a result of growing controversies over its consumption and the decrease in supply—one of the last sectors in which LSD was used was end-of-life care.

The first study of this use for LSD was designed specifically for cancer patients and was conducted by Eric Kast and Vincent Collins of Chicago Medical School and Northwestern University School of Medicine, respectively. Published in 1964, the study measured LSD’s efficiency in comparison to other analgesics. Kast and Collins31 selected 50 patients who complained of “severe intolerable pain” due to a critical condition or metastatic cancer. Upon complaints about pain, patients received doses of either dihydromorphinone or meperidine (100 mcg), and if complaints about pain persisted, the second drug was administered after at least six hours. Upon further complaints (and at least six hours later), patients were administered 100 mcg of LSD.

In that study, pain perception was treated as both physiological and psychological. Drawing on the work of Thomas Szasz (Pain and Pleasure)18 and others (e.g., K. H. Beecher and Robert Wallerstein), Kast and Collins31 were convinced that LSD could potentially reduce “the need to maintain bodily integrity” and “ego boundaries.” In 1966, Kast32 published further results. Based on data collected from 80 patients who suffered from terminal malignant diseases (with a life expectancy of weeks or months), the clinician administered 100 mcg of LSD, which was followed by three weeks of daily observations to assess its “psychic effects” on patients. Kast evaluated pain perception, “metaphysical and affective reactions,” sleep patterns, and, most importantly, “attitudes toward dying.” The last was measured with the help of a numerical scale, labeling attitudes that ranged from (1) “I want to die, life has nothing to offer to me,” to (2) “I want to live, but it does not mean anything to me,” to (3) “life is great, the concept of death does not frighten me.”32 Of the 80 patients, 72 claimed to have gained special insight, and 58 found the experience pleasurable. The authors argued enthusiastically that LSD-generated imagery created “a new will to live and a zest for experience.” Similar arguments were made by a Los Angeles psychiatrist, Sidney Cohen,33 an early enthusiast and later harsh critic of psychedelic drug consumption, who hoped that LSD would provide “a brief, lucid interval of complete egolessness” that would allow a patient suffering from malignant disease to “come to terms with the pain and misery.”

The faith that clinicians had in LSD as an aid in psychotherapy is reflected in research carried out at Spring Grove State Hospital and Maryland Psychiatric Research Center in the state of Maryland.34 There, treatments were designed especially for patients suffering from terminal illnesses—in particular, metastatic cancer. One seminal study, published in 1970, was led by psychiatrist Walter Pahnke and Albert Kurland.35 Pahnke had previously conducted studies with psilocybin at Harvard University, in which he approached psychedelic experiences from the perspectives of both philosophy and experimental psychology. His study in Maryland involved psychiatrists, nurses, family therapists, and oncologists who designed treatments in accordance with patients’ medical and personal records. The therapeutic approach was a combination of existential therapy (patients ideally reached a “peak experience”) and pain management (the analgesic effect of LSD was evaluated in comparison to other analgesics that patients were receiving during their normal treatments). The critical nexus between provoking existential angst and life-transforming experience was further emphasized by Stanislav Grof and Joan Halifax. Also working at the Maryland center, they supported their patients in achieving a “perinatal experience” (the return to a pre-birth state) in order to trigger a “transpersonal” catharsis capable of reducing their fears.36

LSD cancer therapy thus offered a promising model for a clinical association between pain perception and the anticipation of death. It also allowed researchers and clinicians the opportunity to apply, and experiment with, recently developed models of psychotherapy, such as family therapy.

Psychedelic studies contributed to the idea that death can be “mimicked.” In the experimental laboratories cited above, the simulated dying process serves a psychotherapeutic purpose in which the therapist “guides” the patient through anxiety-provoking sensations and perceptions to address what are believed to be the patient’s key issues. For some practitioners, the simulated “death experience” was not sufficient, and they started to look for a “natural” type of dying experience. They questioned people who had nearly died but who had survived a life-threatening situation. Thus, survivors—of accidents, near-drownings, attempted suicide—became the new key informants who helped psychiatric death experts to combine clinical and sociocultural data.

