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. Psycho - Anal. (1998) 79,83

THE PATIENT WITH< D UT A COUCH:

AN ANALYSIS OF A PATIENT WITH TERMINAL CANCER

VIVIANA MINERBO, sxo PAULO

The author reports an unusual clinical experience arising from the tragic circumstances of

a patient who contracted cancer at the

beginning @ f the fifth year of an

analytic process .

Instead of interrupting the analysis, the analyst suggested having sessions by tel ephone, as this patient could no longer leave her home when he terminal phase of her illness set in . The experience proved beneficial for the patient and enriching for the analyst. The patient was able to contain, work through and integrate he meaning and consequences of her disease, make reparations to her objects, and accept death with dignity . The analyst also emerged from the experience strengthened and more aware of her own vulnerability and mortality. The author brings up three relevant questions based on a review of the litera-

ture. These questions are: should the patient be

told of h i s/her diagnosis and to what

purpose? Can there be a productive analysis with such patients? What psychic structure and emotional conditions allow a patient to bear the truth?

INTRODUCTION

I intend to describe here the events in the

h ronological order in which they occurred. I

s

h all give an extensive clinical report on the

l

a st six months of an eight-year analysis with

t

he patient . Then I will present a brief biblio-

g

raphical review of the literature about this

t

opic, focusing on three questions that espe-

cially claimed my attention, based on the lit- erature and my own clinical report . These

questions will be considered in the discussion that follows.

THE CLINICALREPORT

This clinical report is about an unusual experience that made it possible to go ahead with the analysis of a patient in spite of termi- nal cancer she had contracted at the begin- ning of her fifth year of analysis.

I shall leave out facts of her life history and analysis prior to the last six months of our work together, and present only those aspects pertinent to the subject of this paper. The patient was 48 years old, married, and had three teenage children, the youngest being 15 years old. Her sessions were on Tuesdays , Wed esdays and Fridays. She would come very punctually and always let me know in advance if she had to miss a session. She developed cancer four years ' ago at the beginning of her fifth year of analysis and eventually underwent surgery and chemother - apy, to which she seemed to respond well, according to the doctors . About a year ago, in the seventh year of our work together, the can- cer reappeared in an atypical form, as it could not be located in any specific organ. The doc- tor told her this was very serious, and he pro- posed numerous experimental treatments, all to no avail . She was aware of her diagnosis, and participated in the decisions regarding her treatment . In addition, she was able to

84

VIVIANA MI N ERBO

procee d with her analys is normally , although

it was ob v ious that her , heaith w as f a iling and

th at a ll the medical treatments had almost

been exhausted.

O ne da y about six months later she phoned

me and said in a very ' faint voice that she was afr aid she would h av e to interrupt her ana l y-

sis . The l a test blood test s had shown that s he

w as completely without ' resistance', fo r wh i ch reas on the doctor prescribed absolute rest for

a n i n definite period .

I reacted intensely to this news ) could hav e

usu a l w h e n w aiting for her call , as I expecte d

b a d ne ws e v ery t ime. I was not sure i f I w ould

be a ble to deal w i th this tragic situation with- out dev ia ting from an anal y tic s tance . I al s o be ca m e aw a re of the fa c t that her a pp r oach i ng

death w a s al s o making me conscious of my

o w n v uln era bilit y and mort a l i t y a s ne ve r

b e f o r e. On e t hin g s eemed cle a r in m y mind: I was on the s i de of life , a nd it w as th is aspect

o f he r p e r s on a li ty th a t I w ould add r e s s w hen-

e v er po ssibl e. Onl y much l a ter did I realise I

w ould al s o h a ve to help . her in h er d y ing pro-

 

/

c

ut off treatment , and our relationship , t hen

c

ess.

an

d t here, by simply hanging up the phone .

I

al w ays fe lt e x hausted after the first fe w

B u t I realised that it w a s perhaps then t h a t

s h e most needed a n a l y s is. A s if t o echo m y

t

t

w o u ld no w need me m or e th a n e v e r . Aft er we talked fo r a few more minute s, i t

not c ome, s ince s he

ho u ghts , she . sur p rised me by saying herself

co

h a t it w as a pi

s he could

1''lrtO'',

su ddenl y c ame to me th a t w e could cont in u e

t e l eph o ne s e ssion s. I realised this w a s not o n l y

be ca use of th e intense em o tion s o f the ses s i on ,

bu t a lso bec a use t he moments of silence and ref l e ct io n t ha t u sed to punc t ua te the sessio n s on t he co u c h had di sappe a red. W he n I

po i n te d thi s o ut sh e said she felt v ery an x ious

at a ny s i le n ce bet w e e n u s . She h a d no way o f

h

avi ng our se s sions b y t e lephon e , s o I su g -

kn o wing if I w a s s till 0

the other end of the

g

e sted this. She seemed to cheer up insta n tl y .

lin e. I und e rs too d

t hat she f elt she had l ess I

Sh e as k e d if I thought i t w o u ld w o r k , an d I

a ns w e r ed that I did not kno w , but we coul d t r y

if s he wanted. She a greed in s tantly , w ith no

' re sis ta n c e ' , and s a id that s he w a s v er y h a pp y not to lose me so soon .

A fter a brief pause she added that s he kne w

from ex p e rience th a t s he could count on me to

b e ar with her the worst fears and anxieties ,

n o w that death seemed ne a rer . I immedi a t e l y fel t a lump in my thro a t . She a dded that peo-

p le around her, especially her husba n d , tried

to do w nplay the s e riousness of h e r illne s s , a nd

th i s irr itated her profoundly. Not onl y did this

a t titude make her feel misunderstood , it a lso

m a de her feel she could not v oic e her fe a r s

a nd anxieties to those around her. I r ealised

th a t her fatal illness must ha v e mobilised the

defence of denial in tho s e a round her . I t

o c curred t o me to say that she felt strong

e nough to face the truth , but she needed me to he lp her bea r it instead of den y ing it .

We had regula r sessions over the telephone

for th e la s t six month s of her life. She w ould cal l m e up at o ur usual times as punctuall y as

e ver . I noticed that I felt more anxious than

contro l over me by te l e phone . M a y be s h e felt

t ha t I was m ore sep ar at ed from her, re s ulting

i n g r e a t er an x iet y. I s a id t hat s he tried to fil l i n

a ll possible si le n c es b y wa nt i ng m y c on s tan t

attent i on , in order to be certain

th e r e fo r h e r a nd th a t I had not ab a ndoned

h e r , s in ce s he ne e ded me so mu c h . Like tw o

blind pe r sons we were never to set eyes upo n

e a ch o t her a gain . I s h a ll comment " on thi s aspe ct o f our ne w setting later on .

