1. Psycho-Anal.

(1998) 79,83

THE PATIENT WITH<DUT 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 telephone, 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 literature. These questions are: should the patient be told of his/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 hronological order in which they occurred. I shall give an extensive clinical report on the last six months of an eight-year analysis with the patient. Then I will present a brief bibliographical review of the literature about this topic, focusing on three questions that especially claimed my attention, based on the literature 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 terminal cancer she had contracted at the beginning 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 chemotherapy, to which she seemed to respond well, according to the doctors. About a year ago, in the seventh year of our work together, the cancer reappeared in an atypical form, as it could not be located in any specific organ. The doctor told her this was very serious, and he proposed 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

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VIVIANA MINERBO usual when waiting for her call, as I expected bad news every time. I was not sure if I would be able to deal with this tragic situation without deviating from an analytic stance. I also became aware of the fact that her approaching death was also making me conscious of my own vulnerability and mortality as never before. One thing seemed clear in my mind: I was on the side of life, and it was this aspect of her personality that I would address whenever possible. Only much later did I realise I would also have to help .her in her dying process. I always felt exhausted after the first few telephone sessions. I realised this was not only because of the intense emotions of the session, but also because the moments of silence and reflection that used to punctuate the sessions on the couch had disappeared. When I pointed this out she said she felt very anxious at any silence between us. She had no way of knowing if I was still 0 the other end of the line. I understood that she felt she had less control over me by telephone. Maybe she felt that I was more separated from her, resulting in greater anxiety. I said that she tried to fill in all possible silences by wanting my constant attention, in order to be certain that I was there for her and that I had not abandoned her, since she needed me so much. Like two blind persons we were never to set eyes upon each other again. I shall comment" on this aspect of our new setting later on. I soon noticed that our sessions had fallen into a routine different from the way things evolved when using the couch. She would start the sessions by giving me a brief report on her state of health, which was deteriorating daily, and on what the next medical procedure would be. She said that she could no longer drive a car or even leave the house because of her low immunity. To save energy, she also had to limit her physical movements to an absolute minimum. She even had to eat very slowly because digestion consumed so much energy. It occurred to me to say that it seemed she must now live in 'slow motion'. She chuckled and said 'that's right'. She
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proceed with her analysis normally, although it was obvious that her,heaith was failing and that all the medical treatments had almost been exhausted. One day about six months later she phoned me and said in a very 'faint voice that she was afraid she would have to interrupt her analysis. The latest blood tests had shown that she was completely without 'resistance', for which reason the doctor prescribed absolute rest for an indefinite period. I reacted intensely to this news) could have cut off treatment, and our relationship, then and there, by simply hanging up the phone. But I realised that it was perhaps then that she most needed analysis. As if to echo my thoughts, she. surprised me by saying herself co 1''lrtO'', that it was a pi she could not come, since she would now need me more than ever. After we talked for a few more minutes, it suddenly came to me that we could continue having our sessions by telephone, so I suggested this. She seemed to cheer up instantly. She asked if I thought it would work, and I answered that I did not know, but we could try if she wanted. She agreed instantly, with no 'resistance', and said that she was very happy not to lose me so soon. After a brief pause she added that she knew from experience that she could count on me to bear with her the worst fears and anxieties, now that death seemed nearer. I immediately felt a lump in my throat. She added that people around her, especially her husband, tried to downplay the seriousness of her illness, and this irritated her profoundly. Not only did this attitude make her feel misunderstood, it also made her feel she could not voice her fears and anxieties to those around her. I realised that her fatal illness must have mobilised the defence of denial in those around her. It occurred to me to say that she felt strong enough to face the truth, but she needed me to help her bear it instead of denying it. We had regular sessions over the telephone for the last six months of her life. She would call me up at our usual times as punctually as ever. I noticed that I felt more anxious than

added that altft0Ul very active person she did not mind become her natun 'medical reports' could see how muc tainer to deposit . happening to her II and help her bear' After these reps appear, such as he children and her I band. I noticed the tions and no more c we had not a minu as quickly as poss urgent matters. She told me that her children would care after her dea many of his values differen t from her a would influence thl gave the following e When passing b come upon a gang ( who jeered at him 2 no reaction and ran Her husband critici had shown a 'cowa thought that the be even if this meant be The son, however, enough to confron handed. The mother tion was ridiculous. . that once, when he I:J had had a similar e who had provoked quently beaten up. E fear at the time anc himself for having be said she thought heT son to avenge the hu suffered in the past Although her reas it, I could see it was aspect of her person

