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1. Psycho-Anal. (1998)79,83

THE PATIENT WITH


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84 VIVIANA MINERBOproceed with her analysis normally, althoughit was obvious that her,heaith was failing andthat all the medical treatments had almostbeen exhausted.One day about six months later she phoned

me and said in a very 'faint voice that she wasafraid she would have to interrupt her analy-sis. The latest blood tests had shown that shewas completely without 'resistance', for whichreason the doctor prescribed absolute rest foran indefinite period.I reacted intensely to this news) could have

cut off treatment, and our relationship, thenand there, by simply hanging up the phone.But I realised that it was perhaps then thatshe most needed analysis. As if to echo mythoughts, she. surprised me by saying herselfc o 1''lrtO',that it was a pi she could not come, since shewould now need me more than ever.After we talked for a few more minutes, it

suddenly came to me that we could continuehaving our sessions by telephone, so I sug-gested this. She seemed to cheer up instantly.She asked if I thought it would work, and Ianswered that I did not know, but we could tryif she wanted. She agreed instantly, with no'resistance', and said that she was very happynot to lose me so soon.After a brief pause she added that she knew

from experience that she could count on me tobear with her the worst fears and anxieties,now that death seemed nearer. I immediatelyfelt a lump in my throat. She added that peo-ple around her, especially her husband, triedto downplay the seriousness of her illness, andthis irritated her profoundly. Not only did thisattitude make her feel misunderstood, it alsomade her feel she could not voice her fearsand anxieties to those around her. I realisedthat her fatal illness must have mobilised thedefence of denial in those around her. Itoccurred to me to say that she felt strongenough to face the truth, but she needed me tohelp her bear it instead of denying it.We had regular sessions over the telephonefor the last six months of her life. She wouldcall me up at our usual times as punctually asever. I noticed that I felt more anxious than

usual when waiting for her call, as I expectedbad news every time. I was not sure if I wouldbe able to deal with this tragic situation with-out deviating from an analytic stance. I alsobecame aware of the fact that her approachingdeath was also making me conscious of myown vulnerability and mortality as neverbefore. One thing seemed clear in my mind: Iwas on the side of life, and it was this aspectof her personality that I would address when-ever possible. Only much later did I realise Iwould also have to help .her in her dying pro-

/cess.I always felt exhausted after the first few

telephone sessions. I realised this was not onlybecause of the intense emotions of the session,but also because the moments of silence andreflection that used to punctuate the sessionson the couch had disappeared. When Ipointed this out she said she felt very anxiousat any silence between us. She had no way ofknowing if I was still 0 the other end of theline. I understood that she felt she had less Icontrol over me by telephone. Maybe she feltthat I was more separated from her, resultingin greater anxiety. I said that she tried to fill inall possible silences by wanting my constantattention, in order to be certain that I wasthere for her and that I had not abandonedher, since she needed me so much. Like twoblind persons we were never to set eyes uponeach other again. I shall comment" on thisaspect of our new setting later on.I soon noticed that our sessions had fallen

into a routine different from the way thingsevolved when using the couch. She wouldstart the sessions by giving me a brief reporton her state of health, which was deteriorat-ing daily, and on what the next medical pro-cedure would be. She said that she could nolonger drive a car or even leave the housebecause of her low immunity. To save energy,she also had to limit her physical movementsto an absolute minimum. She even had to eatvery slowly because digestion consumed somuch energy. It occurred to me to say that itseemed she must now live in 'slow motion'.She chuckled and said 'that's right'. She

added that altft0Ulvery active personshe did not mindbecome her natun'medical reports'could see how muctainer to deposit .happening to her IIand help her bear'After these reps

appear, such as hechildren and her Iband. I noticed thetions and no more cwe had not a minuas quickly as possurgent matters.She told me that

her children wouldcare after her deamany of his valuesdifferen t from her awould influence thlgave the following eWhen passing b

come upon a gang (who jeered at him 2no reaction and ranHer husband criticihad shown a 'cowathought that the beeven if this meant beThe son, however,enough to confronhanded. The mothertion was ridiculous. .that once, when he I :Jhad had a similar ewho had provokedquently beaten up. Efear at the time anchimself for having besaid she thought heTson to avenge the husuffered in the pastAlthough her reas