I soon noticed that ou r sessions h a d f a llen

th a t I was

in t o a rou t ine di f f e re n t from th e way th i ng s

ev ol ve d w h e n using the couch . She w oul d

st a rt t he ses s ions by giving me a br i ef repor t

on her s t at e o f h e alth , w hich w a s de t eriorat-

in g d a il y, a nd on wh a t the next medical pro-

ce dure

long er d r i ve a car o r e v en l e a v e the hou se

bec a use of her low immunity . To save energy ,

s he a l s o h a d t o limit her ph y sical mo v ements

t o an a b s o l ute minimum . S he e ve n h a d to eat ver y s lo w l y b e cause digestion consumed so

uch energ y. I t occu r red to me to s ay th at it

see m e d s h e must no w li v e in ' slo w motion '.

m

w ou l d be . She said th a t she could n o

S he c hu c kl e d and said ' th a t's right '. She

a d de d that altft 0 U l

v er y acti v e perso n

she did not m i n d be c o m e her na tu n

' medic al r e ports '

could see ho w m uc

t aine r to de pos i t .

happ e ning t o h er I I and help he r b ea r ' Af ter t h ese r e p s app ea r, such as h e child r en and h e r I

band . I not iced the tions a nd n o m o re c

w e h a d no t a min u

as q uickl y as p o s s urgen t matte rs. Sh e t old me t h a t

h er childre n wo u ld

c a re a fte r h er d e a

man y of h is valu e s

di f fere n t fro m h e r a

w oul d influ ence th l

gav e t h e follo win g e

W hen p assi n g b

(

c

w

at hi m 2

n o re a ction a n d r an

He r husb a nd cr i tic i

h ad s ho w n a ' c o wa

t ho u g ht t hat the b e

eve n i f t his mean t b e

T he so n , h owe v e r,

e no u g h to con fron

ha nded . The mo th e r tion wa s ridic u l o u s

t h a t o n ce , wh en h e I:J ha d h a d a sim ila r e

w ho h a d pro voke d

quently beate n up . E fea r a t the time a nc

h i mse l f fo r h av in g be

sa id she thoug ht he T

s on to avenge t h e h u

suffered in the p a s t

ome u po n ho j e ered

a gan g

lthough h er r e as

i t , I could see it w as

aspect of her per s o n

A

s I expected

e- su r e if I would n c i tu a tion with- . st a nce. I also

a

a er a pproaching

_ n sc ious of my

~ lit y as never

i n my mind: I

w as this aspect

a dd ress when-

d id I realise I

h er dying pro-

f

-,

t h e first few

-

. w as not only

~

- of t he session, of s ilence and

t

he sessions

r ed . When I

.~ v ery anxIOUS

h

a d no way of

zher end of the

 

e

s h e had less

;-

Ma y be she felt /

 

h

er , resulting

• e t r i e d to fill in

- . - : :my constant . th at I was

o r ab andoned h. Like two set eyes upon m men t on this

THE PATIENT WITHOUT A COUCH

85

added that although she had always been a very active person, she now felt so weak that she did not mind the slow motion. It had

become her natural pace . I listened to these

'medica l reports'

saying almost nothing . I

could see how much she needed me as a con- tainer to deposit her fears about what was

happeni n g to her, to share and bear it with her,

and help her bear it .

After these reports other material would

appear, such as her daily worries about her

children and her discussions with her hus -

band. I noticed there were fewer free associa - tions and no more dream material . It was as if

we had not a minute to waste and had to deal

as quickly as possible with immediate and urgent matters.

one of her fears was that

her children would be left in her husband ' s care after her death. She did not approve of

many of his values and ways of thinking, so different from her own , and she was afraid he

would influence the children negatively. She gave the following episode as an example.

S h e told me that

When passing by a school , her son had

come upon a gang of youngsters his own age,

who jeered at him and beat him up. He gave no reaction and ran away as fast as possible.

Her husband criticised

had shown a 'cowardly attitude'. The father thought that the boy should have retaliated even if this meant being beaten up even more.

the son and said he

sagacity her children needed to grow up with

the correct values. It would be dangerous to leave their young minds under the care and influence of her husband's way of thinking . I said that she could see for herself that her children were quite grown up and had minds

own . Maybe she believed that she

was indispensable for their survival. Then I reminded her that she had lost her own mother when she was in her early adolescence . At this she remembered that although she had grieved over her mother ' s death, she w as young, and life was ahead of her, full of prom- ise. She had managed to survive quite well. She even added, with a pinch of humour , that she had certainly not missed her mother's con- trolling nature. I said that maybe she wanted to be able to control her children's lives:

maybe the real issue here was the pain of hav - ing to hand over this role to her husband at her death . This was the first time I overtly mentioned her forthcoming death . I shall make some reflections on this subject in the discussion.

One day she told me she felt very hurt b y her daughter who was studying abroad. Eve r since the daughter had heard of her mother ' s failing health , she had started calling her father instead, to give him her news. The mother felt left out and had cried a good dea l over this injustice . Her personal life was so empty that any news of any of her children

of their

o n.

 

The son, however, said he was not

crazy

was 'nectar ' for her. I said that I could under-

T

o

ns

had fallen

enough t o confront a whole gang single -

stand that she felt her life to be empty

at the

-

e w ay things . S he would

handed. The mother thought the father ' s posi- tion was ridiculous. Later the father admitted

moment , confined as she was at home; it was so different from my life and th a t of her

a

br

ief report

that once , when he himself was a teenager, he

daughter abroad, each of us so busy and

 

deteriorat-

had had a similar experience, but it was he

active. Maybe this is what she was rea l ly

. m e dical pro- -' h e could no

who had provoked some boys and was conse - quently beaten up: He had felt paralysed with

resenting, this and the injustice of her daugh- ter turning to the father, instead of to her own

 

'

e t he house

fear at the time and still inwardly criticised

very eedy self. She felt left out, as she had

o

sav e energy ,

himselffor having been a coward. The mother

said. I thought later that her needy self prob-

m

ovements

said she thought her husband had wanted the

ably also felt left out of my personal life, since

 

en had to eat

son to avenge the humi l iation he himself had

I dedicated only three hours a week to her.

o ns umed so

suffered in the past

She remained silent, so I reminded her that

~ t o s ay that it , ow motion'.

Although her reasoning had some logic to it , I could see it was conceali n g an omnipotent

she had once told me how happy she was that I could still be with her, even if only by tele-

- -; r i ght ' .

She

aspect of her personality. She alone had the

phone. I asked if she had thought of telling her

6

VI V IANA MINERBO

da ught er how much she al s o needed her calls .