THE PATIENT WITHOUT as I expected sure if I would nc ituation with. stance. I also aer approaching _ nscious of my ~ lity as never in my mind: I was this aspect address whendid I realise I her dying proef

A COUCH

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-,... the first few - . was not only ~- of the session, of silence and the sessions red. When I .~ very anxIOUS had no way of zher end of the e she had less ;Maybe she felt / her, resulting e tried to fill in - .-:: my constant . that I was or abandoned h. Like two set eyes upon mment on this on. Tonshad fallen - e way things . She would a brief report deteriorat. medical pro-' he could no 'e the house o save energy, movements en had to eat onsumed so ~ to say that it , ow motion'. --; right'. She

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 'medical reports' saying almost nothing. I could see how much she needed me as a container to deposit her fears about what was happening 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 husband. I noticed there were fewer free associations 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. She told me that 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. 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 the son and said he 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, however, said he was not crazy enough to confront a whole gang singlehanded. The mother thought the father's position was ridiculous. Later the father admitted that once, when he himself was a teenager, he had had a similar experience, but it was he who had provoked some boys and was consequently beaten up: He had felt paralysed with fear at the time and still inwardly criticised himselffor having been a coward. The mother said she thought her husband had wanted the son to avenge the humiliation he himself had suffered in the past Although her reasoning had some logic to it, I could see it was concealing an omnipotent aspect of her personality. She alone had the

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 of their 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 was young, and life was ahead of her, full of promise. She had managed to survive quite well. She even added, with a pinch of humour, that she had certainly not missed her mother's controlling 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 having 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 by her daughter who was studying abroad. Ever 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 deal over this injustice. Her personal life was so empty that any news of any of her children was 'nectar' for her. I said that I could understand that she felt her life to be empty at the moment, confined as she was at home; it was so different from my life and that of her daughter abroad, each of us so busy and active. Maybe this is what she was really resenting, this and the injustice of her daughter turning to the father, instead of to her own very eedy self. She felt left out, as she had said. I thought later that her needy self probably also felt left out of my personal life, since I dedicated only three hours a week to her. She remained silent, so I reminded her that she had once told me how happy she was that I could still be with her, even if only by telephone. I asked if she had thought of telling her

VIVIANA MINERBO til the end'. I immediately realised that the lump in my throat was growing, and I felt that a burden had been pur on my shoulders. I could see how much she expected of me, and I was not at all sure I could cope with this dramatic situation. I also became aware of how afraid I was of her dying. This was the first time I had attended a patient with a terminal illness, and I have also been spared from going through any such experience in my personallife. At the same time I was gratified that she felt helped by me. I replied, without knowing what was to come, that I would stay by her as long as she was able to participate. A depressed mood took hold of me for the rest of the day. I will now relate two sessions in the same week that illustrate the oscillations in her mood.

daughter how much she also needed her calls. She said she was so hurt that she didn't want to be the one to phone. It was up to the daughter to call her. I asked if she wasn't acting on 'false pride', not wanting to show her need to her daughter. Maybe that was what the hurt was all about. At the next session she was happy to tell me that she had thought over our conversation and had decided to call her daughter after all. In tears, the daughter had apologised, saying how much she was afraid for her mother's life. She lacked the courage to talk directly to her. She said she loved her very much and that she was thinking of interrupting her course and coming home to be by her mother's side, even though the course would be over in just two months. My patient told her that the greatest joy this daughter could give her mother was to stay and finish the course successfully. I could see there the reparation for the resentment. I said I could see her generosity in not wanting her need and illness to be an obstacle to her daughter's life. She said that one of her great worries was t:.c, a C(; . that she would become a 15ur e.Jlto her family. I said I could appreciate these feelings of not wanting to be needy and dependent on her family, as this could be humiliating for her. I reminded her that we two had a relationship in which we depended on each other for our work together. Didn't she feel that the members of her family had some special responsibility towards her in sickness as in health, as she had towards them? She said that I had put the pro blem in a way she had not thought of before. For my part, I felt that my last question was quite unprofessional. I should have been satisfied with the interpretation that to be needy was humiliating to her. I was probably over-anxious to help. One day she told me she had agreed to try a new chemotherapy exper.iment aimed at 'encapsulating' the affected organ, hoping for a regression of the localised cancer. She was terrified because the doctor said this procedure involved considerable risk. Almost in tears, she asked me if I would stay by her 'un-

do, she said. This seen ing with me. Then I me like a non-psychos haps what she could possible use of the reminded her that s. grateful she was that s vacy of her own hOI tected by the love of being in a desolate maybe she thought, si uation, that it was eas the important thing n4 to enjoy the moments as she was by the one I was trying to ad these words didn't e quiet, feeling very ~ thinking of the su endure. Fr

