Living Well and Dying Well: Tales of counselling older people

Living Well and Dying Well: Tales of counselling older people

An extract from Living Well and Dying Well: Tales of Counselling Older People

How to say goodbye - Maggie

Maggie was just 16 when she went to Whitstable on a day trip with the Bromley Girls Brigade. On the beach, she met John, two years older than her, a soldier on leave. By the end of the day, they were courting; not long afterwards, they were married. When I met Maggie she was 79, living in a care home. Her beloved John had died a few months earlier. He had been the centre of her life and, in the last few years, her only carer. Her family had contacted me as they were worried about how she was coping with the loss of her husband, her independence and her home. She was evidently very upset but had felt unable to talk about it with her close family, or anyone else.

Her family wanted to meet me and were keen to know if I thought counselling would help. Maggie suffered from memory loss due to a series of strokes and had a heart condition that meant her breathing was laboured. They wanted to ensure I was happy that Maggie would be able to cope with the physical and mental demands of counselling. What was, perhaps, left unsaid was, ‘Is this a worthwhile investment? Will Mum be able to get anything out of it?’ What counsellor would be able to answer that question were it to be posed? We had agreed that I would visit Maggie, introduce myself and see how our first meeting went. This first occasion of meeting the family and going in to meet Maggie felt like a rather stilted job interview. I remember walking down the corridor to Maggie’s room trying to centre myself a little and focus on the one thing that mattered here: a coming together of two human beings and the potential for something healing to happen as a result. Not for the first time in the course of my work with Maggie, it was difficult to hold onto this.

In my experience, the triangular relationship between family, client and counsellor needs to be held carefully, reflected on and actively talked about, to ensure everything that happens is in the service of the person I am counselling. This is true, regardless of the age of the client. The challenge of working in an organisational setting such as a care home or at the request of concerned family members who are paying for counselling for a loved one, is how to maintain the contact needed to complete the work without inadvertently, or otherwise, betraying confidences or skipping around the client’s consent. Usually, I email the person who has initiated the counselling relationship – in this case, Maggie’s children – to let them know the session has taken place and to deal with any practical matters such as payment or confirming the next session. As when working in schools or with the parents of a child client, it is incredibly important and difficult in equal measure to tread the line between a simple transaction and the weight of the emotional or political agenda. I am often asked via email how I found my client that day, whether they able to open up, whether they seemed better. I would never respond to such questions from the relatives of a younger adult client who had engaged me themselves. Yet situations where someone is, if you like, commissioning the work seem to allow this sort of dialogue to creep in. Holding steady against this is important and requires strength.

And it isn’t only family members that assume it is their right to enquire. ‘How is Maggie today?’ the receptionist would say to me as I left the care home, in the same well-meaning, sing-song voice that she reserved for residents and concerned family members. She would continue with a statement such as: ‘She’s ever so quiet. I think her chest pains are getting worse and she just won’t come and join with everyone when we play bingo. I think it would be a lot better for her if she did, don’t you?’ Can you imagine bumping into and having that same conversation with a friend of an adult client who initiated contact herself and comes independently each week to see you in your private counselling room? It goes against the counsellor’s code of ethics; not only that, it flies in the face of the received understanding of what a counselling relationship is about. I often wonder what makes it OK for people to talk this way about the elderly and infirm. It has a lot of parallels with how children are spoken about – as if we know better than them.

The answer to this is, of course, along the lines of, ‘Yes, I saw Maggie today, but I can’t discuss what we talk about as I am bound by counsellor/client confidentiality and it wouldn’t be right. I’m sorry.’ However, something about the environment seduces even the strongest willed counsellor to the point of disclosure when in its colonising, proprietorial embrace.

Urie Bronfenbrenner (1993) developed a model of human development that describes five socially-organised sub-systems that influence all human beings over their life cycle and help to support human growth: microsystem (family, friends, immediate environment such as schools); mesosystem (where two of these environments intersect, such as parents and school); exosystem (where two or more environments intersect and where one of them has an external influence, not connected to the individual, such as governing bodies or external policies and procedures); macrosystem (wider cultural, social and political influences) and, finally, chronosystem (influence of historical, time-sensitive factors).

Although originally researched and conceptualised to support educational environments, it is, in my experience, a very useful model when considering growth and barriers to growth in any counselling client, whatever their age. In particular, it is a helpful model when working with clients within organisational settings or with other service providers involved in the person’s care, or where there is likely to be some level of family intervention, such as with children or older adults. I find that considering these five elements allows me to hold myself steady and authentic and keep the individual in front of me, and to notice but not surrender to the pull and influence of these systems.