S he said s he w a s so hurt tha t s he didn ' t w ant

to be the one to phone . It was up to the daugh -

t er to call her. I asked if she w a sn ' t a cting on

'fa ls e p ride ' , not wanting to sho w her need to

h er da ughter . Ma y be that wa s w hat the hurt

til th e e n d' . I immediately realis e d th a t th e

lump in m y thro a t w as gro w ing , and I f e lt that

a bu r d e n h a d b e en pur on m y s houlder s . I could s ee h ow mu c h s he expected of m e , a nd

I was n o t a t a ll s ure I could c ope wi th thi s

dr a m a t i c s i t u a tion. I al s o bec a me awa re of

»

=

do , s he sa id. T h i s s e e n ing wi th me. The n I

m e like a no n - p s y c h os

h a p s what s h e co u ld

po ss ible

reminded h e r th at s

u se o f t he

was all about .

ho

w afrai d I was of her d y ing . T hi s was th e

gr

a tefu l s he was t h at s

 

A

t th e ne x t session s he was happ y to tell me

fir

s t time I h a d attended a patient w ith a ter-

vacy of h er own h O

u

a tion , t h at i t wa s e as

t

h at s h e had thought ov e r our con ver sation

min a l illn ess, and I ha v e also been s p a r e d f rom

tec t e d b y th e l o v e o f

a

n d h a d decided to call her daughter a fter all.

goin g t h ro u g h a n y such e x perience in m y pe r -

being in a d esola te

In t e a rs , the daughter h a d apologised , saying how much she was afraid for her mother ' s life .

son a llife . A t t h e s ame time I was gr a tified that she f e l t h e lped b y me. I replied , withou t know-

mayb e she t h o u gh t , s i

She l a cked the courage to talk directly to her.

ing wh a t wa s to come , that I would s t a y by her

the imp ortan t t hin g n

S

he s a id she loved h er very much and that she

as long a s s he was able to particip a te . A

to enjo y the m om e n ts

w

as t hinking of i nterrupting her course and

depresse d m oo d took hol d of me for t he re s t

as she w a s by the o ne

co

ming home to be by her mothe r' s side, even

of the d a y.

 

I

w as t r y i ng to a d

t hough t he course would be o v e r in just two

m onth s . My patient told her th a t th e greatest

o y this daughter could gi v e h er mothe r w as to

stay a nd finish the cours e su c c essf ull y. I could

j

r s ee th ere t he reparation for t he r e s entmen t . I

sa id I c ould see her genero s i ty in not wan ting

her n eed a nd illnes s to b e a n ob s t ac le t o her

u g ht er's life. She sa id that one of he r g r ea t wor ries w a s

da

t:.c,

a C ( ;

.

th a t s h e w ould become a 1 5 u r e . J lto he r famil y .

I sa id I c ould appreci a t e t h ese f ee ling s of not

wa nting

f a mil y, as this could be humili a ting for her. I

r emind e d her that we t w o had a relationship

i n w hi c h we depended on each other for our

w o rk together. Didn ' t she feel th a t th e mem -

be rs of her family had some spe c i a l responsi-

bility towards her in sickness a s in health , as

she h a d towards them? She said that I had put the pro blem in a way she had not thought of

befo re . For my part , I felt th a t m y l a st ques -

ti on was quite unprofession a l . I s hould ha v e

b ee n sa tisfi e d with the int e rpret a tion that to

b e n e ed y was humiliating to her . I wa s proba - bl y ove r-a nxious to h e lp.

O n e da y s he told me s he h a d agreed to tr y

a n ew ch e motherap y e x per . iment aimed at

' en ca psul a ting ' the a ffected o rg a n , hoping f or

a re g r e s s ion of the loc a lised c a ncer . She w as

t errified because the doctor s a id thi s proce - dur e in v olved considerable ri s k . A lmost in te a r s, she asked me if I would stay by her ' un -

to b e need y and d e p e nd e nt on her

I w ill now r e l a te two sessions in the s a m e

we e k th a t illu s tr a te the oscill a tion s in h e r moo d .

Wednesday

I sen s e d disco u ra gement i n th e brief ' good

morn i ng ' sh e gave me . S he s aid s he was not

res p o nding to the chemother a p y a nd the do c -

h a d s a id h e w ould tr y to think of w h a t

could b e d o ne n ex t . H e w a s ob v iou s l y ' lo s t ' and s he fe l t like ' gi v ing up the f ight ' . I t

d aw n e d o n me th a t it was the first time s he wa s

re a ll y c on sciou s of losing hope of a n o th e r

remission, b e c ause this w as re a lly wh a t th e experiment a l methods she agree d to submit to meant. A s s h e said: they were postponing the momen t of de a th .

She said sh e didn ' t feel like seeing or talk - ing to an y one . I asked if she would r a ther not talk to m e either that day , but she said no immedi a tel y , a s s he had alread y told me how import a nt it was to ha v e me with her. She wa s referring t o coll ea gues from w ork who w ere going to vis it her i n the afternoon. She w ould

ha ve l i ked them not to come , but d i dn ' t wa nt

t or

to hurt a n y on e. This mo v ement of not wa nt - ing to hurt me or the colleague s gave m e a doo r th r ough w hich I could tr y to h e lp h e r bear her mi s e ry . I s aid I could see in thi s con- cern of n o t w a nting to hurt an y one a desire not to ' gi v e up the fight '. What el s e could s he

these wor d s d idn ' t qui et, fe elin g v e r y

think ing of the s u endure .

e

Fr

I fe lt g rea t an x iet y

s ion . Th e fir st t h ing

' good m ornin g ' w as

w h a t h a d h app e ne d

after t h a t sa d and i l l

m y gre a t surprise she

d ay . S h e had b een able

after the sess i on , h ad fast, wa tch ed a fi l m cousin o ver f o r lun c h . expected visit fro m hi all ch a tted and had a ~ aged to forge t ho w si She c a u g ht he rsel f th i to be a l i ve a n d a b le - which m igh t se e m s o son , but w er e so pr e c i

tion . I w as mo ved b y ] and th e gr a titud e s h e momen t s of l ife. Sh e then t o l d

her th e f ollowin g d a y l

c ert. As s he felt re ste d

she a ccepted t h e i n vi

was not risking t o o I

m e -

THE P A TIE N T W ITHOUT A COUCH

87

-

e d t h at the

do, she said . Thi s seemed to be a way of agree -

a

n d I felt that

ing with me . Then I sa id ( in w h a t s ounded to

;

- s h o uld e r s . I

me like a non - p sy cho a nal y ti c s t a n c e ) that per -

e

d

o f me , a nd

hap s w h a t s he could do w a s make the b e st

o

p e wi th this

pos s ible use o f th e t ime sh e had left . I

ca rn e aw are of Th is w a s the

i en t w ith a te r -

s pa r e d f rom

 

e

in m y p e r -

-

gr

a ti fi e d that

 

i

t h o ut k now-

u l d st ay b y her

a rtic i pate .