it, I could see it wasaspect of her person


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THE PATIENT WITHOUT A COUCHs I expectedre if I wouldation with-ance. I alsopproachingious of myy as nevermy mind: Ithis aspectress when-Irealise Idying pro-

f

added that although she had always been avery active person, she now felt so weak thatshe did not mind the slow motion. It hadbecome her natural pace. I listened to these'medical reports' saying almost nothing. Icould see how much she needed me as a con-tainer to deposit her fears about what washappening 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 herchildren and her discussions with her hus-band. I noticed there were fewer free associa-tions and no more dream material. It was as ifwe had not a minute to waste and had to dealas quickly as possible with immediate andurgent matters.She told me that one of her fears was that

her children would be left in her husband'scare after her death. She did not approve ofmany of his values and ways of thinking, sodifferent from her own, and she was afraid hewould influence the children negatively. Shegave 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 gaveno reaction and ran away as fast as possible.Her husband criticised the son and said hehad shown a 'cowardly attitude'. The fatherthought that the boy should have retaliatedeven if this meant being beaten up even more.The son, however, said he was not crazyenough to confront a whole gang single-handed. The mother thought the father's posi-tion was ridiculous. Later the father admittedthat once, when he himself was a teenager, hehad had a similar experience, but it was hewho had provoked some boys and was conse-quently beaten up: He had felt paralysed withfear at the time and still inwardly criticisedhimselffor having been a coward. The mothersaid she thought her husband had wanted theson to avenge the humiliation he himself hadsuffered in the pastAlthough her reasoning had some logic to

it, I could see it was concealing an omnipotentaspect of her personality. She alone had the

he first fewas not onlythe session,silence andthe sessions. When Iery anxIOUSno way ofend of thehe had less ;-

ybe she felt /er, resultingied to fill inconstantthat I was

abandonedh. Like twoeyes uponnt on thishad fallenway thingsShe wouldbrief reportdeteriorat-edical pro-e could nothe housee energy,

movementshad to eatnsumed sosay that itmotion'.right'. She

sagacity her children needed to grow up withthe correct values. It would be dangerous toleave their young minds under the care andinfluence of her husband's way of thinking. Isaid that she could see for herself that herchildren were quite grown up and had mindsof their own. Maybe she believed that shewas indispensable for their survival. Then Ireminded her that she had lost her ownmother when she was in her early adolescence.At this she remembered that although shehad grieved over her mother's death, she wasyoung, 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, thatshe had certainly not missed her mother's con-trolling nature. Isaid that maybe she wantedto 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 ather death. This was the first time I overtlymentioned her forthcoming death. Ishallmake some reflections on this subject in thediscussion.One day she told me she felt very hurt by

her daughter who was studying abroad. Eversince the daughter had heard of her mother'sfailing health, she had started calling herfather instead, to give him her news. Themother felt left out and had cried a good dealover this injustice. Her personal life was soempty that any news of any of her childrenwas 'nectar' for her. Isaid that I could under-stand that she felt her life to be empty at themoment, confined as she was at home; it wasso different from my life and that of herdaughter abroad, each of us so busy andactive. Maybe this is what she was reallyresenting, this and the injustice of her daugh-ter turning to the father, instead of to her ownvery eedy self. She felt left out, as she hadsaid. I thought later that her needy self prob-ably also felt left out of my personal life, sinceI dedicated only three hours a week to her.She remained silent, so I reminded her thatshe had once told me how happy she was thatI could still be with her, even if only by tele-phone. I asked if she had thought of telling her

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6 VIVIANA MINERBOdaughter how much she also needed her calls.She said she was so hurt that she didn't wantto be the one to phone. It was up to the daugh-ter to call her. I asked if she wasn't acting on'false pride', not wanting to show her need toher daughter. Maybe that was what the hurtwas all about.At the next session she was happy to tell me

that she had thought over our conversationand had decided to call her daughter after all.In tears, the daughter had apologised, sayinghow 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 shewas thinking of interrupting her course andcoming home to be by her mother's side, eventhough the course would be over in just twomonths. My patient told her that the greatestjoy this daughter could give her mother was tostay and finish the course successfully. I could

r see there the reparation for the resentment. Isaid I could see her generosity in not wantingher need and illness to be an obstacle to herdaughter's life.She said that one of her great worries wast : . c , a C(; .that she would become a 15ur e.Jlto her family.

