ACT when a client dies.

Recently a woman I have seen on and off for 30 years died of a sudden cardiac arrest (SCA). She was 52 years old. Like many trauma folk she had episodes of treatment and relapse and came in and out of therapy. She was one of my most difficult complex trauma clients and probably my best teacher for working with trauma.

I am planning on retiring from clinical work in a couple of years and a big focus on our work was how she would navigate this. Once she told me “It would be easier for me if you were dead. You being out in the world and me not being able to talk to you is too hard.” I suggested to her that it might not be better for me and we laughed. I understood what she meant. Our relationship would have an ending and that would be hard. For both of us. But I’ll tell you I’d much rather have her out there and not know what she’s doing. I keep thinking “Really, this is therapy interfering behavior” and I can imagine her laughing. Doing trauma work gives people a really dark sense of humor.

She died in one of her favorite vacation spots. She had books, and friends and her life was the best it had ever been, but her body wasn’t. I’m not sure if her body felt worse because she no longer dissociated or if she was just living in a body that had been through hell. She had diabetes, obesity, chronic nightmares, daily panic events, anorexia, vaginismus, unstable blood pressure, depression, an eating disorder and chronic pain. Over the last few years she was able to lose a lot of weight after being prescribed a GLP-1. For the first time in many years she was able to move freely through the world. She was thrilled when her body shrunk enough to fit in the phlebotomist’s chair when she had a blood draw. She loved giving away all of the huge clothes that were too big for her.

Once I asked her if the weight gain make her feel safer from abuse. “Absolutely,” she replied. So letting go of it was an extremely brave act.

It seems we ignore the effects of C-PTSD on the body, or we give it only glancing importance. Traumatic events permanently change a person’s body and these bodies don’t age well.

When I was looking for literature on SCA and PTSD I found a lot on how SCA can lead to PTSD, but nothing on how SCA can be caused by PTSD.

This woman taught me a lot about working at the edge of my abilities. She was not an easy client and there were days when I wished fervently that I wasn’t her therapist. But I don’t regret any of the time we spent together. She was one of the clients that motivated me to learn ACT and DBT because I needed SOMETHING that would help and my psychoanalytic training wasn’t. I learned ACT and DBT under fire with her. She was chronically and acutely suicidal until her last few years. She was never what you would call completely stable. Her eating disorder necessitated daily check in with her dietician to make sure she was eating and she struggled with restriction constantly. (In case you didn’t know, obesity and anorexia can co-occur.) The GLP-1 drug was actually a calculated risk as it decreases appetite.

I always thought that if she died while in treatment it would be from suicide. It never occurred to me that her body would just give up. It’s only been since her death that I realized my unspoken assumption that to survive trauma, acceptance is the sufficient condition. That if avoidance and control were minimized that somehow a body that had been starved and brutalized for decades would just magically heal.

Living through a life of trauma is massively destructive to a person’s body. Psychological flexibility will not heal a chronically dysregulated autonomic nervous system or balance the endocrine system. Muscles and bones damaged and stunted by starvation and abuse will not magically grow back. The damage is cumulative and progressive. She made it into her 50s. I have several trauma folk in my practice who are approaching that age and it’s hitting me that I may outlive them. They have and continue to work to save their own lives. The brutal unfairness of this is hard to bear.

This is one of those situations where “as it is, not as it says it is (or as I assume it is)” truly and absolutely sucks.

“Fully and without defense” is also a challenge in this situation. I’m feeling a lot of grief for her and no one knows what she endured and survived like I do. I can’t share memories of her with others because I’m her therapist. I can’t reach out and comfort her family and share their loss. I’m telling some close colleagues about this, but they still don’t know her. So I go minute by minute sometimes. Something in a session will remind me of her and I have to just pause and let the grief in.

It’s often the case that we know our clients better than anyone else in their lives. What do we do with this when they die and we can’t share that knowledge?

“Move in the direction of my values in this moment.” I don’t really know how to do that except moment by moment. This post is probably part of the process. You didn’t know her but you should know that the therapist, trainer and supervisor I have become is due to her and others like her. So there’s that.