Returning to my regular encounters with the receptionist, for example, the care home is part both of the mesosystem within which Maggie and I exist and the exosystem, the wider care home group and organisation, which has its own set of procedures, ways of doing things, culture, language and demeanour towards its residents. My role as Maggie’s counsellor was to notice this and not to become part of that pattern; to treat her as a unique individual and certainly not as an someone to be discussed with all and sundry and cajoled into ‘cheering up’.

When I was training and exploring the theoretical frameworks that underpin counselling, I remember reading a dog-eared copy of RD Laing’s The Divided Self and being moved to tears by his passionate stance against the medical, deterministic model that sees people as objects to be arrogated by diagnosis and his call for the therapeutic encounter to value the wholeness of a person (Laing, 1960). Laing wanted therapists to respond to the unique behaviour created by both client and therapist together, in the moment, rather than fixing ourselves to a diagnostic model that perpetuates the person’s alienation, disempowerment and distress.

For me, with Maggie, this started even as I entered the care home premises and signed my name in the visitors’ book at reception.

I’ll paint more of a picture of the environment to illustrate this further. Invariably, when I arrived at the home, the residents would be gathered in the communal lounge, having had their lunch not long before. Usually the television would be on loud or there would be dance-hall music coming from a stereo. Most of the residents would be sitting or dozing in comfortable chairs; some might be playing board games or participating in organised activities at a table at the far end of the room. The air would be warm, stuffy and thick with unsaid words: carers patiently helping residents to play, their minds elsewhere, or trying to maintain patience and compassion despite their own tiredness or frustration; residents frowning in confusion or looking around in wide-eyed surprise at finding themselves here, unable to comprehend how it had come to this or angry with their bodies for letting them down. Somewhere in this scene, I would see Maggie’s familiar pink slippers, then her legs and then her sunken body, bent over, sleeping in her wing-back chair.

Our first task together was to negotiate moving her to her room, where we could have some privacy for our session. If entering the communal room hadn’t fully immersed me within the cultural embrace of the care home setting, this experience certainly did. I’d been advised that Maggie should walk to her room, rather than use a wheelchair, as it was good for her continuing mobility to walk a little every day. The problem was that, due to her poor health, she found this process exhausting and distressing. It took two members of staff to lift her upright so she was leaning on her frame, and the four of us then shuffled through the room, out into the corridor and along the 15 metres or so to her room and manoeuvred her into her chair. Throughout the 10 minutes or so that this took, her carers encouraged her with bright, upbeat phrases about how well she was doing.

Never did I feel so out of place (perhaps my own issues were emerging about not being able to help) or so judged by the staff. I did not join in with the ‘well dones’ and the ‘not far to go nows’, as I could plainly see the exhaustion and frustration on Maggie’s face. When we finally sat facing each other, it felt important that I acknowledge what was happening by being in her exhaustion with her, allowing her to express it and acknowledging this lived experience. Each time I would notice a pull within me to make her more comfortable, to ask if she needed anything and to continue the helping dialogue. ‘This is not my role,’ I would remind myself; my role is to be with her in her experience, however uncomfortable.

Care homes have good, caring people working in them; they are designed to facilitate a happy life for residents, to support and care for them. Many residents, and their relatives, have no other option once living independently at home is no longer possible for them. Most elderly people still at home are cared for by their partners (some 1.4 million carers in the UK are aged over 65 (Age UK, 2018)). However, while care homes do not take the bulk of the responsibility for care of the elderly infirm (only 14.8% of people age 85+ live in a care or nursing home (Age UK, 2018)), they do tend to be where older people die. The median time between admission to a care home and death is 15 months (Age UK, 2018). Thus, they carry a considerable responsibility.

Try as they might, it is very hard for care home staff to allow residents to live authentically. In Being Mortal, a wonderful, ground-breaking book about death, Atul Gawande (2015) advocates passionately for nursing homes that respond to the individual needs of residents, rather than pursue societal or organisational goals. Mostly, activities in caring institutions are, in a word, institutional – organised group activities that have some kind of evidence base for their therapeutic benefits, with residents cajoled into taking part. Meals are made and served up to everyone at the same time every day, regardless of individual hunger or tastes. Residents who choose to stay in their rooms or refuse to eat at the allotted time are considered either be not coping well or to be trouble-makers; socialising in the communal areas is praised as a sign of psychological good health.

