If psychotherapy is working the way it is supposed to, an important phenomenon occurs. Psychiatrists call it transference.
The patient draws on relationships of the past -- good ones and painful ones -- and lives them again, applying the old emotions of love or hate, friendship or anger, to the psychiatrist.
"He literally transfers feelings about other people to the therapist," said Dr. Alan Levenson, director of psychiatry at the University of Arizona. Because of this emotional attachment, he said, the death of a psychiatrist involves a "much more intricate set of feelings than the death of another professional -- an attorney or internist or accountant."
Levenson and other mental health professionals view the loss of a therapist as a potential medical emergency, one requiring immediate help with the grieving process and, eventually, returning to the problems that drove the person to seek mental help in the first place. Some patients may be on drug therapy, such as lithium, that needs to be continued and monitored. And if the therapist was practicing strict analysis -- which centers on early childhood development -- then the relationship would probably have been especially intense.
An estimated 1.4 million Americans see the country's 35,000 psychiatrists on a regular basis, according to the American Psychiatric Association. Thousands more see psychologists and other therapists. Just how many patients confront the death of an analyst at some point in their lives is difficult to ascertain, but several psychiatrists interviewed said they had personally treated patients in this situation.
It is clear, however, that because of the way psychiatry works, finding a new analyst is particularly difficult.
Many psychiatrists, for example, keep sketchy notes, if they keep notes at all. While this is an effective way to protect patients from prying courts or other investigators, it also means the new therapist has little on paper to work with. So the new therapist must start from scratch.
Psychiatrists also are much more likely than other doctors to practice alone rather than in a group practice. This means that when the psychiatrist dies, there is no partner to step in and take care of patients. Often there is not even a receptionist to notify patients that the therapist has died.
Most important, the choice of a therapist is more personal than that of any other health professional. "The dentist is working on your teeth," said Dr. George Pollock, president of the APA and a faculty member at the University of Chicago. "The analyst is working on your psyche."
Pollock, who has studied grief for 30 years and is author of the forthcoming book "The Mourning-Liberation Process in Health and Illness," believes that every life change is in some sense a loss, since a "prior state" is abandoned. In major life losses -- such as the death of a spouse, a child or an analyst -- it can be difficult for a person to complete the grieving process.
It is ironic, said grief counselor Judith Pollatsek, that psychiatry is among the least prepared of all specialties to help patients in the event of a death. Many psychiatrists are not expert in helping people through grief, and it is left to the patient to find a new "keeper of your soul."
Pollatsek, a counselor at the St. Francis Center, said she has counseled two patients whose analysts died, one of them by suicide. She and others offered this advice to people who must find a new therapist:
First confront the grief. While it will take time to find someone with whom to resume therapy, a grief counselor can help in the short term.
Find a new therapist who knew the one who died. This may provide "some sense of continuity," Pollatsek said, or can be a way to get a referral.
Look for a "successor," not a "replacement."
The analyst who died, Pollatsek said, "knows how far you've come, how hard you've worked. And that sense of history is gone."