A

e

f or th e r e s t

-

i

n t h e s ame

at

ions i n h er

reminded

grateful s h e w a s th a t sh e could stay in t h e p r i -

v a cy of h e r own hom e, w he r e s he f e lt pro-

tect e d b y th e lo v e of he r f a mil y , in s te a d of

being in a de s olate hospit a l .

ma y be s he thought , s in c e I w a s not in h e r s it -

uation , that it w as ea sy fo r me t o te ll h e r th a t

the import a nt thing no w w a s for he r to be a ble

to enjo y the moments s h e c o uld , s ur r ounded

a s she wa s b y the one s s h e lo ve d .

h e r that s he had once said h ow

I a d de d that

I w as tr y ing to a ddres s the life i n

h e r , but

thes e w ord s didn ' t s eem to help . I re main e d

orde r s to s t ay at home . If s h e we nt to h os p ita l

s o fr e quently fo r te s t s , wh y not a n e x cepti o n

for som e e njo y men t? S h e h a d lo v ed t he c o n -

ceit a nd it felt so go od to b e i n a t h e a t re

a mong other p e ople. I c ould s e e h e re a wi sh t o

den y her illn ess for a mom e n t a nd reall y be

like he a lth y pe o ple . I said I c o u ld see how

proud s he w a s of her s elf : i n s pite of th e

ou s ne ss of he r i llne s s , s h e c ould enjoy wha t

she was a ble t o a nd feel full ofli fe. I a dde d t h at

mayb e she w a s a lso telling me t hi s to mak e m e

feel h a pp y f o r h e r a nd f or our w or k tog ether. She t h anked me f or t h e w ork I w a s doi ng wi t h

h e r , esp e cially f or be a r i ng w i t h her desp a i r as

I h a d o n W edne s d ay , w ith o ut falling

de s pair m ysel f . S he f e l t tha t th is was w h a t she

r e all y needed. W a s sh e s eeing me then , fo r a

s er i -

in to

quiet , fe e ling v er y s a d a nd im p ot e nt

and

mom e nt , as a sep a r a t e pe rso n , on e w h o d id

thinking of the endu r e .

suf f ering

she w a s yet to

not d espair w ith h e r but w ho c ould co n tai n her de s pai r?

Fr id ay

My holid ay br e ak w a s a ppr o a c hing and I felt guilt y for le a v ing he r i n s u c h f ai lin g he a l t h and appreh e nsi v e of how she w ou l d r e a ct to

I

f e lt great an x iet y a t the hou r of o u r ses -

the s eparation .

s ion. The first thing sh e s a id after the u s u a l

' good morning ' w a s th a t I c ouldn 't i ma g ine wh a t h a d happened to he r on W edne s d ay after that sad and disheartening s ess ion . To

m y great surpris e s h e s a id she had had a good

day . She had been able t o pull he r sel f t o get her

after th e s e s sion , had her s ho w e r a n d br e ak -

S he said th a t a lth o ugh s h e wo uld miss o u r

s e ssions , he r daughter ' s return

compensation . T h ey wo uld h av e a lot t o tal k

a bout . She a dd e d , h a l f -j o kin g l y , that s h e

thought she could h a ng

retu r n . I t had not occu rr ed

could ind ee d die w hile I wa s aw a y. I r ea lis e d

to me that s h e

on to life until my

w ould b e a

a st , w atch e d

f

a film on tele v i s i o n ,

h ad a

th

a t this w a s a denial on m y p ar t a nd it mad e

cousin over for lunch , a nd finall y rec e i ve d th e

m

e feel that I w a s reall y abandoning

her w h en

- g or t a lk -

d r at h er no t

s h e sai d no tol d m e ho w

h e r . S he was

- - w h o w e re

_S he w ould

- di dn' t want

n o t wa nt-

- g av e me a -0 h elp h e r

i n t hi s con- ne a desire - c o uld she

e x pected v isit from her coll e ague s. The y had

all ch a tted and had a g o od time . Sh e h a d man -

aged to forget ho w sick she wa s fo r a w hile .

She caught herse l f thinking ho w good i t wa s to be alive and able to enjoy su c h moments,

which might seem so simple to a nothe r per-

son , b u t were so precious to her in he r c ondi- tion . I wa s moved b y her courage , moral fibre

and the gratitud e she felt f o r such nice , brief

moments of l ife. Sh e then told me that a friend had called her the following day and invited her t o a c on -

cert . As she felt rested after h er afternoon nap she accepted the in v itation . She thought she was not risking too m u ch , in spite of s trict

ne e ded me m os t , and s he was

reminding m e of thi s in her own w a y . I r ~ mem - bered a y oung p a tient I h a d had w ho wa s so

that s h e told me s h e

would li l ke to die just to s e e he r mother fee l

guilt y for having mi s treated her s o . I said that

it felt as if s he was g e n er ousl y gi v in g me p er -

mission t o have m y holid ay , but a t t he s ame time she wa s reminding me th at I r an the r i sk of her dying w hen she w ould ne e d me mo s t .

angr y with her mother

s he probabl y

How would I feel if this happened? M a ybe she thought this was what I de s er v ed to happen

for ab a ndoning h e r. Sh e a s k e d i f I wa s not going too far in my analy s is of what she had

s aid . It seemed to me that she agreed to m y

88

VIVIANA MINERBO

interpretation but it was almost more than she could bear . At the first session after vacation she told me she must have misunderstood the date for my return . She had telephoned as usual a . week ago and it was the silly answering machine that took her call instead of me.

Then she realised her mistake. I said I under - stood she had missed me , and that maybe such

a long holiday seemed to mean that 1 did not

really care for her. If I cared, I would have

come back sooner . Maybe she was resentful

holiday away

from her and could leave her out . With an awkward laugh she said she did not want to sound demanding and ungrateful . I said maybe she was ashamed to realise she had such feelings about me, especially a s she also liked me and needed me so much . I was emphasising that she could have negative as well as positive feelings towards me. As her health was failing rapidly , she had to go to hospital for blood transfusions immedi- ately after my return . We thus missed one ses-

that I could have my life and

s ion , and the next was a holiday. I would like to describe the subsequent session , as it reflects how much she had matured even in the face of death, or perhaps because of it .

Tuesda y

She said she had spent a miserable time in hospital having her blood transfusions. She had been in such pain that she had been given morphine . What was worse , she had not responded to the transfusions . The doctor said there was nothing more he could do for her. At her request she was taken back home and was bed-ridden again. She said how good it was to talk to me although the effort left her a little out of breath. I said she was glad to count on my understanding and support in this time of need. The fact that we could not actually see each other had its positive aspects. She was spared the humiliation of being exposed to my wit- nessing her suffering and probable physical

alteration. I remember her telling me, just a few months before the terminal phase set in, that she had an ex-colleague who was dying of AIDS . She was forcing herself to visit him at home once a week for humanitarian reasons as he was completely alone, with no friends, and with only very old disabled parents. These visits were very trying, Week by week she noticed his visible physical deterioration, his hair falling out , the massive loss of weight which left him with a skin - and-bone appear- ance , the magnitude of the pain and weakness were of such an order that he could not even leave his water mattress to go to the toilet . When he f i nal l y died she remarked that it was a blessing his misery was over.