As we approach the end of our life and fully confront and accept its limits, taking a philosophical view of our suffering and death affords an opportunity to find personal growth and meaning. In Erikson’s model, the task for the final developmental stage of life is to experience our historical continuity of existence and crown our whole experience – to reflect upon it while acknowledging the painful reality that it is coming to an end (Erikson & Erikson, 1998). As Dylan Thomas wrote so powerfully (1952/2003), ‘Old age should burn and rave at close of day.’ My own practice is informed by existential approaches and I find this a powerful way of being with clients who are very old or at the end of life. Existential counselling is a philosophical investigation, one that aims to understand life by exploring its boundaries and its possibilities (van Deurzen-Smith, 1988).

Maggie seemed to be pre-programmed to not talk to me about things that were difficult or below the surface. At the beginning of each session, I would ask her what was going on for her in that moment. She’d lift her chin from her clavicle, where it often rested, fix her eyes on me and, registering who I was, smile her bright smile and say something like, ‘Oh, I’m ok today, thank you, yes.’ Encouraging people to make full contact with pain of loss and fear of death never feels easy, but it is even harder to navigate with those who are elderly, vulnerable and perhaps cognitively impaired. Who wouldn’t want to stop at ‘I’m ok’ and talk about the weather and how nice their hair looks?

Gawande references extensive research showing that terminally ill patients admitted into palliative care, where death is actively talked about, tend to live longer than in hospital environments that focus on keeping people alive. The conclusion is clear: not playing down or ignoring the reality of death can prolong life (Gawande, 2015). From an existential rather than medical standpoint, we would say the same: individualisation and growth continues right up to and on considering our death (van Deurzen-Smith, 1988). If Victor Frankl, writing from a concentration camp where there was nothing else to consider apart from survival and death, could find meaning and growth in this experience, those of us who enjoy relative freedom can surely do the same (Frankl, 1977). By avoiding the realities of our situation, both immediate and existential, we aren’t perhaps fully being ourselves. Tolstoy’s Ivan Ilyich is in psychological agony for most of the story while his family and his doctors keep up the pretence that all will soon be well. The moment those around him began to accept his death, he does too and ‘instead of death there was light’. (Tolstoy, 1882/2008).

Seen through this lens, I considered it my responsibility to Maggie to find a way into her lived experiences by both of us metaphorically breaking free of the trappings of the mesosystem around her.

I started by noticing what I was seeing, rather than replying to her ‘I’m ok’ with an equally light response like, ‘Oh good!’

Instead, I said: ‘You are looking at my shoes and you seem far away in thought, you are shaking your head slowly, Maggie.’

Bringing Maggie into her body and the space between us usually brought about eye contact. Many of Maggie’s responses were quite slow, due to the strokes she had experienced, so this eye contact was usually prolonged and intense, and I was careful to hold it and tried to regulate my breathing with hers where possible. This wasn’t a deliberate technique but seemed to help me tune into her rhythm and pace. One of the first times this happened, after a long interval, Maggie’s face crumpled and she turned to the photo next to her and said, ‘I miss my John’ and wept. We had moved quite quickly from ‘ok’ to grief, simply by being present in our bodies.

This was the pattern of most of our sessions. Sometimes Maggie was too tired to talk with any regularity of back-and-forward conversation. I drew heavily on pre-therapy approaches in these times: using simple word repetition and mirroring actions to maintain contact at even a most basic level (Prouty, Portner & Werde, 2002). Once I gently eased myself onto a cushion on the floor as Maggie seemed to be struggling to hold up her head to make any eye contact. This worked well in that session; mostly it was trial and error, sometimes getting it wrong. What guided me was staying with whatever was going on for Maggie that day, letting her know I was there and trying not to direct her but feel into places that felt important.

One day she was absent-mindedly fingering a necklace around her neck. I reflected this back to her and then, when she looked puzzled, I held a mirror to it for her to see it. She told me that John had given it to her for her 21st birthday ‘a few weeks ago’. This conversation led her to talk to me about how angry she was at him being away so much for his work, leaving her alone in Bromley. She cried for him, telling me how painful it was to be alone. I felt these could be memories from his time in the military when they were newly married but the parallels with her loss now seemed important. Simone de Beauvoir (1972) noted that that we relive unpleasant memories in later life so that we can process and reflect on them. I wondered if making contact with her anger and disappointment at him leaving her then somehow felt healing now, when she was feeling abandoned and lonely in a care home, having had to leave her own home after John died.