Wednesday
I sensed discouragement in the brief 'good morning' she gave me. She said she was not responding to the chemotherapy and the doctor had said he would try to think of what could be done next. He was obviously 'lost' and she felt like 'giving up the fight'. It dawned on me that it was the first time she was really conscious of losing hope of another remission, because this was really what the experimental methods she agreed to submit to meant. As she said: they were postponing the moment of death. She said she didn't feel like seeing or talking to anyone. I asked if she would rather not talk to me either that day, but she said no immediately, as she had already told me how important it was to have me with her. She was referring to colleagues from work who were going to visit her in the afternoon. She would have liked them not to come, but didn't want to hurt anyone. This movement of not wanting to hurt me or the colleagues gave me a door through which I could try to help her bear her misery. I said I could see in this concern of not wanting to hurt anyone a desire not to 'give up the fight'. What else could she

I felt great anxiety sion. The first thing l 'good morning' was what had happened after that sad and ill my great surprise she l day. She had been able after the session, had fast, watched a film cousin over for lunch. expected visit from hi all chatted and had a ~ aged to forget how si She caught herself thi to be alive and able which might seem so son, but were so preci tion. I was moved by ] and the gratitude she moments of life. She then told me her the following day l cert. As she felt rested she accepted the invi was not risking too I

THE PATIENT WITHOUT A COUCH - ed that the and I felt that ;- shoulders. I ed of me, and ope with this carne aware of This was the ient with a terspared from e in my per- gratified that ithout knowuld stay by her articipate. A e for the rest - in the same ations in her do, she said. This seemed to be a way of agreeing with me. Then I said (in what sounded to me like a non-psychoanalytic stance) that perhaps what she could do was make the best possible use of the time she had left. I reminded her that she had once said how grateful she was that she could stay in the privacy of her own home, where she felt protected by the love of her family, instead of being in a desolate hospital. I added that maybe she thought, since I was not in her situation, that it was easy for me to tell her that the important thing now was for her to be able to enjoy the moments she could, surrounded as she was by the ones she loved. I was trying to address the life in her, but these words didn't seem to help. I remained quiet, feeling very sad and impotent and thinking of the suffering she was yet to endure. Friday I felt great anxiety at the hour of our session. The first thing she said after the usual 'good morning' was that I couldn't imagine what had happened to her on Wednesday after that sad and disheartening session. To my great surprise she said she had had a good day. She had been able to pull herself together after the session, had her shower and breakfast, watched a film on television, had a cousin over for lunch, and finally received the expected visit from her colleagues. They had all chatted and had a good time. She had managed to forget how sick she was for a while. She caught herself thinking how good it was to be alive and able to enjoy such moments, which might seem so simple to another person, but were so precious to her in her condition. I was moved by her courage, moral fibre and the gratitude she felt for such nice, brief moments oflife. She then told me that a friend had called her the following day and invited her to a concert. As she felt rested after her afternoon nap she accepted the invitation. She thought she was not risking too much, in spite of strict

87

- g or talkd rather not she said no told me how her. She was - - who were _She would - didn't want not want- gave me a -0 help her in this conne a desire - could she

orders to stay at home. If she went to hospital so frequently for tests, why not an exception for some enjoyment? She had loved the conceit and it felt so good to be in a theatre among other people. I could see here a wish to deny her illness for a moment and really be like healthy people. I said I could see how proud she was of herself: in spite of the seriousness of her illness, she could enjoy what she was able to and feel full oflife. I added that maybe she was also telling me this to make me feel happy for her and for our work together. She thanked me for the work I was doing with her, especially for bearing with her despair as I had on Wednesday, without falling into despair myself. She felt that this was what she really needed. Was she seeing me then, for a moment, as a separate person, one who did not despair with her but who could contain her despair? My holiday break was approaching and I felt guilty for leaving her in such failing health and apprehensive of how she would react to the separation. She said that although she would miss our sessions, her daughter's return would be a compensation. They would have a lot to talk about. She added, half-jokingly, that she thought she could hang on to life until my return. It had not occurred to me that she could indeed die while I was away. I realised that this was a denial on my part and it made me feel that I was really abandoning her when she probably needed me most, and she was reminding me of this in her own way. I r~membered a young patient I had had who was so angry with her mother that she told me she would lilke to die just to see her mother feel guilty for having mistreated her so. I said that it felt as if she was generously giving me permission to have my holiday, but at the same time she was reminding me that I ran the risk of her dying when she would need me most. How would I feel if this happened? Maybe she thought this was what I deserved to happen for abandoning her. She asked if I was not going too far in my analysis of what she had said. It seemed to me that she agreed to my