She had mentioned being glad s he had not lost her hair w ith the on-going treatment; in the pa s t she had had to wear a wig . She had also lost less weight than she would have liked to, as she was quite stout . Maybe this infor- mation helped me, when I thought of her , maint a in the visual image I had of her the last time I saw her . A lot of denial was at work here because I did not take into account the alter- ations the disease and pain I knew she was suffering might be cau ing to her appearance. The fact that I was spared seeing her a nd espe- cially that I was spared witness i ng at first hand the great physical pain she was in from this time on, undoubtedly helped me continue to be useful to her to her dying day , and facil - itated for both of us what was to transpire from now on. She said she had discovered that if she lay

quite still she felt almost

a v oiding fe e ling the pain was a wa y of trying

not to think how sick she really was and not to realise that she was actually dying . She said she knew that, and the thought was unbear- able. She surprised me by saying she had a favour to ask me. Her daughter was taking her illness and coming death very badly , and asked if I would agree to see her if she needed me after her death. I said I could see her but not treat her . I felt sh e was saying , with rea - son, that the real i sation that she was dying was unbearable to her. I wondered whether

no pain. I said that

th i s mean t th a t she was pos s i b f fantasy t h at sh e he r death t hr o u wa s wh y I wa s ~ was con v i nce d t ded in he r ob j e

ho w ever, i f I C O t ho w she wo u ld n bec a use o f th e TI

t r u s t she h ad d

this interp reta tio

delicately as I C o t

' D o you ha v e t o b

But I felt t hat, n c

pre t ation was t o t and still want e d t

t he ' e nd ', as s he 1

l ong a go .

S h e wen t o n I (

her f ather and b r c felt lo ved a nd g r at did n ot fee l at all a fea re d she wou ld l wa s f in a lly able t o depe n den t o n th e n

Sh e said that s h cess' . I wa s s u r p r i lik e a ' littl e pr i n o ex pl a ined th at s he

l o v e d before . S he 1

fa th er, as h e was a J

himse lf be tou c he

N o w he woul d sit

h and . She felt f ul l

s orry to ha ve to in

wi t h her pr ema t u re :

t hi s s a dnes s .

S h e had also h ac

t ion w ith he r h u s l

t ime i n their m arri e

i ng cheated on h e r a

g i v eness, sa yi n g t h a i

w a s str onger t h a n a

v er y grateful for t he

r emembered ho w m

t his in f idelity, whi c h

a nd h u miliat ion . S h

g me, just a

p hase set in,

o w as dying of

t : -0 v isit him at

ta n an reasons

THE PATIENT WITHO U T A COUCH

89

this meant that, as a defence against her fears, ! me that she would never forget this or forgive

she was possibly harbouring the unconscious / him f or his betrayal . Now she felt this was

fantasy that she could stay on with me after / behind them , and though she had not forgot- her death through her daughter. Maybe this / ten, she had forgiven him for this weakness.

was why I was so surprised at the request . I She now understood the real meaning oflove.

. i th no friends,

was convinced that this fantasy was embed-

She w as also grateful, she said, that

the chil -

. pa r ents, These

ded

in her objective request . I didn ' t know,

dren had their father to care for them after her

r by week she

however, if I could dare say this to her, and

deat.

 

e

r i o ration, his

how she would react to it . I then thought that I was very moved by the obvious reparation

l

o

ss of weight

because of the respect I had for her, and the

she was making to her loved ones, and so

-

b

o ne appear-

trust she had deposited in me, I should risk

grateful that she had matured to this point . I

a

n d weakness

this interpretation. I tried to formulate it as said that the love she was telling me about

~co u ld not even

~ o t o the toilet .

r e d that it was

d s he had not

-= t r e atment; in

w i g. She had

u l d have liked

: ',b e this infor-

u g ht of her,

- o f her the last

a t work here

o

u nt the alter-

m ew she was IT a p pearance. =. h e r and espe- - ssi n g at first . -e w a s in from

m e continue

r

y, and facil -

- - 1 0 transpire

: : .tha t if she lay

, . I said that

ray of trying

; ' w as and not yi n g . She said

~ as unbear -

( g s he had a - ~

,

~ if s h e needed

t aking her b adly, and

d s e e her but

i ng w ith rea-

- e w as dying

"

l er e d whether

seemed to have helped her come to peace with herself and her beloved ones. I added that it seemed to me that she was accepting the harsh

pretation was to bear, she was agreeing with it fact that she was dying, and that maybe she

But I felt that, no matter how hard the inter-

delicately as I could, and she responded with:

'Do you have to be an analyst to the very end?'

felt ready any time now . After a slight pause

the ' end', as she herself had requested not so she said that this was so, although it did not

long ago.

and still wanted to have me as an analyst to

mean she was not terrified of the unknown .

She went on to say that over the weekend

I had

a feeling she was saying goodbye to

her father and brother had come to visit. She me with this session, and that it was a gift to ,

felt loved and grateful for their company, and

did not feel at all a burden

feared she would be in the past . I thought she I was not too surprised when

me that represented the epitome of our wor k together .

he r husband

to them, as she had

was finally able to accept needing and being dependent on them without humiliation.

cess'. I was surprised like a 'little princess'

explained that she had never felt so genuinely loved before. She used to be angry with her

father, as he was always distant and never let himself be touched or show any emotion.

N ow he would sit by

hand. She felt full of love for him and was

sorry to have to inflict so much pain on him with her premature death. He didn't deserve

this sadness. She had also had a very intimate conversa-

tion with her husband, maybe for the first time in their married lives. He confessed hav - ing cheated on her and was asking for her for- giveness, saying that the love that bound them was stronger than any passing affair . She was

very grateful for these words of affection . She

remembered how much she had hated him for

this infidelity, which had caused her great pain and humi l iat i on. She remembered her telling

at this remark: feeling on her deathbed? She

her bed and hold her

called me the next day to say that she had died during the night .

She said that she had felt like a 'little prin- It was shortly after this patient ' s death that

I decided to review the literature on the psy- choa alysis of patients with a diagnosis ofter- minal cancer .

BRIEF REVIEW OF THE LITERATURE

The literature on the dying shows that pro- fessionals who deal with patients who have terminal diseases such as cancer are divided in their opinion as to the utility of telling thes e patients their diagnosis. Dupont Munoz (1974) ( Klafke (1991), Telis (1991). I am, how - ever, more interested in discussing the psycho- analytic technique with terminal patients. e Kurt Eissler's book The Psychiatrist and the Dying Patient (1955) seems to have exerted a great influence on technique regarding the question of whether the psychoanalyst should help the terminal patient become conscious of the fact that she or he is dying, or collude with,

90

V

I V I ANA MINER B O

a'

" '-0 r, -'

-

1

r:

t

Eiss l er is f or t h e l atter attitu d e , steer in g

from a psyc h oanal y tic stance and ration al is -

ing that w h a t t he patien t needs is presence a n d before the onset of t h e di sease ( A l iza l de , 1993), / com f ort . Ma n y a u t h ors cite Eissler and have w hich was the case wit h m y patient , and one /

c onsiste n tly use d techniques that confo r m to undertaken after t h e diagnosis, w hen n o /

hi s mode l , even p u tting

patient ' s di s p osa l , s uffering un n ecess ary lished with t he a n a l yst . /

intrusions in to their time and persona l lives The abo v e review of t h e literat u re on the /