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SURVIVORS’ EXPERIENCES BEFORE THE IDENTIFICATION OF POSTTRAUMATIC STRESS DISORDER

The 1970s saw a series of significant changes in academic psychiatry that transformed studies on death and dying and ultimately led to the development of a novel field, the systematic investigation of near-death experiences. These changes included the following: the growing support for social psychiatry and epidemiology;37 the establishment of classificatory approaches to mental illnesses and disorders, which led to the revision of DSM-II; and the institutionalization of medical humanities, which was a response to the waning of psychoanalysis in academic psychiatry.38 As a consequence of these changes, some psychiatrists and psychologists continued to adopt an approach to mental health and dying that integrated medical humanities and descriptive/classificatory methods. One distinctive example of this integration can be seen in the work of the psychiatrist Russell Noyes Jr. and clinical psychologist Roy Kletti, who worked in the 1970s at the Iowa Hospitals and Clinics, directed at the time by George Winokur. They began to transform lessons from the past—narratives on dying and reports from the nearly dead—into empirical research for the present. Noyes and Kletti’s project was to collect and systematically evaluate experiences from survivors of nearly fatal accidents to measure the impact that a dangerous, life-threatening experience had on the beliefs and attitudes of the surviving individual. Looking at these studies enables us to see how psychiatrists evaluated survivors’ experiences before DSM-III (1980) introduced posttraumatic stress disorder as a distinct disorder.

Noyes and Kletti read extensively on death and dying, from William Osler to Kübler-Ross, and translated key studies, which they made available to the growing community of thanatologists and the field’s specialized journals. The foundation of thanatology was established in 1969 in New York. Referring to thanatos (in Greek, death), its purpose was the scientific and multidisciplinary study of death and dying. This effort led to the founding of Omega: The Journal of Death and Dying in 1970, followed by the Journal of Thanatology: The Scientific Study of Death (published from 1971 to 1975), Essence (published from 1976 to 1981), and many others. These journals offered extensive commentary on “the art of dying.” Noyes and Kletti published several important pieces in those journals. Noyes commented on passages from Michel de Montaigne’s Essays and evaluated them from the perspective of biomedicine and ethics,39 and Kletti translated and commented on a study conducted in the 1930s by Swiss psychoanalyst Oskar Pfister and also on one by Swiss geologist Albert Heim on accidents in the Alps, published originally in 1892.40,41 In fact, the work by Pfister and Heim laid the foundations for Noyes and Kletti’s theoretical interpretation of near-death experiences and methods of conducting surveys with survivors.1

However, the most important contributions of Noyes and Kletti was to revive the use of the syndrome of depersonalization to describe a near-death experience. Thus, at around the same time that Raymond Moody published Life After Life (1975) and declared that the near-death experience proved the survival of the soul after bodily death, Noyes and Kletti revived a quite different literature that led back to nineteenth-century clinical descriptions of depersonalization. At the intersection between neurology, psychoanalysis, phenomenology, and studies on affective reactions, the researchers invoked depersonalization to describe a transient protective mechanism triggered by a life-threatening situation. Taking account of earlier work that saw depersonalization as either a normal adaptive response to anxiety or a protective mechanism masking anxiety, they delineated a transient depersonalization syndrome with two “opposing reaction tendencies”: “one serving to intensify alertness, and the other to dampen potentially disorganizing emotions.”42 Based on the distinction between the observing and participating self, from the writings of H. J. Shorvon43 and Jacob Arlow,44 Noyes and Kletti42 illustrated the personality split using a series of subcategories and tensions, such as reality (sense of increased familiarity—estrangement); sensation (heightened perception, imagery—perception, mental imagery dulled); attachment (heightened awareness of body—detachment from body); and memory (revival of memories—loss of memories).42(p 383) Noyes and Kletti further developed the category of memory via the concept of panoramic memory. A somewhat apocryphal term, it refers to the often-reported claim by victims of nearly fatal accidents that in the “midst of a danger,” sequences from their lives “flashed before their eyes.”45 Labeled interchangeably as panoramic/memory review, life-review phase, or revival of past images, this phenomenon had been widely discussed by alienists and neurologists since the mid-1800s. It has been explained as a pathology of memory46 or as an epiphenomenon of déjà vu (observed in epilepsy).47 Notably, déjà vu was also a major concern for psychoanalysts, from Freud’s memories of the Acropolis to Castelnuovo-Tedesco’s The Mind as Stage.48

Noyes and Kletti’s associating of depersonalization and panoramic memory to describe a psychological response to the threat of death was not entirely novel, but it was significant because it connected death and dying studies to trauma studies that conceptualized shock as beneficial to a survivor’s mental health. In fact, the researchers reintroduced the work of Oskar Pfister (and to a lesser extent, that of Otto Fenichel) to claim that a near-death experience is potentially transformative. Both Pfister and Fenichel argued, based on analyses of shell-shocked World War I soldiers, that repressed memories from childhood protect the individual from trauma in a life-threatening situation: “when the unconscious protects us from shock, it occupies us with emotionally comforting images.”40 Both also argued that these images can awaken memories of past dangers that have been surmounted, reminding individuals that the current danger can be managed—and death, avoided. Fenichel49 called this tendency to “repeat the traumatic scene” screen experience. Pfister50 used the term shock thoughts and fantasies to describe this same phenomenon, suggesting that some self-healing can be seen in potentially traumatic, life-threatening events.