On other days, Maggie would be more awake, more in the present. At these times we encountered together her experience of her advancing years. As we meandered through dialogue about the weather (‘so hot at the moment!’), the Turkish delight in the bowl next to her (her favourite treat) and the roses at her bedside, received for her recent birthday, I asked about her age. ‘I think I’m 80,’ she said tentatively. The card indeed said that, so we read the messages in it together and she cried out very suddenly, as if physically hurt, ‘Oh! I’m 80! But I’m so old, I don’t want to be old!’ Her face contorted into one of such pain and her eyes darted around as if seeing the room for the first time: a folded wheelchair in the corner, a sink with a handle on it for stability, a bed with bars that could be raised for safety, the wipe-clean cushion she was sitting on, the red button strung permanently around her neck to push in emergencies. At this moment I felt an involuntary flex of the culturally-learned response to minimise or dismiss her assertion that she was ‘so old’.

We hear it said so often: ‘Oh no, you don’t look a day over 50; you look incredible for your age,’ or, ‘You have years left in you, don’t be silly!’ It’s all around us in social discourse, reflected in the media in products advertised as ‘age-defying’. Contemporary Western society honours youth over old age and sees vitality and physical strength as the most dignified way of being (Byock, 1997). De Beauvoir (1972), writing in her advancing years, maintained that we experience old age through internalising other people’s reactions to us that are starkly at odds with how we feel about ourselves.

Added to this, we now have more old people than young people globally than at any time in recorded history (Carstensen, 2011), meaning that taking care of older people could place a burden on the younger people and, crucially, that each old person has less perceived value in society. This is in stark contrast to traditional societies where older people are usually the leaders and most revered for their extensive knowledge about politics, medicine, religion, songs and dances (Diamond, 2013).

How do we counsellors liberate elderly clients from this usual way of relating? I regard the potential gift of a therapeutic encounter to be the presence of another person who experiences you for all you are and explores what this means, rather than fitting you into categories. Identity cannot be categorised, as it is relational and historically situated, created by an ever-evolving and ongoing dialogue (Butler, 1990). Therefore, to me, our role as counsellors is to introduce possibility and emancipate clients from ‘the usual’ way of relating. Indeed, research has borne out that the progression of dementia can be slowed if those caring for people with the condition relate to them and emphasise their individuality and unique identity, rather treating them purely as someone with dementia (Greenfield, 2008). By introducing the possibility of a different way of relating within the microcosm of the therapeutic dyad, we can challenge the experience in the macrocosm of the rest of the world (Bronfenbrenner, 1993).

I tried to hold myself steady in those moments by simply noticing what was pulling me to minimise her experience of her age and by staying focused on Maggie, her lived experience of her age and what she was trying to express. I reflected to her that it seemed distressing for her to consider her age in that moment, and I asked her what it meant to her to be 80.

‘Oh well, it means I am old, I’m going to die soon,’ she replied.
‘That feels hard to think about,’ I offered.
‘Hmm.’ Here Maggie’s gaze drifted off beyond me to the photographs on the shelves to the right of me. The tiniest trace of a frown came onto her face and she narrowed her eyes.
I followed her gaze. ‘Are you looking at these photos?’ I asked.
Maggie reached out her hand towards them and I asked if she’d like me to lift them down.
‘That’s my Mum on that side,’ and she pointed to a tiny, framed, black-and-white photo of a lady in a wool suit and hat. ‘And the one on the other side is my Dad,’ she finished, gesturing to another black-and-white photograph of a man in a white t-shirt, arm raised to shield his eyes from the sun. I reach them both down and gently placed them on the bedside table to her right. She looked at them and reached out to touch them both in turn.
‘Can you tell me about them?’ I asked.
‘Oh, I loved them very much. I miss them... I wonder what they think of me now, in here.’ Maggie paused to look around: ‘If they think I’ve done alright in my life.’
There seemed to be a strong connection between considering her own advancing age and approaching death and her experience of her parents.

Later, at her funeral, I learned that Maggie had moved her parents near to her as they grew older and cared for them both as much as she could. Perhaps her advancing age and death took her full circle to being someone’s daughter, dependent and vulnerable.