(Josep h , 19 62; Norton ,

Adams - S il va n , 1 994) . brought three questions t o my attention: /

Feife l /$L Na g y ( 1 98 1 ) an d especially Hag- 1) Sho u ld a p atien t w ith t erminal cancer b e

glund ( 19 8 1) hold

t o e n d ur e the pai n o f so

wor k i n g thr o ugh mou rni n g in a way that tive in s u ch case s ? / leads to a da p ta ti on t o death depends g r eatl y 3) What, in t heore ti c a l t erms, enabled m y on t h e m a turit y of th e psychic apparatus, bu t patie n t to have t h e ma tu re psychic apparatus also o n t h e qu a lit y of the inner objects and t h e and emo t ional condi t i on to b ear the - truth and abil i t y to c om m u n i cate with them ' (p . 45). consequences o f her disease? / Some anal ys t s b e li eve that a psychoanalyt -

ical stance w i th proper regard fo r truth and

rea l ity

th at t h e pa ti en t 's ca pa c it y told of the diagn o sis, an d t o what purpose? ; /

h e patie nt ' s

as pect that den i es th i s fact .

u ndertaken b eca u se o f th e fatal diag n os i s .

away There i s a ma r ked d iff e r e n ce between the s u e - /

cessful outcome of a n a n a l ys i s u ndertaken z"

former relations h ip of trust had been estab - /

anal y sis of patients with terminal

cancer /

2) Is psychoa n a l ysis possi b le and produc -

themselves a t the

1963 ; Roose , 1 969 ;

'massive a l oss a s

he lp s the dy i ng patient

to work

DI

SCUS SION AN ; D CON C L U SIONS

thro u gh the meaning of the di s e a se and bear the fea r of deat h.

! Mayer suggests that anal y si s w ith ter mi nal

p a tients is ' p o ssi bl e and producti v e ' ( 19 9 4 , p .

, 1) , emphas i si n g

the need for empathic

I

scarcity of s u c h r eports mig h t be a n i n dicat i on of t h e d i fficul ty a n a l ysts have work i ng w i th

s u c h patie n ts an d . writi n g reports a b o u t t hem . Bai l says tha t 'T ruth t hro u gh i nt erp r e tation is love, i s c omfort for de spa i r, i s se curit y aga i nst te rror, is g ro wt h in t he face o f d e ath , i s frien dli nes s i n th e f ace of l onel i ness; it i s, i n sho r t.s umm i ng up th e mos t vir tu o u s qua l it ies develope d b y hum a nit y ' (1981, p . 6 4 ). He

nvolvement w i t h t h em. She remarks th at the

be l ieves t h at coll ud i n g wit h the pa ti e nt ' s ne ga - tion of d eath i s deceitf ul a nd destroys w h a t is most co ur ageo u s i n man . The a b ov e qu otation , ideal as i t may b e , coincides to a cer t a in extent with the privi- leged experi e n ce I h a d w ith t h e patie n t I a n a -

l

abo v e .

A no t h e r as p ect in vo l ved i s t h at most c l i ni cal

reports o n th e a n a l ys i s o f patie n ts w i t h te r m i - nal can cer m e nti o n th a t the a n a l ysis was

y sed, as d escr ib ed

i n t h e clinica l report,

M y re v ie w of the li terat u re on patients with

terminal cancer ra i sed t h e peren n ial issue o y whether to te l l the pa t ient the truth , and to wh a t purpos e . T h e pat i ent ' s psychic maturity; " and emotiona l co ndi tio n s h ave b een taken as criteria by some professiona l s to reso l ve t h { pro b lem. Do ub ts a l so ex i st as to whether pSy i choana l ysis is p o ssible a n d prod u ctive witl i > such patients, o r if o ther ' co m forting' tec h- ! niques better s e rv e the i r n ee d s. / I lear n e d f r o m my l im ited ex p er i ence in th e . /

case presented that a p ati e nt s h o ul d be to l d / the truth a b o ut hi s or her d ia g n o sis a n d s t a t e / of h ea lt h a t a ll t ime s, as we ll as th e medica l / procedures ava il a bl e at eac h step of t h e dis - ease . This is the o nl y way to treat a pat i en / with the respect he or s h e d ese r ves and make it possible to become a participant in the deci- sion s regarding t h is p ers on ' s b est interests.

O n ly then can a n a n a l yt i c process con - > "

tinue , or e v en b egi n , o n a forthright b asis and /

be as prod u ctive and h e l pful to th e patient a ~ possible.

an analyt i c ap - /

p ro ach a ll ows fo r p sych ic g r owt h a n d emo - /

It is my co n v i c tion t h at

i onal matu r i t y in also prote cts the intrusion s i n t o h time , in con tra s t

t

a naly st at th e ten posal.

In the ca se o f J

t he ps y cho ana l) .

A lthough the se a

last six month s o l

t o ha v e ou r us u al

up to the v er y e n d I do not a g r e e

1969) , Adam s - S i l

help the p a t ien t SI

(

a

void ambival e n ce

s

idered that ambi :

s

hould not be a vo i

ing for the i n teg n

i ntern a l an a l y st,

a nalytic pro ce s s to

n the terms qu o te

us ed a s a goo d c on

a nd a nxieties, h o

my acti v e lif e a s (

m y lea v ing h er

ealth in oppo s i tio de a th ?

h

i

I also do not ag i

ers who collud e wi

denies the fa ct th a i

a s K ubler-Ros s (B

have to use so m e

diffic ult to loo k a

t ime. Indeed , I Iu

material that b o th

i nto the mech a n i

a bove that this e ve

an a lytic sta nc e a n ,

he r in very pa i n fu

Thi s wa s s ee n b tl

v i s ual imag e o f th

w hile kno w i ng o f

s

uffering .

I did not , howe-

a tec hnique t o s p a

out in the clini c a l D

t o help her in h er c

91

tional maturit y in both patient and a nal y st . It / to be able to bear the pain of knowing she wa s

d y ing , overcome the res i stance , and interpret

this to her when the mate ria l allowed. I belie v e

that the f a ct that I was a ble t o contain a nd interpret t h e horror of her dying made it eas-

ier for her to speak of her coming death a nd voice her fe a r of death. A t th e Wednesd ay s e s -

s ion , she said th a t she wa s aw are that the med -

ic al experim e ntal m e thods w ere m ea n t to

po s tpone th e moment of h er d e ath . I n th e las t

s ession , s he asked me if I c ould see he r d a ugh-

ter after h e r death as the l a tt er w as ve r y mu ch affected at the idea of lo s ing her. After s he told me that she had become r e concile d wi t h her loved ones, I was able to interpret to her that she w as telling me that s he had com e t o peace with herself and h e r belo v ed one s , a nd that it see m e d s he wa s a c c epting the har s h f ac t that she w as re ad y to d ie , t o w hich she agr ee d , but added t hat she was terrified of t h e unkno w n . From the v e r y beginning of her a n a l ys i s , before the malignant disease had set in, she courageously sought the truth about herse lf.