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VIVIANA MINERBO 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 appearance, 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 finally died she remarked that it was a blessing his misery was over. She had mentioned being glad she had not lost her hair with the on-going treatment; in the past 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 information helped me, when I thought of her, maintain 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 alterations the disease and pain I knew she was suffering might be cau ing to her appearance. The fact that I was spared seeing her and especially that I was spared witnessing 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 facilitated 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 no pain. I said that avoiding feeling the pain was a way 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 unbearable. 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 she was saying, with reason, that the realisation that she was dying was unbearable to her. I wondered whether

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 understood she had missed me, and that maybe such a long holiday seemed to mean that 1did not really care for her. If I cared, I would have come back sooner. Maybe she was resentful that I could have my life and 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 as 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 immediately after my return. We thus missed one session, 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. Tuesday 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 witnessing her suffering and probable physical

this meant that she was possibf fantasy that she her death throu was why I was ~ was convinced t ded in her obje however, if I COt how she would n because of the TI trust she had d this interpretatio delicately as I Cot 'Do you have to b But I felt that, nc pretation was to t and still wanted t the 'end', as she 1 long ago. She went on I( her father and brc felt loved and grat did not feel at all a feared she would l was finally able to dependent on then She said that sh cess'. I was surpri like a 'little prino explained that she loved before. She 1 father, as he was aJ himself be touche Now he would sit hand. She felt full sorry to have to in with her premature: this sadness. She had also hac tion with her husl time in their marrie ing cheated on her a giveness, saying thai was stronger than a very grateful for the remembered how m this infidelity, which and humiliation. Sh

THE PATIENT WITHOUT A COUCH g me, just a phase set in, o was dying of t: -0 visit him at tanan reasons . ith no friends, . parents, These by week she erioration, his loss of weight -bone appearand weakness ~could not even ~o to the toilet. red that it was
r

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d she had not

-= treatment; in

wig. She had uld have liked :..., 'be this inforought of her, - of her the last at work here unt the altermew she was IT appearance. =. her and espe- ssing at first .-e was in from me continue r y, and facil- - 10 transpire

::.that if she lay , . I said that ray of trying ;' was and not ying. She said ~ as unbear( g she had a -~ taking her , __badly, and ~ if she needed d see her but "ing with rea- e was dying l ered whether

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 for his betrayal. Now she felt this was fantasy that she could stay on with me after/ behind them, and though she had not forgother 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. was convinced that this fantasy was embedShe was also grateful, she said, that the childed in her objective request. I didn't know, dren had their father to care for them after her however, if I could dare say this to her, and deat. how she would react to it. I then thought that I was very moved by the obvious reparation because of the respect I had for her, and the she was making to her loved ones, and so trust she had deposited in me, I should risk grateful that she had matured to this point. I this interpretation. I tried to formulate it as said that the love she was telling me about delicately as I could, and she responded with: seemed to have helped her come to peace with 'Do you have to be an analyst to the very end?' herself and her beloved ones. I added that it But I felt that, no matter how hard the interseemed 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 and still wanted to have me as an analyst to 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. 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 me that represented the epitome of our work did not feel at all a burden to them, as she had together. feared she would be in the past. I thought she I was not too surprised when her husband was finally able to accept needing and being called me the next day to say that she had died dependent on them without humiliation. during the night. She said that she had felt like a 'little prinIt was shortly after this patient's death that cess'. I was surprised at this remark: feeling I decided to review the literature on the psylike a 'little princess' on her deathbed? She choa alysis of patients with a diagnosis ofterexplained that she had never felt so genuinely minal cancer . 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. BRIEF REVIEW OF THE LITERATURE N ow he would sit by her bed and hold her hand. She felt full of love for him and was The literature on the dying shows that prosorry to have to inflict so much pain on him fessionals who deal with patients who have with her premature death. He didn't deserve terminal diseases such as cancer are divided in their opinion as to the utility of telling these this sadness. patients their diagnosis. Dupont Munoz She had also had a very intimate conversation with her husband, maybe for the first (1974)( Klafke (1991), Telis (1991). I am, howtime in their married lives. He confessed hav- ever, more interested in discussing the psychoing cheated on her and was asking for her for- analytic technique with terminal patients. e Kurt Eissler's book The Psychiatrist and giveness, saying that the love that bound them was stronger than any passing affair. She was the Dying Patient (1955) seems to have exerted very grateful for these words of affection. She a great influence on technique regarding the remembered how much she had hated him for question of whether the psychoanalyst should help the terminal patient become conscious of this infidelity, which had caused her great pain and humiliation. She remembered her telling the fact that she or he is dying, or collude with,