When language and conversation grew difficult, as it often did, due to Maggie’s tiredness, we looked around the room and I asked her about the other people whose photos were on the shelves. As we toured around these photos, there seemed to be a circularity of experience as Maggie talked to me about her own daughters and grandchildren. She often found it difficult to remember their names and their relation to her. I tried hard not to correct her; accuracy didn’t feel as important as the connections between the pictures and her feelings. Sometimes she smiled broadly; at other times she frowned. This all felt like a meaningful connection for her between her experience, that of her parents and the love of her wider family.

She appeared less distressed than usual but nonetheless thoughtful and quiet as I left her that day. I was reminded of the Nietzsche quote I’d read in Frankl’s tiny, powerful book (1977: 84): ‘He who has a why to live for can bear any how.’ It felt as though we had moved from dying to the love of family and within that there was both comfort and meaning.

However, it would be untrue to look at our work together through rose-tinted spectacles. Some of it did appear to be healing, but there were many times when it was awkward or difficult. After Maggie spent some time in hospital with pneumonia, her daughters asked her if she’d like me to continue visiting, to which she’d consented. There were times during our subsequent sessions when Maggie fell asleep as we sat in silence. This presented me, a relatively inexperienced counsellor, with a dilemma. We had already reduced the length of the sessions to 30 minutes, in discussion with Maggie and with her daughters, as I felt the effort of talking one-on-one over a sustained period was very tiring for Maggie. If a client sleeps through a session that they are paying for, is this ethically ok? What if a client sleeps through a session someone else is paying for, does that change things? Ethically, I subscribe to never exploiting a client, and this felt close to financial exploitation if I was merely sitting while my client dozed (BACP, 2018).

Supervision helped me get more comfortable with this. I felt I wasn’t doing anything in those times, so the client and her family were not getting their money’s worth, as it were, from me. I wondered whether the initial conversation with Maggie’s family had allowed me to interject an expectation on their part that I would somehow ‘fix’ Maggie. Once we’d identified this, my supervisor encouraged me to go back to basics: to centre myself back within my theoretical frame and the fundamentals of my practice. As a practitioner, two things matter to me: being fearlessly phenomenological by noticing and responding to the present moment, and to journey alongside a client’s lived experience. Nothing in either of these elements of my practice encourages me to ‘do stuff’ or ‘give the client their money’s worth’. So how did I balance my ethical foundations with my beliefs about my practice?
I found the answer in both. As Maggie’s eyelids fluttered closed one day, I leaned in and gently said: ‘Maggie, I notice you seem very tired today.’
A slow nod, with closed eyes.
‘It feels like talking with me today is making you more tired.’
No response, her eyes remained closed.
‘I wonder if it would be better for you if we left it for today and I came back another time, Maggie?’
On this occasion she opened her eyes, squinted a little in looking for me and, when she found my eyes, said very slowly: ‘I like you being here.’
I paused and nodded. Then I asked her: ‘What it is like for you when I am here?’
There was a long pause, so long that I thought she had returned to sleep. Then she said, simply: ‘Safe.’
I stayed with her for the 10 minutes that remained while she dozed. It felt ok. I have since reflected on this experience through the lens of Buber’s theory of I-Thou. He wrote that the ‘thou’ relation between two people is below language, pre-verbal as it were (Morgan-Williams, 2002). I feel Maggie and I experienced this together in those moments. I believe that, as death approaches, we can experience a reversal of Lacan’s mirror (Lacan, 1980). Lacan theorises that, as new-borns, we resolve our sense of fragmentation by seeing our wholeness reflected in those who care for us. So too, I would argue, the close attention of another helps prevent the fragmentation of self and confusion that can be experienced in profoundly old age.

In focusing only on what was happening and what it was like for Maggie, even in those simple terms, I was staying true to my practice. However, I also kept us focused on Maggie’s autonomy and choice. She and I were within an environment where residents’ autonomy is contained within certain limits. Ours is also a society that has a collective view of elderly people and what is right or wrong for them. The best I could do was focus wholeheartedly on her experience and choice in our moments together.

Maggie died peacefully after we had been meeting for about nine months, following a short stay in hospital. We were to take a few weeks’ break from our sessions over the summer holidays. When I left at the end of the final session before the break, deep inside I sensed I wouldn’t see her again. Our sessions, as I said, had become introspective and quiet, and I noticed Maggie was turning towards herself and away from the world around her. I asked if I could return in three weeks, as I always did at the end of a session. She squeezed her eyes shut and nodded firmly and slowly, then opened her eyes and smiled at me. I remember leaning in and squeezing her hand and saying ‘Goodbye’ before leaving the room. I quietly wept as I walked the familiar route along the corridor, down the stairs, signed out and climbed into my car.