I said I could appreciate these feelings of notwanting to be needy and dependent on herfamily, as this could be humiliating for her. Ireminded her that we two had a relationshipin which we depended on each other for ourwork together. Didn't she feel that the mem-bers of her family had some special responsi-bility towards her in sickness as in health, asshe had towards them? She said that I had putthe pro blem in a way she had not thought ofbefore. For my part, I felt that my last ques-tion was quite unprofessional. I should havebeen satisfied with the interpretation that tobe needy was humiliating to her. I was proba-bly 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 fora regression of the localised cancer. She wasterrified because the doctor said this proce-dure involved considerable risk. Almost intears, she asked me if I would stay by her 'un-

til the end'. I immediately realised that thelump in my throat was growing, and I felt thata burden had been pur on my shoulders. Icould see how much she expected of me, andI was not at all sure I could cope with thisdramatic situation. I also became aware ofhow afraid I was of her dying. This was thefirst time I had attended a patient with a ter-minal illness, and I have also been spared fromgoing through any such experience in my per-sonallife. At the same time I was gratified thatshe felt helped by me. I replied, without know-ing what was to come, that I would stay by heras long as she was able to participate. Adepressed mood took hold of me for the restof the day.I will now relate two sessions in the same

week that illustrate the oscillations in hermood.

do, she said. This seening with me. Then Ime like a non-psychoshaps what she couldpossible use of thereminded her that sgrateful she was thatvacy of her own hOtected by the love obeing in a desolatemaybe she thought, suation, that it was eathe important thing nto enjoy the momentsas she was by the oneI was trying to ad

these words didn't equiet, feeling verythinking of the suendure.

WednesdayFr

I sensed discouragement in the brief 'goodmorning' she gave me. She said she was notresponding to the chemotherapy and the doc-tor had said he would try to think of whatcould be done next. He was obviously 'lost'and she felt like 'giving up the fight'. Itdawned on me that it was the first time she wasreally conscious of losing hope of anotherremission, because this was really what theexperimental methods she agreed to submit tomeant. As she said: they were postponing themoment of death.She said she didn't feel like seeing or talk-

ing to anyone. I asked if she would rather nottalk to me either that day, but she said noimmediately, as she had already told me howimportant it was to have me with her. She wasreferring to colleagues from work who weregoing to visit her in the afternoon. She wouldhave liked them not to come, but didn't wantto hurt anyone. This movement of not want-ing to hurt me or the colleagues gave me adoor through which I could try to help herbear her misery. I said I could see in this con-cern of not wanting to hurt anyone a desirenot to 'give up the fight'. What else could she

I felt great anxietysion. The first thing'good morning' waswhat had happenedafter that sad and ilmy great surprise sheday. She had been ableafter the session, hadfast, watched a filmcousin over for lunch.expected visit from hall chatted and had aaged to forget how sShe caught herself thto be alive and ablewhich might seem soson, but were so precition. I was moved byand the gratitude shemoments of life.She then told meher the following day

cert. As she felt restedshe accepted the inviwas not risking too


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THE PATIENT WITHOUT A COUCHdo, she said. This seemed to be a way of agree-ing with me. Then I said (in what sounded tome like a non-psychoanalytic stance) that per-haps what she could do was make the bestpossible use of the time she had left. Ireminded her that she had once said howgrateful she was that she could stay in the pri-vacy of her own home, where she felt pro-tected by the love of her family, instead ofbeing in a desolate hospital. I added thatmaybe she thought, since I was not in her sit-uation, that it was easy for me to tell her thatthe important thing now was for her to be ableto enjoy the moments she could, surroundedas 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 remainedquiet, feeling very sad and impotent andthinking of the suffering she was yet toendure.

d that theI felt thatoulders. Iof me, andwith thisaware ofis was thewith a ter-pared fromin my per-atified thatout know-stay by hericipate. Afor the restn the samens in her