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VIVIANA MINERBO
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the patient's aspect that denies this fact. Eissler is for the latter attitude, steering away from a psychoanalytic stance and rationalising that what the patient needs is presence and comfort. Many authors cite Eissler and have consistently used techniques that conform to his model, even putting themselves at the patient's disposal, suffering unnecessary intrusions into their time and personal lives (Joseph, 1962; Norton, 1963; Roose, 1969; Adams-Silvan, 1994). Feifel /$L Nagy (1981) and especially Hagglund (1981) hold that the patient's capacity to endure the pain of so 'massive a loss as working through mourning in a way that leads to adaptation to death depends greatly on the maturity of the psychic apparatus, but also on the quality of the inner objects and the ability to communicate with them' (p. 45). Some analysts believe that a psychoanalytical stance with proper regard for truth and reality helps the dying patient to work through the meaning of the disease and bear the fear of death. Mayer suggests that analysis with terminal patients is 'possible and productive' (1994, p. , 1), emphasising the need for empathic Involvement with them. She remarks that the scarcity of such reports might be an indication of the difficulty analysts have working with such patients and.writing reports about them. Bail says that 'Truth through interpretation is love, is comfort for despair, is security against terror, is growth in the face of death, is friendliness in the face of loneliness; it is, in short.summing up the most virtuous qualities developed by humanity' (1981, p. 64). He believes that colluding with the patient's negation of death is deceitful and destroys what is most courageous in man. The above quotation, ideal as it may be, coincides to a certain extent with the privileged experience I had with the patient I analysed, as described in the clinical report, above. Another aspect involved is that most clinical reports on the analysis of patients with terminal cancer mention that the analysis was

undertaken because of the fatal diagnosis. There is a marked difference between the sue- / cessful outcome of an analysis undertaken z" before the onset of the disease (Alizalde, 1993), / which was the case with my patient, and one/ undertaken after the diagnosis, when no / former relationship of trust had been estab-/ lished with the analyst. / The above review of the literature on the / analysis of patients with terminal cancer / brought three questions to my attention: / 1) Should a patient with terminal cancer be told of the diagnosis, and to what purpose? ;/ 2) Is psychoanalysis possible and productive in such cases? / 3) What, in theoretical terms, enabled my patient to have the mature psychic apparatus and emotional condition to bear the-truth and consequences of her disease? /

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DISCUSSION

AN;D CONCLUSIONS

My review of the literature on patients with terminal cancer raised the perennial issue oy whether to tell the patient the truth, and to what purpose. The patient's psychic maturity;" and emotional conditions have been taken as criteria by some professionals to resolve th{ problem. Doubts also exist as to whether pSyi choanalysis is possible and productive witli > such patients, or if other 'comforting' tech-! niques better serve their needs. / I learned from my limited experience in the./ case presented that a patient should be told/ the truth about his or her diagnosis and state/ of health at all times, as well as the medical / procedures available at each step of the disease. This is the only way to treat a patien / with the respect he or she deserves and make it possible to become a participant in the decisions regarding this person's best interests. Only then can an analytic process con->" tinue, or even begin, on a forthright basis and / be as productive and helpful to the patient a~ possible. It is my conviction that an analytic ap- / proach allows for psychic growth and emo- /

tional maturity in also protects the intrusions into h time, in contrast analyst at the ten posal. In the case of J the psycho anal) . Although the sea last six months ol to have our usual up to the very end I do not agree (1969), Adams-Sil help the patient SI avoid ambivalence sidered that ambi: should not be avoi ing for the integn internal analyst, analytic process to in the terms quote used as a good con and anxieties, ho my active life as ( my leaving her health in oppositio death? I also do not agi ers who collude wi denies the fact thai as Kubler-Ross (B have to use some difficult to look a time. Indeed, I Iu material that both into the mechani above that this eve analytic stance an, her in very painfu This was seen b tl visual image of th while knowing of suffering. I did not, howea technique to spa out in the clinical D to help her in her c