0 pretensions at being original or of

With

intrusions into his or her pe rs onal life and

also protects the analy s t from unnecessar y

THE PATIE N T WI T HOUT A COUCH

a

'

t

t

a l diagnosis.

w een the sue- /

si s undertaken /

A

pa t i e nt, and one /

l

iz alde,1993), /

o

s

is, when no

time, in co n trast to techniques which put the analyst at the termina l patient ' s complete di s -

posal . In the case of m y patient I tried to respect

- h a d been estab- /

.t e ra tu r e on the /

/ the ps y choanal y tic stance a s f ar as pos s ible .

A lthough the setting had been a l t er e d for the

t

er m ina l

cancer I

last si x months of her disea s e , i t w a s possible

. a t t ention:

/

to ha v e our usual three session s b y telephone

 

. a l cancer be

up to the ver y end .

. ' h a t purpose? ; /

I do not agree w ith the position of Roose

 

I

e

a

nd produc-

(1969) , Adams-Silv a n (1994) and others who help the patient split off aggressiv e feelings to

 

s

,

enabled my

avoid ambivalence towards the an a lyst . I con-

sy hie apparatus

 

sidered that ambivalent feelings to w ards me

a r t h . truth and

should not be a v oided , but int e rpreted , allo w - ing f or th e integr a tion of th e good and bad internal anal ys t , c reating conditi o ns for the

anal y tic proce ss to be producti ve a nd truth f ul ,

in th e terms quot e d from Bail ( 19 77 ). I f ! w as

used as a good cont a iner for m y p a tient ' s fear s

o

n pa tients with

n

nial issue of / '

J-

- e t r uth, and to /"

_ s y c h ic maturit y z"'

e e n taken as /

- to r esolve th ~

- 0 w h ether psy y ro du cti v e witl i > mf o r t ing ' tech- (

b

s :

/

and anxiet i es, how could she not a lso resent

my active life as compared to her empty one ,

m y leaving her to enjoy

health in oppo s ition to her cert a in , oncoming

death ?

my hol i days, my

I also do not ag r ee w ith Ei ssler a nd follo w -

er s who collud e w ith the pati e nt ' s a spect th at

deni es the fact th a t he/she is d y ing , a lthough , as Kubler - Ross ( 19 0 9 ) says , terminal patients have to use some kind of negation , as i t is

exhausting the subject , I would like to use th is characteris tic of hers to bring up a few th eo-

r e tical co ns ideration s to tr y to a cc ount fo r

w hat ga v e he r the ps y chi c a nd emotion a l a bil-

it y to bear the truth of her di s ea s e , a cce pt th a t

s he w as d y ing , make reparations and be gr ate- ful for the good moments . I feel that K leinian thought best sustains my purpose.

p

e

r

i ence in the , /

difficult to l ook a t death in the face all the

For clarity's sake , I will differenti a te p s y-

t - sh o uld be told >'

 

time. Indeed, I have shown i n the clinical

chic from emotional conditions , although t h e

_ o s i s a nd state /

material that both the patient a nd I d i d lap s e

di

s tinction i s common knowledge. I t ake ps y-

a

s t he medical /

into the mech a nism

of denial . I reflected

chic c ondition s as th e s t r uc t ural c onfigu ra -

e p of the dis -

above that this e v en helped m e maintain the

t ion of a p s ychic appar a tu s a t a gi v en momen t

t

r e a t a patien

.J

an a l y tic stance and continue to b e useful to

that makes the correspond i ng emotion a l c on-

<

- n · es and make

h e r in v ery painful moments of th e anal ys i s .

ditions po ssible.

 

t i n the deci-

Thi s w as seen by the fact that I kept an intact

From the point of v i ew o f ps y chi c c o nf igu-

t i nterests.

vi s ual image o f the patient as I last saw her ,

ration , I understand that , to w a r d s the e nd of

- p ro cess con /

while knowing of her disease a nd dreadful

her life , my pa t ient had set up a relati v ely well-

i g ht basis and j.

"0 t h e patient a ~ )

r

a n a lytic ap - /

i h and emo - )

suffering .

integr a ted ego. One of t h e factors that mad e
I

I did not , however, collude with denial as / this possible was that it h a d not been deple t ed

a technique to spare the patient . As I point

out in the clinical material , I felt that if! w ere

to help her in her dying process , I m y self had / s eems to ha v e been w ell internalised , and th e

, by excessive use of denial and projecti v e id en - }

/ tificat 1 0n . Th e analyst ' s containing functio n - )

92

V IVIANA MINERBO

pati e nt became able to count on a relatively well-integrated ego and a good internal object in order gradu a lly to create the emotional ability to contain her fears and anxieties along with the undesirable aspects of her ' self ' . I am . of the opinion that this psychic configuration enabled her to bear the truth and fear of the fatal consequences of her disease. This relatively well-constituted ego also allowed her to integrate her good and bad internal objects. IfI was sometimes felt to be a bad object, especially because of the separa-

t ions and their implications regarding my per-

sonallife, at other times I was seen as a good

object, and she was grateful for my containing function and for my having made her anxie-

process. Her receptivi ty also helped me make interpretations I could hardly dare to formu- late , so delicate and painful were their nature. I learned with her that dignity and courage are ; /' possible even in the most adverse of situa- j- tions. Perhaps this is what maturity is all

about: accepting one ' s fate and mortal it y. I . > came out of this an a lysis strengthened and more mature a s a professional and as a humaii Z being. W ith each failure of hers to respond t o '

medical procedures, I became more conscio p § of m y own v ulnerabil i ty and mortality. !

TRANSLA TI O N SO F SUMMARY

ties and fears more tolerable by not despairing L ' auteur rapporte une experiencecliniqueinhabi- with her. With time she was able to establish tuelle qui surgit du fait des circonstances tragiques

d ' une patiente qui contra ot a un cancer au debut de la

cinquieme annee d'un p n ocessus analytique . Plut6t que d ' interrompre l ' analyse, l'analyste suggera de

that continuer l e s seances par telephone car lorsque la

rela t ion to phase terminale de sa maladie s'installa la patiente ne

t h is ambivalence was also

i ngs towards

could direct

the emotional condit i ons to accept that she

both negative and positive feel-

me. Later she became aware

true in

her father and her husband . fut plus en mesure de se deplacer. L'experiences ' ave-

I n my opinion, s h e also created t he emo- / ra benefique pour.la patiente et en.richissantepour

. l'anal y ste. La patien t e put contemr, perlaborer et

.

t i onal conditions needed to ma k e reparatIOn / integrer la significationet es consequencesde sa ma-

to me as an internal object by accepting her / ' !,' ladie , faire des reparations a ses objets, et accepter la

need and dependence on me as a separate, mort avec dignite. L ' anal y ste emergea aussi de l'ex-

object by accepting my interpretations an d / , r erie,nce ' p'l~sforte et p~u,sconsciente de s~ prop~e

, . by progressmg m her analysis , As can be seen in the clinical material of the last session, she

was a l so able to make reparation to her father qu'une analyse soit productive.avecde tels pat!e.nts?

j' vulnerablhte et mortalite. L ' auteur souleve trois questions: devrait-on dire la verite du diagnostique a un/une patient(e) , et a quelle fin? Est-il possible

.