FridayI felt great anxiety at the hour of our ses-

sion. The first thing she said after the usual'good morning' was that I couldn't imaginewhat had happened to her on Wednesdayafter that sad and disheartening session. Tomy great surprise she said she had had a goodday. She had been able to pull herself togetherafter the session, had her shower and break-fast, watched a film on television, had acousin over for lunch, and finally received theexpected visit from her colleagues. They hadall chatted and had a good time. She had man-aged to forget how sick she was for a while.She caught herself thinking how good it wasto be alive and able to enjoy such moments,which might seem so simple to another per-son, but were so precious to her in her condi-tion. I was moved by her courage, moral fibreand the gratitude she felt for such nice, briefmoments oflife.She then told me that a friend had calledher the following day and invited her to a con-

cert. As she felt rested after her afternoon napshe accepted the invitation. She thought shewas not risking too much, in spite of strict

g or talk-rather nothe said nold me hower. She waswho wereShe woulddn't wantnot want-gave me a0 help hern this con-e a desirecould she

orders to stay at home. If she went to hospitalso frequently for tests, why not an exceptionfor some enjoyment? She had loved the con-ceit and it felt so good to be in a theatreamong other people. I could see here a wish todeny her illness for a moment and really belike healthy people. I said I could see howproud she was of herself: in spite of the seri-ousness of her illness, she could enjoy whatshe was able to and feel full oflife. I added thatmaybe she was also telling me this to make mefeel happy for her and for our work together.She thanked me for the work I was doing withher, especially for bearing with her despair asI had on Wednesday, without falling intodespair myself. She felt that this was what shereally needed. Was she seeing me then, for amoment, as a separate person, one who didnot despair with her but who could containher despair?My holiday break was approaching and I

felt guilty for leaving her in such failing healthand apprehensive of how she would react tothe separation.She said that although she would miss our

sessions, her daughter's return would be acompensation. They would have a lot to talkabout. She added, half-jokingly, that shethought she could hang on to life until myreturn. It had not occurred to me that shecould indeed die while I was away. I realisedthat this was a denial on my part and it mademe feel that I was really abandoning her whenshe probably needed me most, and she wasreminding me of this in her own way. I r~mem-bered a young patient I had had who was soangry with her mother that she told me shewould lilke to die just to see her mother feelguilty for having mistreated her so. I said thatit felt as if she was generously giving me per-mission to have my holiday, but at the sametime she was reminding me that I ran the riskof her dying when she would need me most.How would I feel if this happened? Maybe shethought this was what I deserved to happenfor abandoning her. She asked if I was notgoing too far in my analysis of what she hadsaid. It seemed to me that she agreed to my

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88 VIVIANA MINERBOinterpretation but it was almost more than shecould bear.At the first session after vacation she told

me she must have misunderstood the date formy return. She had telephoned as usual a.week ago and it was the silly answeringmachine that took her call instead of me.Then she realised her mistake. I said I under-stood she had missed me, and that maybe sucha long holiday seemed to mean that 1did notreally care for her. If I cared, I would havecome back sooner. Maybe she was resentfulthat I could have my life and holiday awayfrom her and could leave her out. With anawkward laugh she said she did not want tosound demanding and ungrateful. I saidmaybe she was ashamed to realise she hadsuch feelings about me, especially as she alsoliked me and needed me so much. I wasemphasising that she could have negative aswell 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-sion, and the next was a holiday. I would liketo describe the subsequent session, as itreflects how much she had matured even inthe face of death, or perhaps because of it.

TuesdayShe said she had spent a miserable time in

hospital having her blood transfusions. Shehad been in such pain that she had been givenmorphine.What was worse, she had not responded to

the transfusions. The doctor said there wasnothing more he could do for her. At herrequest she was taken back home and wasbed-ridden again. She said how good it was totalk to me although the effort left her a littleout of breath. I said she was glad to count onmy understanding and support in this time ofneed.The fact that we could not actually see eachother had its positive aspects. She was sparedthe humiliation of being exposed to my wit-nessing her suffering and probable physical