Ii

THE PATIENT WITHOUT A COUCH atal diagnosis. tween the sue- / 'sis undertaken/ Alizalde,1993),/ patient, and one/ osis, when no - had been estab-/

91

/
.terature on the / terminal cancer I . attention: / . al cancer be . 'hat purpose? ;/ Ie and producs, enabled my sy hie apparatus ar th . truth and

on patients with Jnnial issue of/' - e truth, and to /" _sychic maturityz"' been taken as / - to resolve th~ - 0 whether psyy roductive witli > mforting' tech-(
s: /

perience in the,/ should be told>' _ osis and state/ as the medical / ep of the distreat a patien .J - nes and make t in the decit interests. - process con/ right basis and "0 the patient a~)
tj.

analytic ap- / ih and emo- )

tional maturity in both patient and analyst. It /to be able to bear the pain of knowing she was also protects the analyst from unnecessary dying, overcome the resistance, and interpret intrusions into his or her personal life and this to her when the material allowed. I believe time, in contrast to techniques which put the that the fact that I was able to contain and analyst at the terminal patient's complete dis- interpret the horror of her dying made it easposal. ier for her to speak of her coming death and In the case of my patient I tried to respect voice her fear of death. At the Wednesday sesthe psychoanalytic stance as far as possible. sion, she said that she was aware that the medAlthough the setting had been altered for the ical experimental methods were meant to last six months of her disease, it was possible postpone the moment of her death. In the last to have our usual three sessions by telephone session, she asked me if I could see her daughup to the very end. ter after her death as the latter was very much affected at the idea of losing her. After she I do not agree with the position of Roose (1969), Adams-Silvan (1994) and others who told me that she had become reconciled with help the patient split off aggressive feelings to her loved ones, I was able to interpret to her avoid ambivalence towards the analyst. I con- that she was telling me that she had come to sidered that ambivalent feelings towards me peace with herself and her beloved ones, and should not be avoided, but interpreted, allow- that it seemed she was accepting the harsh fact that she was ready to die, to which she agreed, ing for the integration of the good and bad internal analyst, creating conditions for the but added that she was terrified of the unknown. analytic process to be productive and truthful, in the terms quoted from Bail (1977). If! was From the very beginning of her analysis, used as a good container for my patient's fears before the malignant disease had set in, she courageously sought the truth about herself. and anxieties, how could she not also resent my active life as compared to her empty one, With 0 pretensions at being original or of my leaving her to enjoy my holidays, my exhausting the subject, I would like to use this characteristic of hers to bring up a few theohealth in opposition to her certain, oncoming retical considerations to try to account for death? I also do not agree with Eissler and follow- what gave her the psychic and emotional ability to bear the truth of her disease, accept that ers who collude with the patient's aspect that she was dying, make reparations and be gratedenies the fact that he/she is dying, although, ful for the good moments. I feel that Kleinian as Kubler-Ross (1909) says, terminal patients have to use some kind of negation, as it is thought best sustains my purpose. For clarity's sake, I will differentiate psydifficult to look at death in the face all the chic from emotional conditions, although the time. Indeed, I have shown in the clinical material that both the patient and I did lapse distinction is common knowledge. I take psychic conditions as the structural configurainto the mechanism of denial. I reflected above that this even helped me maintain the tion of a psychic apparatus at a given moment analytic stance and continue to be useful to that makes the corresponding emotional conher in very painful moments of the analysis. ditions possible. This was seen by the fact that I kept an intact From the point of view of psychic configuvisual image of the patient as I last saw her, ration, I understand that, towards the end of while knowing of her disease and dreadful her life, my patient had set up a relatively wellsuffering. integrated ego. One of the factors that made I did not, however, collude with denial as / this possible was that it had not been depleted a technique to spare the patient. As I point , by excessive use of denial and projective iden- } out in the clinical material, I felt that if! were /tificat10n. The analyst's containing function- ) to help her in her dying process, I myself had / seems to have been well internalised, and the
<

92

VIVIANA MINERBO process. Her receptivity also helped me make interpretations I could hardly dare to formulate, so delicate and painful were their nature. I learned with her that dignity and courage are ;/' possible even in the most adverse of situa-jtions. Perhaps this is what maturity is all about: accepting one's fate and mortality. I .> came out of this analysis strengthened and more mature as a professional and as a humaii Z being. With each failure of hers to respond to' medical procedures, I became more consciop of my own vulnerability and mortality.