Noyes and Kletti’s reactivation of Pfister stood in stark contrast to the developing literature on posttraumatic stress disorder, which considered the experience in a life-threatening situation (war, disaster, violence, abuse) from a diagnostic perspective of trauma. Their interpretation has to be viewed, however, within a broader context in which personality dissociation was conceptualized from a humanistic and, increasingly, transpersonal perspective. It also connects to psychological studies on extreme sports that cast risk taking, dangers, fears, and anxiety as sources of well-being.51 More importantly, however, their work resonates strongly with contemporary studies on survivors of attempted suicides. Two researchers in California must be mentioned in this regard: Richard Seiden of the University of California, Berkeley and David Rosen of the Langley-Porter Neuropsychiatric Institute in San Francisco. These researchers interviewed survivors who attempted suicide by jumping from the Golden Gate Bridge and San Francisco–Oakland Bay Bridge in the early 1970s.52,53 They wrote of one survivor who said that when he hit water, he realized that he needed a life-style change and actually began to believe in God. The popular press picked up on this, reporting that the survivor is a “man more rare than the apostles. He can tell you about his leap from Golden Gate Bridge. It was not lethal. It was exhilarating.”54 Adopting a post-Jungian psychological perspective, Rosen52 turned the survivors’ experiences into life lessons of conversion and growth. His position echoes Grof’s symbolic interpretation of death; Grof55 argued that “the shocking emotional and physical encounter with the phenomenon of death is the opening up of spiritual and religious dimensions that appear to be part of an intrinsic dimension of human personality.” Similarly, James Hillman,56 the founder of archetypal psychotherapy, compared attempted suicide to a “personal transformation.” As these examples show, potentially devastating experiences were reinterpreted as a source of spiritual and personal renewal. (This conclusion did not match with the experiences of all survivors interviewed by Rosen.) To a great extent, these suicide studies also reflect the impact that Tibetan Buddhism had on Western conceptions about death and dying at the time. To give an example, The Tibetan Book of the Dead (with a foreword by C. G. Jung) was a highly influential book, which circulated widely in therapeutic circles. Its reception and interpretation at the time reflect the extent to which Western psychologies appropriated Oriental philosophies to explain the dying process as a mystical or psychic event.57

The survivor studies that I have discussed here offer an empirical counterpart to work done in cancer ward units; they give insights into the beliefs of the general population. Moreover, these studies show how information gained from survivors contributed to the development of new psychotherapeutic approaches. But, ultimately, the survivors’ narratives indicated that death, if experienced unexpectedly, may unfold without sensations of pain.

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EASY DEATH PAST AND PRESENT

Death is not only a medical or biological category but also a cultural definition. Its meaning is deeply informed by cultural and spiritual conceptions about death and the ways of coping with it. Furthermore, the question of how to learn more about death is among the oldest problems with which humanity has wrestled, engaging philosophers from Seneca and Horace to Michel de Montaigne. The latter famously claimed in his Essays “that to study philosophy is to learn to die.” Sensitive to cultural meanings of death, post–World War II psychiatrists understood that dying remained a profoundly philosophical, existential, and spiritual problem. They therefore engaged actively in long-standing medical and philosophical discussions, such as the one on “good death.” This notion has had a conflicted history in medicine: as medicine increasingly separated itself from religion over the course of the nineteenth century, the “good death” replaced the pious belief inherited from the Middle Ages—namely, that pain was part of the end of life—with the conviction that dying processes can, and must be, alleviated. The idea that dying might not be altogether agonizing gained strength particularly after the mid-1850s and in conjunction with the progressive medical utilization of narcotics.58 These developments led to discussions of euthanasia, a term that was understood to refer not to the intentional ending of lives but to the palliation of pain and to addressing the emotional and physical distress of hospitalized patients. In William Munk’s study on palliative care published in 1877, reports from survivors who had nearly drowned claimed that the experience of sudden, approaching death was painless. Munk’s study, Euthanasia: Or, Medical Treatment in Aid of an Easy Death, was reedited by a key thanatologist, Robert Kastenbaum, in 1977.59 This shows once more how important lessons from the past were to the mental health care practitioners engaged in the death-awareness movement. More generally, in the 1960s and 1970s, thanatologists referred frequently to Freud, Heidegger, Jung, and Schopenhauer. Another prominent reference was Leo Tolstoy, whose Death of Ivan Ilyich was discussed as a lesson on the patient-doctor relationship and how to overcome one’s own disbelief about mortality. (In the novel, the dying Ivan Ilyich is surrounded by his family, who continues to ignore the fact that he is dying. It is only through a trusted relationship with his servant Gerasim that the main protagonist overcomes his own illusions about immortality and starts to feel grief.)60 One could therefore ask whether psychiatrists were actively responding to the problem of dying with “dignity”—a question that humankind has struggled with for generations. In the twentieth century, an increasing number of people died in solitude and in hospitals. To talk about death as a painless experience was thus a way for mental health caretakers to allay the fear of dying. One event that illustrates this effort is a 1972 conference in Detroit organized by the American Association of Suicidology. At that conference various panels on death and its meaning tried to articulate what a “good death” meant in the past and in the present. One, called “The American Way of Death: Is It on Its Way Out?,” invoked Jessica Mitford’s popular critique of corporate funeral services (The American Way of Death). It was articulated as a way to break out of the medical “taboo of death.” Another panel was called “Appropriate Death.” Jacques Choron, a suicide researcher, lectured on “Death and Western Thought,” the title of a book he published the next year. Suicide attempts, accidents in the Alps (Noyes lectured on the Swiss alpinist Heim), the deaths of Freud and Federn (Robert E. Litman), and thoughts on euthanasia (Jacques Choron) prompted discussion of an ancient conundrum: what is a “good death,” and how can the physician contribute to it?