alteration. I remember her telling me, just afew months before the terminal phase set in,that she had an ex-colleague who was dying ofAIDS. She was forcing herself to visit him athome once a week for humanitarian reasonsas he was completely alone, with no friends,and with only very old disabled parents. Thesevisits were very trying, Week by week shenoticed his visible physical deterioration, hishair falling out, the massive loss of weightwhich left him with a skin-and-bone appear-ance, the magnitude of the pain and weaknesswere of such an order that he could not evenleave his water mattress to go to the toilet.When he finally died she remarked that it wasa blessing his misery was over.She had mentioned being glad she had not

lost her hair with the on-going treatment; inthe past she had had to wear a wig. She hadalso lost less weight than she would have likedto, as she was quite stout. Maybe this infor-mation helped me, when I thought of her,maintain the visual image I had of her the lasttime I saw her. A lot of denial was at work herebecause I did not take into account the alter-ations the disease and pain I knew she wassuffering might be cau ing to her appearance.The fact that I was spared seeing her and espe-cially that I was spared witnessing at firsthand the great physical pain she was in fromthis time on, undoubtedly helped me continueto be useful to her to her dying day, and facil-itated for both of us what was to transpirefrom now on.She said she had discovered that if she lay

quite still she felt almost no pain. I said thatavoiding feeling the pain was a way of tryingnot to think how sick she really was and notto realise that she was actually dying. She saidshe knew that, and the thought was unbear-able. She surprised me by saying she had afavour to ask me. Her daughter was taking herillness and coming death very badly, andasked if I would agree to see her if she neededme after her death. I said I could see her butnot treat her. I felt she was saying, with rea-son, that the realisation that she was dyingwas unbearable to her. I wondered whether

this meant thatshe was possibffantasy that sheher death throuwas why I was ~was convinced tded in her objehowever, if I COhow she would nbecause of the TItrust she had dthis interpretatiodelicately as I Cot'Do you have to bBut I felt that, ncpretation was to tand still wantedthe 'end', as she 1long ago.She went on I(

her father and brcfelt loved and gratdid not feel at all afeared she would lwas finally able todependent on thenShe said that sh

cess'. I was surprilike a 'little prinoexplained that sheloved before. Shefather, as he was ahimself be toucheNow he would sithand. She felt fullsorry to have to inwith her prematurethis sadness.She had also hac

tion with her husltime in their marrieing cheated on hergiveness, saying thawas stronger than avery grateful for theremembered how mthis infidelity, whichand humiliation. Sh


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me, just aase set in,as dying ofisit him atn reasonsno friends,ts, Theseweek sheration, hisof weightappear-

weaknessnot eventhe toilet.that it wase had nottment; in. She hadhave likedthis infor-t of her,er the lastwork herethe alter-she was

pearance.and espe-g at firsts in fromcontinueand facil-transpireif she laysaid thatof tryingand not. She saidunbear-he had aaking herdly, ande needede her butwith rea-as dyingwhether

THE PATIENT WITHOUT A COUCHthis meant that, as a defence against her fears,! me that she would never forget this or forgiveshe was possibly harbouring the unconscious/ him for his betrayal. Now she felt this wasfantasy 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.was convinced that this fantasy was embed- She was also grateful, she said, that the chil-ded in her objective request. I didn't know, dren had their father to care for them after herhowever, 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 reparationbecause of the respect I had for her, and the she was making to her loved ones, and sotrust she had deposited in me, I should risk grateful that she had matured to this point. Ithis interpretation. I tried to formulate it as said that the love she was telling me aboutdelicately 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 itBut I felt that, no matter how hard the inter- seemed to me that she was accepting the harshpretation was to bear, she was agreeing with it fact that she was dying, and that maybe sheand still wanted to have me as an analyst to felt ready any time now. After a slight pausethe 'end', as she herself had requested not so she said that this was so, although it did notlong 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 workdid 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 husbandwas finally able to accept needing and being called me the next day to say that she had dieddependent on them without humiliation. during the night.She said that she had felt like a 'little prin- It was shortly after this patient's death that

cess'. I was surprised at this remark: feeling I decided to review the literature on the psy-like a 'little princess' on her deathbed? She choa alysis of patients with a diagnosis ofter-explained that she had never felt so genuinely minal cancer .loved before. She used to be angry with herfather, as he was always distant and never lethimself be touched or show any emotion.N ow he would sit by her bed and hold herhand. She felt full of love for him and wassorry to have to inflict so much pain on himwith her premature death. He didn't deservethis sadness.She had also had a very intimate conversa-

tion with her husband, maybe for the firsttime in their married lives. He confessed hav-ing cheated on her and was asking for her for-giveness, saying that the love that bound themwas stronger than any passing affair. She wasvery grateful for these words of affection. Sheremembered how much she had hated him forthis infidelity, which had caused her great painand humiliation. She remembered her telling