patient became able to count on a relatively well-integrated ego and a good internal object in order gradually 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 separations and their implications regarding my personallife, at other times I was seen as a good object, and she was grateful for my containing function and for my having made her anxieties and fears more tolerable by not despairing with her. With time she was able to establish the emotional conditions to accept that she could direct both negative and positive feel-

wuBter.Die Autorin iiberdie Literatur dre Patient seine Diagn Zweck?Kann esmit 5 ve Analyse geben?" welche emotionalen demPatienten, dieW

La autora present habitual, surgida de una paciente que cor quinto afio de su pre rrumpir el analisis, la nes por telefono, y imposiblesalir de cas

TRANSLATIONS OF SUMMARY
ADAMS-SILVAN, A

L'auteur rapporte une experiencecliniqueinhabituelle qui surgit du fait des circonstancestragiques d'une patiente qui contraotaun cancerau debut de la cinquieme annee d'un pnocessus analytique. Plut6t que d'interrompre l'analyse, l'analyste suggera de ings towards me. Later she became aware that continuer les seances par telephone car lorsque la this ambivalence was also true in relation to phase terminalede sa maladies'installala patientene her father and her husband. fut plus en mesurede se deplacer. L'experiences'aveIn my opinion, she also created the emo- / ra benefique pour.la patiente et en.richissante pour . .. . l'analyste. La patiente put contemr, perlaborer et tional conditions needed to make reparatIOn/ integrer la significationet es consequencesde sa mato me as an internal object by accepting her/'!,' ladie, faire des reparations a sesobjets,et accepterla need and dependence on me as a separate, mort avec dignite. L'analyste emergeaaussi de l'exobject by accepting my interpretations and/,rerie,nce 'p'l~sforte et p~u,sconscientede s~ prop~e , . . . j'vulnerablhte et mortalite. L'auteur souleve trois by progressmg m her analysis, As can be seen questions:devrait-ondire la veritedu diagnostiquea in the clinical material of the last session, she un/une patient(e), et a quelle fin? Est-il possible was also able to make reparation to her father qu'une analysesoit productive.avecde tels pat!e.nts? and husband especially when she became Quellessont la s~ructurepsyc?ique e~les conditions , h d d d emotionnellesqUIpermettent a un patient de supporable to accept er nee an depen ence on ter la verite. them in spite of her ambivalent feelings. She was able to feel sorry about the pain her father Die Autorin berichtetiiberdieungewohnlichekliwould suffer at her premature death, and be nische Erfahrung, die sich aus den tragischen Umthankful that her children had their father standen einer Patientin entwickelte,die am Anfang with his qualities and defects to care for them. des fiinften Jahres ihres analytischenProzesseseine . . . . (, Krebserkrankung entwickelte.Statt die Analyse zu I thmk It was he.r good mte~nal 0 bjects tha / unterbrechen,schlugdie Analytikerinvor, Sitzungen 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~roften present even in adverse conditions, / lassen konnte. Diese Erfahrung stellte sich als hilf. . . /reich fur die Patientin und bereichernd fiir die I feel privileged for havmg been able to Analytikerinheraus.DiePatientin konnte die Bedeutreat 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- ,.',durcharbeitenund integrieren,sie konnte ihren Obtinue her analysis until her last day. With her /f~ekten gegen~ber.~iedergutmachun~en leiste~ u~d . ihren Tod nut Wurde annehrnen.DIe Analytikerin courage, she helped me bear and contam the war nach dieser Erfahrung ebenfalls gestarkt und mental pain of her gradual, inexorable dying ihrer eigenen Verletzlichkeitund Sterblichkeit be-

about to pass'. 1 tient. PsychoanaL

ALIZALDE,

A. (199

paciente 'por mor 235-253.

BAIL, B. W. (1977) .:

Dare Disturb the l Bion. BeverlyHills

8l.
DUPONT MUNOZ,

_I

morir. Rev. Psicar

EISSLER,

K. R. (19: Dying Patient. Te FEIFEL, H. & NAGY

at fear of death. J 49: 278-286.

JOSEPH,

F. (1962).

transference in the
choana!. Rev., 49:
HAGGLUND,

T.-B. dying process. Inc.

Viviana Minerbo 5Ave. St. Honore d'E 75116Paris 102565.l00@compus (Initial version receiv (Final revised version

".