During our three-week break, Maggie was taken to hospital, then returned to the home for respite care before slipping away and dying in her sleep. Her family were kind enough to let me know. I asked if there was a way I could pay my respects that felt comfortable for them and received an open invitation to the funeral and wake in return. This was the first funeral of a client that I had attended. I had experienced the death of another client, but had no contact with his relatives, having worked only with and through the care home, so was not able to find out where the funeral was taking place or where his ashes were laid. His family remained as elusive after his death as they had been in his memory during our time together. I had found this difficult and was therefore grateful for the opportunity to say goodbye to Maggie.

I realise that this chapter is a strange, perhaps bleak way to open a book. My editor would rather I didn’t. In itself, what Maggie and I experienced together doesn’t constitute an empowering, uplifting account. However, I am an existentially informed therapist and talk of dying and death is my currency. Death is part of life. It is a given. Why not start with it? In the closing chapter of her memoirs, Diana Athill reflects that it is not possible to end such a book with a ‘bang’. Perhaps it is not possible to begin a book about therapeutic work with those who are nearing the end of life without talking about death. Athill perceptively writes:

From up here, I can look back and see that, although human life is less than the blink of an eyelid in terms of the universe, within its own framework, it is amazingly capacious. One life can contain serenity and tumult, heartbreak and happiness, coldness and warmth, grabbing and giving.’ (2008: 177)

Human life is a question of opposites: death allows us to reflect on life and, if we are brave enough, life allows us to reflect on death. That is why the title of this book focuses on both.

And so, I found myself attending Maggie’s funeral. Is there a kind of hierarchy of grievers at a funeral? Until then I had only ever attended funerals of family members. I had been so swept along by grief, reflection and my own thoughts on those occasions that I had never noticed or thought about these dynamics. As I travelled there, I noticed how nervous I was, how unsure of how to act, how to strike the right balance of reverence of the occasion and allow myself to grieve and find my goodbye. I was mentally preparing myself not to lose control completely. My tears are very unpredictable, even at the best of times – what if I were to cry too much? I found myself struggling to get a sense of how much emotion was appropriate for the counsellor of the person who had died, as if there were some accepted scale of sadness.

At some point before the start of the service, I noticed that I was trying to intellectually organise the experience in my head instead of feeling into the occasion with authenticity. Where would I sit? What should I say if someone asked me who I was and how I knew Maggie? Should I approach the grieving family at the end? Tuning into these reflections within the moment can be so helpful, like an inner supervisory voice (Bager-Charleson, 2010). In the end, I surmised, what did it matter? As the celebrant eloquently put it, we were all there because our lives were touched by Maggie in some way; my only task today was to make my own goodbye in the way that felt appropriate.

What I wasn’t prepared for was the eulogistic speech made by the celebrant, the family having chosen not to give one. As the ceremony unfolded, she gave a life history, facts of Maggie’s life, if you will, provided by the family. In what other situation would a counsellor be provided with a factual timeline of their client’s life? I felt myself resenting this intrusion into our work together, into my memories of her and the meaning of what she had chosen to reveal through our sessions.

Maggie’s memories were muddled towards the end of our time together but, as with any work with individuals with dementia or cognitive impairment, the content is not what is important; rather, what matters is the process or the clues to the client’s experiences that are revealed and afford opportunity for meaning-making. On one occasion, after a period of silence spent looking at the chair opposite, Maggie raised her eyebrows in surprise. When I reflected this back to her, she said: ‘I think I got married this week.’ We explored together what had happened – she had married someone other than John, but John had given her his blessing. She said she couldn’t be sure if it really happened but that it felt real. As we explored it further, she told me John was happy for her to move on and she smiled a faraway smile. The facts of the situation were entirely irrelevant but the meaning was vital.

As the eulogy progressed, I found myself stacking up everything we had talked about and putting it into categories of real versus fantasy. Then I caught myself: why was this important? In some ways, it felt like the moment you chance on a client in the supermarket with their family and find yourself involuntarily comparing what you see with what they have told you in the work. In some ways, my internal process was helpful; it left me in the end with acceptance that what Maggie and I shared in our sessions was important at the time. Like a photograph taken on a certain day, with a certain type of weather, at a certain time, the same view will look completely different to someone else who visits in a different season, at a different time, in different weather. There is no truth to the matter, only meaning.

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