Walter White
Intake Information: Client is a 50 year old male who seeks therapy for support after recently receiving a terminal cancer diagnosis. Client describes this news as “crushing,” and also considers his deteriorating financial position and added strain of a second child on the way as contributing to growing feelings of hopelessness and depression. Client reports feeling stunned and numb by recent events in his life, and has come to therapy for help navigating these issues. Client is married, has one child , is expecting another, and reports no previous therapy experience.
Walter White sits on the couch across from me in silence, dressed in rumpled khakis and a beige windbreaker. He looks beaten down and numb, staring off into the distance in an unfocused way. I sit in the uncomfortable silence with him.
After a long moment, he finally speaks. “So, what do we do here?”
“Well, we usually talk about the issues that bring us to therapy. However, sometimes those issues can be so big that we might just sit here and process them. Try to make sense of them, figure out how to react to them. That seems like what we’re doing right now.”
I watch as Walter nods and thinks about this. I give him some space to reply, but he doesn’t, so I continue.
“I mean, you’ve just received a scary diagnosis. Stage four lung cancer. In your intake paperwork you use words like “inoperable” and “terminal.” We can’t expect to just take that news in and go on about our day without some kind of reaction. And the bigger the shock, the longer the news might take to process.”
Walter sits there, still taking it all in. Then he squints and looks closer at me.
“What’s that stain on your shirt?” he asks.
I look down at my shirt to see a tiny yellow dried drop of mustard.
“Oh, that’s a bit of mustard from lunch. Great cheeseburgers at the taco stand down the street, if you like cheeseburgers.”
Walter nods, then sighs loudly. “Lung cancer. Terminal. Inoperable. It’s amazing how much these words have the power to turn my life upside down. Not that it was going so well right side up, though.”
“How long ago did you get this news?”
“A week. But here I am, still walking around in a daze, like I don’t know what to do with myself. How long does this last? This feeling of… emptiness?”
“I don’t know. But I think talking about it here will help shorten that period, or at least help in the processing of the experience.”
“I haven’t cried. Is that normal?” Walter asks.
“It’s normal to react in the way you’re reacting,” I say. “You’ve just had a traumatic experience, getting some scary news, and it makes sense your reaction is to shut down. Some people wail and cry and emote, some people withdraw and go numb.”
“Numb. That’s a good word. That’s how I feel. That and angry.”
“Tell me about the anger.”
Walter sits up, becoming engaged now. “I’m angry that this happened to me. I don’t deserve cancer. I don’t deserve a death sentence. But I also didn’t deserve a lot of things that have happened to me. Things with school, with work, with relationships… I’ve been getting screwed over my whole life.”
“Tell me about some of the ways you’ve gotten screwed over.”
“Well, I’m thinking specifically of a business venture that could have made me a millionaire. Gray Matter Technologies. You’ve heard of them, right?”
“Sorry, I haven’t.”
“That’s fine, it’s just a billion dollar company that a close friend and I started, built on my research and scientific findings. But the trouble was more about a relationship I was in. That I was scared of. With someone involved with the company. So I bailed on it. The relationship. Which led to me bailing on the company. I took a five thousand dollar payout that would be worth five million right now if I’d stayed.”
“And how did you get screwed?”
Walter cocks his head and thinks about this. “I guess I didn’t really get screwed. I screwed myself. I was scared. I felt small and powerless, and I acted in an immature, childish way to get myself out of the situation. I certainly could have handled it better. And if I had I definitely wouldn’t find myself in the situation I am now, teaching high school chemistry to kids who don’t care making peanuts a day and unable to support my family in the way they deserve.”
Walter leans back on the couch, letting this all sink in. “I think about it every day. How things could have been different. I mean, with work and finances and all. Not the cancer. I supposed that was unavoidable. Unless years of regret and jealousy can cause cancer. Can they?”
“I don’t know. I think we should assume that the cancer was unavoidable. The feelings of jealousy and regret we can work with.”
Walter continues, on a roll. “I know I’ve had these feelings my whole life, and I’ve been carrying them around but pushing them down, they’ve been running in the background, but still there. Always there. And this cancer news was a spark that lit those old emotions back on fire.”
“You know, I often hear clients talk about the regrets they have in life, and how they would like to have done things differently. To have reacted to certain news differently, to have handled a situation differently, to have taken a different course of action. Some of them end up making the changes or taking the actions in the present that they wish they had taken in the past, and after they’ve done that, almost every one of them said to me some version of “I thought it was too late, but it turns out it wasn’t.”
Walter looks at me, unconvinced. “Is that supposed to be inspiring?”