BRIEF REVIEW OF THE LITERATURE

The literature on the dying shows that pro-fessionals who deal with patients who haveterminal diseases such as cancer are divided intheir opinion as to the utility of telling thesepatients their diagnosis. Dupont Munoz(1974)( Klafke (1991), Telis (1991). I am, how-ever, more interested in discussing the psycho-analytic technique with terminal patients. eKurt Eissler's book The Psychiatrist and

the Dying Patient (1955) seems to have exerteda great influence on technique regarding thequestion ofwhether the psychoanalyst shouldhelp the terminal patient become conscious ofthe fact that she or he is dying, or collude with,

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VIVIANA MINERBO a1- r:"'-0 r, -'the patient's aspect that denies this fact. undertaken because of the fatal diagnosis.Eissler is for the latter attitude, steering away There is a marked difference between the sue- /from a psychoanalytic stance and rationalis- cessful outcome of an analysis undertaken z"ing that what the patient needs ispresence and before the onset of the disease (Alizalde, 1993), /comfort. Many authors cite Eissler and have which was the case with my patient, and one/consistently used techniques that conform to undertaken after the diagnosis, when no /his model, even putting themselves at the former relationship of trust had been estab-/patient's disposal, suffering unnecessary lished with the analyst. /intrusions into their time and personal lives The above review of the literature on the /(Joseph, 1962; Norton, 1963; Roose, 1969; analysis of patients with terminal cancer /Adams-Silvan, 1994). brought three questions to my attention: /Feifel /$ L Nagy (1981) and especially Hag- 1) Should a patient with terminal cancer be

glund (1981) hold that the patient's capacity told of the diagnosis, and to what purpose? ;/to endure the pain of so 'massive a loss as 2) Is psychoanalysis possible and produc-working through mourning in a way that tive in such cases? /leads to adaptation to death depends greatly 3) What, in theoretical terms, enabled myon the maturity of the psychic apparatus, but patient to have the mature psychic apparatusalso on the quality of the inner objects and the and emotional condition to bear the-truth andability to communicate with them' (p. 45). consequences of her disease? /Some analysts believe that a psychoanalyt-

ical stance with proper regard for truth andreality helps the dying patient to workthrough the meaning of the disease and bearthe fear of death.!ayer suggests that analysis with terminalpatients is 'possible and productive' (1994, p., 1), emphasising the need for empathicInvolvement with them. She remarks that thescarcity of such reports might be an indicationof the difficulty analysts have working withsuch patients and.writing reports about them.Bail says that 'Truth through interpretationis love, is comfort for despair, is security

against terror, is growth in the face of death, isfriendliness in the face of loneliness; it is, inshort.summing up the most virtuous qualitiesdeveloped by humanity' (1981, p. 64). Hebelieves that colluding with the patient's nega-tion of death is deceitful and destroys what ismost courageous in man.The above quotation, ideal as it may be,

coincides to a certain extent with the privi-leged experience I had with the patient I ana-lysed, as described in the clinical report,above.Another aspect involved is that most clinical

reports on the analysis of patients with termi-nal cancer mention that the analysis was

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DISCUSSION AN;D CONCLUSIONS

My review of the literature on patients withterminal cancer raised the perennial issue oywhether to tell the patient the truth, and towhat purpose. The patient's psychic maturity;"and emotional conditions have been taken ascriteria by some professionals to resolve th{problem. Doubts also exist as to whether pSyichoanalysis 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 dis-ease. This is the only way to treat a patien /with the respect he or she deserves and makeit possible to become a participant in the deci-sions 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 inalso protects th eintrusions into htime, in contrastanalyst at the tenposal.In the case ofthe psycho anal)

Although the sealast six months oto have our usualup to the very endI do not agree