.

Quelles sont la s~ructurepsyc?ique e~les conditions

emotionnellesqUIpermet t ent a un patient de suppor-

them in spite of her ambivalent feelings. She

was able to feel sorry

would suffer at her premature death , and be nische Erfahrung , die sich aus den tragischen Um- thankful that her chi l dren had their father standen einer Patientin entwickelte, die am Anfang

about the pain her father Die Autorin berichtet iiber die ungewohnlichekli-

and husband especially when she became

,

h

d

d

d

able to accept

er nee

an

depen ence on

ter la verite.

with his qualities and defects to care for them.

.

.

even in adverse conditions,

.

des fiinften J ahres ihres analytischen Prozesses eine ( , Krebserkrankung entwickelte. Statt die Analyse zu

I thmk It was he.r good mte~nal 0 bjects tha / unterbrechen, schlug die A nalytikerin vor, S itzungen

gave her the emotional capacity for love and / uber Telefon abzuhalten , als diese Patientin in der

reparation and fo~ the feelings o.f. gratitude y Endphase ihrer Krankheit nicht mehr ih: Heim v~r-

often present

/ reich fur die Patient i n und bereichernd fiir die

/ lassen konnte . Diese Erfahrung stellte sich als hilf-

I feel privileged for havmg been able to · Analytikerin heraus. Die Patientin konnte die Bedeu-

treat this patient who, in the face of imminent / tung und die Folgen ihrer Krankheit "containen" , death was also able to face the truth and con- ,.', durcharbeiten und integrieren , sie konnte ihren Ob-

/f ~ekten gegen~ber.~iedergutmachun~en leiste~ u~d

t inue her analysis until her last day. With her

. ihren Tod nut Wurde annehrnen. DIe Analytikerin

war nach dieser Erfahrung ebenfalls gestarkt und ihrer eigenen Verletzlichkeit und Sterblichkeit be-

the

mental pain of her gradual , inexorable dying

co u rage, she helped me bear and contam

".

wuBter .Die Aut o r in iiber die Literatu r d r Patient seine Di a g n Zweck?Kann es m i t

v e Analyse gebe n ? "

welche emotion a l e n dem Patienten , di e W

La autora pr e se nt habitual, surgida d e una paciente que c o quinto afio de s u pr rrumpir el analisi s , la

nes por telefon o , y

i mposiblesalir d e ca s

A DAMS-SILV A N,

A

about to pa ss ' .

tient. Psycho a n a L

A L I ZALDE ,

A . ( 1 9 9 1

paciente ' por m or

235-253.

BA IL, B. W . ( 1 9 7 7 ) .:

Dare Distur b t h e l

Bion. Bever ly H il l s 8l .

DUPONT MU N O Z , _

morir. Rev . Psicar E ISSLER, K. R . ( 19 :

Dying Patien t. Te

F EIFEL, H . & N AG Y

at fear of death . J

4 9: 278-286 .

J OSEPH, F. ( 1 9 6 2 ).

transference i n t h

choana! . Rev . , 49 :

H AGGLUND, T . - B .

dying process . I nc

V iv i ana Mine r b o

5

A ve . St . Hono re d ' E

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e a n d mo r t a lit y . I

~I e ng then e d a nd nal a n d as a hu m a n f h ers t o res pond t 6

-

e m o r e c on sci o f s

m or ta li ty .

SL ~ M AR Y

c

e

n

n gew o h n l ic h e kl i-

e n t r a gisc h en

i t e , d ie a m A nf a n g

U m-

ch en P r ozes s es e in e S :au d i e A n a l ys e z u eri n v o r , S i tz u nge n

in d er

v er - sz e ll te s ich als h i lf- cer e i c h e rn d f u r die

- ra eh r i hr H ei m

P

a t i ent in

co n n te di e B e deu -

nkh ei t " c o nta in e n " ,

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O b-

und

Di e A n a l yti k er in

fal l s ge sta r kt

u nd

S t e r bl i c h ke it b e -

-,

T H E P A T I ENT W ITH OU T A C OUC H

93

w uBt er . Die A utorin wirft aufgrund e in es U b e r bli cks

u b e r die Literatur drei wichtige F r a gen

Pat i e nt seine Di a gnose

Zw e c k ? K a nn es mit solchen Patient e n e in e produkti-

v e A n a ly s e geben? Welche psych i sch e S truktur und

w e l c h e emotionalen Bedingungen e rm o gli c h e n es

a u f : S o llt e e in

erfahr e n und z u we l c hem

d e m P a tient e n , die Wahrheit zu ertr age n ?

L

ha bitu a l ,

a a u t or a

una exp e rienci a

su r gid a de las circun s t a nci a s

pre s enta

cli nic a p oco

trag i c a s

d e

u

n a p a c i e nte que contr a jo

un ca nc e r , a l e mpe z a r

e l

q

uin to af i o d e s u proceso

analitico .

E n vez de in te -

rr umpir el a n al i s is , la anali s ta sugi ri6 h ace r l as s e sio -

Ie e r a

se i nstal 6 l a fa s e fin a l

n

i m pos ible sa lir de casa , cuando

es p or

te l e f ono ,

ya que a esta p ac i en t e

d

e s u e n ferme d a d . L a e xperiencia result6 b e n e fi c i os a

p

ara L a pac i en t e y en ri qu ec edora para la

an a li s t a . La

p

a c iente f u e ca p a z d e co ntener , elaborar

e in t eg r a r e l

s igni f ic a d o y l as conse c uencias de su enfermed a d ;

r ep ~ ra r a s u s O bjet os y a ceptar

d a d t La a n a li s t a

La muerte con di gni -

t a m b ie n s ur g io de esta e x p er i encia

r e f o r za d a

d a d y m o rt a lid a d .

esenc i a l es, b a s a da s e n un a r e vi s i6n de l a bibli ogr a f i a .

So n l as s i g ui e n tes: l . d e b e s e r e l paciente inform a d o

s u di a g n 6st i co;

va , co n qu e f in a lid a d ? ;

pro du c ti vo

di

p e rmi te n a un p a cient e s oportar la verdad?

y m a s co n sc i en te de su propia vulne r ab i l i -

L a a utor a pl a ntea tres c ue s ti o n es

de

y, e n el cas o d e una re s pue s t a po s i t i -

i

, P u e de hace r se

un a na li s i s

co n t a l es p a ci e ntes ? ; l . cuales s on l as co n-

y 1 a e structura

psi q ui ca qu e

c ion e s e mo c i o n a l es

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ps i - I n

Da Mo rte: V E s t u do s Bras ile iro s, e d . R . C a s-

se

rla , Ga m p i na s:

P a p i ru s E dit o ra.

i v i a n a Mine r bo

V

5 Ave . St . H o no r e

7 511 6 P a ri s

d 'Eyl au

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