“It’s not supposed to be anything. It’s just an experience that I wanted to share with you because I think it applies to your situation.”
Walter seems annoyed. “Were any of those clients recently diagnosed with Stage III Bronchogenic Carcinoma?”
“No. It’s more common for me to hear clients talk about regrets and it being too late in terms of relationship conflict or career struggles. Your situation is certainly more—”
“Life or death,” Walter interrupts. “And trending towards death. I know I can’t go back and change how I acted, or what I did. I can certainly continue to torture myself about it, but that’s not going to change the predicament I find myself in, I know that. But I guess I should start thinking about what I can do now. What I can do now to change what’s happening right now, instead of feeling like a sad sack for what I could have done in the past.”
“Yes!” I’m excited to hear Walter say this, but try to stop myself from getting too enthusiastic. “I think that’s exactly the kind of attitude that will help as you deal with what’s going on right now and what you can do in this moment, instead of ruminating on what happened in the past, and what you could have done back then.”
Walter looks like he’s got more of a spark now. “Somehow this news of impending death makes me want to finally be more proactive in life.”
Walter takes out a piece of paper from his jacket pocket and unfolds it.
“I’ve run the numbers and determined that, in order for my wife, son, and unborn child to be somewhat comfortable financially going forward after my death, they’re going to need seven hundred and thirty seven thousand dollars.”
“That’s pretty specific,” I observe. “How did you come up with that number?”
“It’s the combination of mortgage debt, cost of living, educational outlays, and other assorted expenses.”
“Seven hundred and thirty seven. You didn’t want to just round that to seven hundred and forty?”
Walter gets serious. “I’m a scientist. I don’t round.” Then he looks back down at the number on the piece of paper. “You know, it’s funny, but this death sentence is starting to make me more focused on life than I’ve ever been.”
“It sounds like you’re changing from thinking about what you could have done in the past, which is out of your hands, to what you can do now, which is within your power.”
“Exactly. At first I was sad, but now I’m inspired. Shouldn’t I be, like, grieving?”
“That’s an interesting question,” I observe. “In therapy we often deal with grief. This is usually thought of as the experience we have after someone passes away. But there are many kinds of grief, including anticipatory grief. That’s something we can experience when a loved one has a terminal disease that forces us to reckon with the idea that they’ll soon be dead even as they’re still alive. And this gives us a chance to take action regarding an event that hasn’t happened yet.”
“So that’s what I have, this anticipatory grief, only it’s about myself?”
“I think that concept could apply here. I mean, It’s different for everyone. Some people find themselves stuck, unable to act, until the anticipation of death leads to the actual death. Some people, on the other hand, find themselves compelled to act, to do the things they might want to do now that, if not for this anticipatory period, they would regret not having done after their loved one dies. Or they do.”
“I see. Yes, that certainly puts a name to what I’m feeling,” says Walter. “I do feel like I want to act. Like I need to act. I just don’t know what the action is yet.”
“That can be an upside of anticipatory grief. The event that will eventually cause the actual grief hasn’t happened yet, so there’s still time to, if not change the outcome, change the experience leading up to it.”
Walter nods, sitting up straighter, his mood more upbeat now. “Yeah. I like that. It does make me feel a little better. Like, it’s motivating me to get off my butt and do something. I just wish I could have felt like this years ago, before the diagnosis.”
“Yes, well, life is full of ironies.”
“It is indeed.”
Walter’s watch alarm goes off.
“Sorry, I’m going to have to cut this short. I have to get back to school for a meeting with a student. When are we set to meet next?”
“Same time next week. Also, we discussed the possibility of a psychiatric referral to see if anti-depressant medication was something you might benefit from. Would you like that referral?”
“No thanks, I’m not into drugs. But I’ll reach back out if that changes.”
I rise and open the office door for him.
“No problem. Good luck!”
“Thanks. Pretty sure I’m going to need it.”
After he exits I close the door behind him, then sit down to write up my notes.
Clinical Notes: Client presented with a flat affect, dealing with the aftereffects of a terminal cancer diagnosis. Client regrets choices he’s made in the past regarding his career, and wishes he was better able to support his family financially, especially in light of new information regarding his health. Time was spent processing this regret, and how holding on to it has prevented Client from taking action to change his life in the present. Therapist and Client discussed anticipatory grief, how Client is experiencing this regarding his own possible death, the idea of regrets in life, and the possibility for Client to take actions now to mitigate that regret. Client exhibited a change in affect after this discussion, and ended session remarking on how he felt better.
Diagnosis:
F43.21: Adjustment Disorder with Depressed Mood
Z71.85: Encounter for Anticipatory Grief
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