(1969), Adams-Silhelp the patient Savoid ambivalencesidered that ambishould not be avoing for the integninternal analyst,analytic process toin the terms quoteused as a good conand anxieties, homy active life asmy leaving herhealth in oppositiodeath?I also do not ag

ers who collude wdenies the fact thaas Kubler-Ross (Bhave to use somedifficult to look atime. Indeed, I Imaterial that bothinto the mechaniabove that this evanalytic stance anher in very painfuThis was seen b tvisual image of thwhile knowing ofsuffering.I did not, how e-a technique to spaout in the clinical Dto help her in her c


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l diagnosis.een the sue- /undertaken/alde,1993),/nt, and one/when no

been estab-//ture on the /l cancer I

ention: /al cancer bepurpose? ;/and produc-enabled mye apparatush . truth and

tients with J-ial issue of/'uth, and to /"ic maturityz"'en taken as /resolve th~hether psyyctive witli >rting' tech-(

/ience in the,/uld be told>'is and state/the medical /of the dis-t a patien . Jand makein the deci-nterests.cess con/t basis and j.e patient a~)nalytic ap- /and emo- )

THE PATIENT WITHOUT A COUCH 91tional maturity in both patient and analyst. It /to be able to bear the pain of knowing she wasalso protects the analyst from unnecessaryintrusions into his or her personal life andtime, in contrast to techniques which put theanalyst at the terminal patient's complete dis-posal.In the case of my patient I tried to respectthe psychoanalytic stance as far as possible.

Although the setting had been altered for thelast six months of her disease, it was possibleto have our usual three sessions by telephoneup to the very end.I do not agree with the position of Roose

(1969), Adams-Silvan (1994) and others whohelp the patient split off aggressive feelings toavoid ambivalence towards the analyst. I con-sidered that ambivalent feelings towards meshould not be avoided, but interpreted, allow-ing for the integration of the good and badinternal analyst, creating conditions for theanalytic process to be productive and truthful,in the terms quoted from Bail (1977). If! wasused as a good container for my patient's fearsand anxieties, how could she not also resentmy active life as compared to her empty one,my leaving her to enjoy my holidays, myhealth in opposition to her certain, oncomingdeath?I also do not agree with Eissler and follow-

ers who collude with the patient's aspect thatdenies the fact that he/she is dying, although,as Kubler-Ross (1909) says, terminal patientshave to use some kind of negation, as it isdifficult to look at death in the face all thetime. Indeed, I have shown in the clinicalmaterial that both the patient and I did lapseinto the mechanism of denial. I reflectedabove that this even helped me maintain theanalytic stance and continue to be useful toher in very painful moments of the analysis.This was seen by the fact that I kept an intactvisual image of the patient as I last saw her,while knowing of her disease and dreadfulsuffering.I did not, however, collude with denial asa technique to spare the patient. As I pointout in the clinical material, I felt that if! wereto help her in her dying process, I myself had

dying, overcome the resistance, and interpretthis to her when the material allowed. I believethat the fact that I was able to contain andinterpret the horror of her dying made it eas-ier for her to speak of her coming death andvoice her fear of death. At the Wednesday ses-sion, she said that she was aware that the med-ical experimental methods were meant topostpone the moment of her death. In the lastsession, she asked me if I could see her daugh-ter after her death as the latter was very muchaffected at the idea of losing her. After shetold me that she had become reconciled withher loved ones, I was able to interpret to herthat she was telling me that she had come topeace with herself and her beloved ones, andthat it seemed she was accepting the harsh factthat she was ready to die, to which she agreed,but added that she was terrified of theunknown.From the very beginning of her analysis,

before the malignant disease had set in, shecourageously sought the truth about herself.With 0 pretensions at being original or ofexhausting the subject, I would like to use thischaracteristic of hers to bring up a few theo-retical considerations to try to account forwhat gave her the psychic and emotional abil-ity to bear the truth of her disease, accept thatshe was dying, make reparations and be grate-ful for the good moments. I feel that Kleinianthought best sustains my purpose.For clarity's sake, I will differentiate psy-

chic from emotional conditions, although thedistinction is common knowledge. I take psy-chic conditions as the structural configura-tion of a psychic apparatus at a given momentthat makes the corresponding emotional con-ditions possible.

ThePatientWithoutACouch-Minerbo

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