Why Existential Coaching Could Help People at the End-of-Life

By Erick Messias, M.D., Ph.D., M.P.H. | Published 7/29/2018 3

Tolstoy by Leonid Pasternak (wikimedia commons) 800 x 651

Photo credit: Tolstoy by Leonid Pasternak (wikimedia commons)

With his place among history’s greatest writers cemented by War and Peace and Anna Karenina, Leo Tolstoy published a gem of a novella in 1886 titled The Death of Ivan Ilych. In the few pages of the novella, we follow the last days in the life of this member of the Court of Justice whose life had been “most simple, most ordinary, and therefore most terrible”.

Ivan Ilych was the second of three children of a mediocre official – for whom “posts are specially created” since he could not be dismissed. He followed his father’s footsteps into public service. Eventually, he met and married Praskovya Fedorovna who “came of a good family, was not bad looking, and had some property”. They lived seventeen years together and had two surviving children. By the time of his death, the girl was sixteen and the son “a young boy”. Tolstoy is quite brutal in describing their middle-class existence writing that their house “was just what is usually seen in houses of people of moderate means who want to appear rich, and therefore succeed only in resembling others like themselves”.

Their lives proceeded as scripted until the first signs of illness appear with “a queer taste in his mouth and some discomfort in his left side”. On the way back from the first doctor’s visit Ivan started to feel his condition was “very bad” and started to watch the world “with a new and oppressive feeling.” As his condition worsened, Ivan Ilych looks for ways to treat his illness with a variety of doctors, one who diagnosed a floating kidney, another an inflamed appendix, until one day Ivan himself realized: “It’s a not a question of appendix or kidney, but of life and…death.” At the moment a realization paralyzed him:

“When I am not, what will there be? There will be nothing.”

He also notices that, as he is deepening this sense of his own ending, others around him go about their lives – including his own daughter and wife. Eventually, Ivan himself admits that dying would “release the living from the discomfort caused by his presence and be himself released from suffering.” As his condition continues to deteriorate he starts to require help “for his excretions” and in that he finds unexpected solace in the figure of the Gerasim, a “clean, fresh peasant lad, grown stout on town food and always cheerful and bright”. Gerasim is a no non-sense simple soul whose straight and honest attitude holds great contrast to the dissimulation of Ivan’s colleagues and even his family. Fed up with what he perceives as their “deception” Ivan comes close to calling out:

“Stop lying! You know and I know that I am dying. Then at least stop lying about it.”

Except “he had never had the spirit to do it.”

The only one willing to acknowledge what’s happening, in Ivan’s eyes, is Gerasim. One day as Ivan asks Gerasim to stay a little late to comfort him he hears:

“If you weren’t sick it would be another matter, but as it is, why should I grudge a little trouble?

Gerasim even comes to the point of saying:

“We shall all of us die, so why should I grudge a little trouble?”

Which Ivan interprets as him saying he was “doing it for a dying man and hoped someone would do the same for him when his time came.”

With the continuation of his illness, he finally finds a moment where he can be alone and cry. As he wept an inner dialogue clarifies his fears and concerns – including “his helplessness, his terrible loneliness, the cruelty of man, the cruelty of God, and the absence of God”. His inner dialogue is a good draft of an existential coaching session.

“Why hast Thou done all this? Why hast Thou brought me here? Why, why dost Thou torment me so terribly?” and continues “What is this for? What have I done to Thee? What is it for?”

To which his inner voice responds:

“What is it you want?” which is a very powerful question.

Ivan replies: “to live and not to suffer.”

And his inner voice asks for more: “To live? How?”

“As I used to – well and pleasantly.”

These questions lead him to examine his life’s path, from childhood to Law School, to marriage, and his “official life and those preoccupations about money” on and on, “always the same thing.” Which brings him to the terrible realization:

“It is as if I had been going downhill while I imagined I was going up…I was going up in public opinion but to the same extent life was ebbing away from me.”

And the awful conclusion:

“Maybe I did not live as I ought to have done.”

It’s just too late.