THE PATIENT WITHOUT A COUCH so helped me make y dare to forrnuwere their nature. _ and courage are , adverse of situa1 maturity is all ze and mortality. I - ~Iengthened and nal and as a human f hers to respond t6 e more consciofs mortality.
wuBter. Die Autorin wirft aufgrund eines Uberblicks uber die Literatur drei wichtige Fragen auf: Sollte ein Patient seine Diagnose erfahren und zu welchem Zweck? Kann es mit solchen Patienten eine produktive Analyse geben? Welche psychische Struktur und welche emotionalen Bedingungen ermoglichen es dem Patienten, die Wahrheit zu ertragen? La autora presenta una experiencia clinica poco habitual, surgida de las circunstancias tragicas de una paciente que contrajo un cancer, al empezar el quinto afio de su proceso analitico. En vez de interrumpir el analisis, la analista sugiri6 hacer las sesiones por telefono, ya que a esta paciente Ie era imposible salir de casa, cuando se instal6 la fase final

93

de su enfermedad. La experiencia result6 beneficiosa para La paciente y enriquecedora para la analista. La paciente fue capaz de contener, elaborar e integrar el significado y las consecuencias de su enfermedad; rep~rar a sus Objetos y aceptar La muerte con dignidadt La analista tambien surgio de esta experiencia reforzada y mas consciente de su propia vulnerabilidad y mortalidad. La autora plantea tres cuestiones esenciales, basadas en una revisi6n de la bibliografia. Son las siguientes: l.debe ser el paciente informado de su diagn6stico; y, en el caso de una respuesta positiva, con que finalidad?; i,Puede hacerse un analisis productivo con tales pacientes?; l.cuales son las condiciones emocionales y 1a estructura psiquica que permiten a un paciente soportar la verdad?

SL~MARY ADAMS-SILVAN, about to pass'. A. (1994). 'That The treatment

REFERENCES darknesspay el KLEIN, M. (1946). Notes on some schizoid mechanisms, In Developments in Psychoanalysis, ed. J. Riviere. London: Hogarth, 1952, pp. 292-320. -~ (1948). On the theory of anxiety and guilt. In Developments in Psychoanalysis, ed. J. Riviere. London: Hogarth, 1952, pp. 271-29l. KLAFKE, T. E. (1991). 0 medico lidando com a morte. Aspectos da relacao medico paciente terminal em cancerologia. In Da Morte: V Estudos Brasileiros, ed. R. Cassoria. Gampinas: Papirus Editora. KUBLER-ROSS, E. (1969). Sobre a Morte e 0 Morrer. Sao Paulo: Martins Fontes. MAYER, E. L. (1994). Some implications for psychoanalytic technique drawn from the analysis of a dying patient. Psychoanal. Q., 63: 1-19. NORTON, J. (1963). Treatment of a dying patient. Psychoanal. Study Child, 18: 541-560. ROOSE, L. J. (1969). The dying patient. Int J. Psychoanal., 50: 385-395. TELES, C. M. T. (1991). Comportamento psic~16gico de pacientes com cancer avancado. In Da Morte: V Estudos Brasileiros, ed. R. Casserla, Gampinas: Papirus Editora.

of a dying el silencio

tient. Psychoanal. Study Child, 49: 328-348. ALIZALDE, A. (1993). EI analista, paciente 'par morir'. 235-253.

Rev. Psicanal. (Arg.), 15:

BAIL, B. W. (1977). To practice

one's art. In Do I Dare Disturb the Universe?A Memorial to W. R. Bion. Beverly Hills: Caesura Press, 1981, pp. 5981.

DUPONT MUNOZ, M. (1974). El paciente que va a morir. Rev. Psicanal. (Arg.), 31: 1005-1057. EISSLER, K. R. (1955).

The Psychiatrist and the

look

Dying Patient. New York: Int. Univ. Press.

FEIFEL, H. & NAGY, U. T. (1981). Another at fear of death. 49: 278-286. JOSEPH, F. (1962). Transference and countertransference in the case of a dying patient. Psynngewohnliche klicen tragischen Umeite, die am Anfang chen Prozesses eine S:au die Analyse zu erin vor, Sitzungen Patientin in der - raehr ihr Heim verszellte sich als hilfcereichernd fur die connte die Bedeunkheit "containen", .~ konnte ihren Obgen leisten und Die Analytikerin falls gestarkt und Sterblichkeit be-

J. Clin. & Consulting Psychol.,

choanal. Rev., 49: 21-34.

HAGGLUND, T.-B. (1981). The final stage of the dying process.

Int. J. Psychoanal., 62: 45-50.

Viviana Minerbo 5 Ave. St. Honore d'Eylau 75116 Paris 102565.100@compuserve.com (Initial version received 25/3/97) (Final revised version received 4/9/97)

Copyright

Institute

of Psycho-Analysis,

London,

1998

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