As I have shown, the reinterpretation of writings from the past became important in the 1970s as illness narratives and personalized medicine took on greater importance. In fact, the use of medical humanities was an institutional response to the general decrease in spiritual caretaking delivered to the dying patient in Western societies throughout the twentieth century. One could argue therefore that clinical pastoral care, the hospice movement, the psychiatric management of dying experiences, and, eventually, humanist/transpersonal therapies were mid-twentieth-century responses to the diminishing authority of the priest/minister in Western medicine and therapy.

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CONCLUSION

In this essay, I have shown how humanistic principles were applied in psychiatry and how practitioners made death a relevant topic in their daily clinical practice. One way to deal with death was to utilize knowledge on grief, loss, or separation garnered from empirical research on survivors’ experiences. Another way was to discuss the long-standing tradition of the study of suicidal thought, depression, and, more generally, attitudes toward death. Moreover, in the context of LSD studies, psychotherapeutic treatment took into consideration spiritual or transpersonal aspects of the patient. (This approach has been taken up again in the context of the recent psychedelic revival. The latter frequently cites studies from the 1960s and conceptions about mystical consciousness.) The increasing communication between oncology, pain management, and psychological theories led to the dying (or incurably ill) patient being turned into a role model for learning more about fears of, and coping with, threats of imminent death. Studies on near-death experiences helped validate the ancient idea that death can happen without agony (if consciously experienced and happening in a sudden way).

In the light of the studies discussed here, it is possible to argue that we have inherited a post–World War II assumption that emotional suffering necessarily leads to human potential. Some voices at the time criticized this “will to meaning” (to quote Viktor Frankl), because the fear or burden of dying correctly lies on the shoulders of the dying person. Today, we seem not to have escaped a conviction that stipulates that dying is worthwhile only if life has been truly “lived.” Or, to use Paul Tillich’s words: “if one is not able to die, is he really able to live?”61

To conclude, the main insight contributed by mid-twentieth-century death experts is one that may still be of relevance today: when it comes to death, the key issues are not only the fears of the patient and his or her problems in confronting them, but also the ways in which practitioners can approach these issues with their patients. For instance: Is it important to explore one’s own fears in the process of accompanying a patient with death-related anxieties? Should one make a universal claim about the meaningfulness of dying? If so, based on what data and convictions? How does one decide to tell (and at what stage does one tell) a patient that there is no cure, and how does that decision ultimately affect the psychotherapeutic process?

A second insight is that it might be worth looking back in time and beyond psychiatry to examine philosophical traditions of both Western and non-Western interpretations of death and life. To address the challenging transitions in patients’ lives—in particular, when confronting imminent death—it could be helpful to explore cross-cultural perspectives in planning appropriate therapy, as not every person has the same cultural belief about death. This leads me back to the initial claim that death is not just a matter of biological, but also cultural and moral, definition. Hence, a final insight gleaned from the critical examination of the mid-twentieth-century death experts is this: still today, while helping those in despair, mental health caretakers might have to find creative ways of ultimately understanding their own mortality.

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Declaration of interest

The author reports no conflict of interest. The author alone is responsible for the content and writing of the article.

I am grateful to Ashley Riggs and Fiona Smyth for their comments and edits on earlier drafts.

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Keywords:

death and dying; oncology; palliative care; psychedelic therapy; trauma

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