A brief overview of the model

Existential psychology has its roots in philosophy, first with Kierkegaard then with the 20th-century existentialists including Heidegger and Sartre, who famously proclaimed “we are condemned to freedom”. In psychology and psychotherapy, the main contributors are Viktor Frankl, Rollo May, and Irvin Yalom. Frankl’s experience in concentration camps – recounted in the classic Man’s Search for Meaning – consolidated his ideas around the key role meaning has in human life: “striving to find meaning in one’s life is the primary motivational force in man”. May emphasizes courage and freedom in his work, saying in Man’s Search for Himself: “Freedom is man’s capacity to take hand in his own development. It is our capacity to mold ourselves.” In his book Existential Psychotherapy, Yalom lists four major themes to be explored:

  • Freedom
  • Isolation
  • Meaninglessness
  • Death

In summary, from an existential perspective, we are subjectively alone, free to create ourselves in this one life we have, craving for meaning and purpose, and aware of the presence and inevitability of death. These feelings of isolation, the responsibility that comes with freedom, the fear of meaninglessness, and the dread of death, can all conspire to create anxiety and at times despair. Overcoming these, at times taking solace or even pleasure in our conscious isolation in the universe, in our freedom to be – and create ourselves, and in our time-constrained nature, can replace this profound sense of existential despair with a sense of mature and self-aware joy of being-in-the-world, here and now.  

Related Content: Is it Better to Plan for End-of-Life? Or Strategic Aging?

The rationale for choosing the existential model

Each of the four existential themes can help us approach Ivan Ilych’s difficulties with his process of dying and can help coach him towards a better resolution. He had the freedom to choose his life and that’s why the question “Maybe I did not live as I ought to have done” is so terrifying. He is alone in his suffering, unable to share the subjective experience of dying; and this loneliness is compounded by his inability to communicate with those around him. He is searching for a final meaning and purpose of his existence. Finally, he’s facing not-existing, he’s facing death itself.

How to apply the existential model in talking to a dying man

By using direct communication, the coach would avoid the dissimulation – which comes from the denial of death – that so irritated Ivan in his deathbed. By active listening, we could pick up his concerns about dying, his worries about his own choices and path in life. With powerful questioning, we could follow his self-discovery and help him understand those choices and their outcome – mainly his family and his job. One example of powerful questions would be:

“If you were not pursuing the life you did, what would be doing instead?” or “What is it that you would like to say to your wife?” or to his children, or to his friends? In challenging him to action we could rehearse some of these dialogues with him.

Someone with coaching presence, being spontaneous, flexible, and confident, would provide relief from the dissimulation Ivan feels around him. In the story, the one who comes closest to that coaching presence is Gerasim – and it’s palpable the effect it has on him.

Expanding the knowledge and skill in coaching

Pondering about the use of existential perspective in coaching makes one realize the incredible potential coaching has to help us help one another. Being a therapist and psychiatrist for twenty years, I can attest to the power of the therapeutic relationship. I am also restricted by medical necessity and the medical model.

In coaching, we are free from those restrictions and thus able to help people without the need to designate them as patients. As a therapist, that’s liberating. Using the existential approach allows one to go beyond the traditional coaching topics, usually work or personal conflicts, and expand to an authentic deeply human conversation. It’s possible the existential perspective will help inform coaching efforts in end-of-life conversations, within hospice populations, for example, allowing for those people to die with dignity, not only free of physical pain but also relieved from some existential angst in their final moments.


Erick Messias, M.D., Ph.D., M.P.H.

Erick Messias was born and raised in Brazil, where he completed medical school and practiced family medicine in rural areas before moving to Baltimore for residency training.

He completed a psychiatry residency at the University of Maryland, in 2001, and preventive medicine at the Johns Hopkins Bloomberg School of Public Health, in 2003. While at Hopkins he also received a master in public health and a PhD in Psychiatric Epidemiology.

Since graduation, he has held academic positions in medical schools in Brazil, and later in Georgia and Arkansas where he was medical director of the Walker Family Clinic and responsible for the House Staff Mental Health Service at the University of Arkansas for Medical Sciences (UAMS) in Little Rock.

Dr. Messias has over 40 publications in scientific journals, has published several book chapters, and edited a volume on schizophrenia for psychiatrists; he’s the recipient of many research and teaching awards. He’s currently the Associate Dean for Faculty Affair for the UAMS College of Medicine.


Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Comment will held for moderation