Pavor Nocturnus or Night Terrors Revisted
2006

The More Things Change
2006

TO PRACTICE ONE’S ART

by Bernard W. Bail, M.D.

     While direct access to the truth is available, it would seem, to poets and mystics only, those less fortunate have finally been able, in this century, to take advantage of the most remarkable heuristic device of modern times: psychoanalysis.  Yet Freud’s discoveries rapidly became frozen into a rigid body of laws not to be transgressed at any cost.  Thus, knowingly or not, Freud implicitly allowed those who followed him to reinstate the bliss of ignorance, and a series of “thou shalt not’s” grew up around the original insights that should have opened up more pathways into the human psyche than has been the case.  The extraordinary persistence to this day of such interdictions can be gauged with respect above all to the “narcissistic neuroses,” deemed unamenable to analysis. We are still warned against analyzing schizophrenics, manic depressives and adolescents – despite the fact that these admittedly onerous tasks have been undertaken and a great deal learned in the process.  What irony instead resides in the fact that, having given us the tools to understand this awful, forbidding conscience which terrorizes, constrains us to prayer, and virtually addicts us to superstition, Freud should somehow have given consent to successive generations of analysts to maintain this terrible force and keep it from perishing!

     Thus enthroned in what has come to be the psychoanalytic Establishment, which has set forth guidelines for a good number of years for all aspirants, the respectability of certain taboos can hardly be accused with impunity. We are indeed reminded here of Cicero’s views on the authority of those who teach: often an obstacle, he judged it, to those who want to learn.  We must vigilantly guard our intrinsic freedom in this domain and, following Montaigne’s example, begin among the liberal arts with that art which liberates us. Such man-made prohibitions on knowledge and exploration as I have been evoking thus far stem, I am convinced, from fear and ignorance.  It is in this perspective, too, that the prohibition on the analysis of dying patients must inevitably be viewed.  Indeed, the remarkable paucity of analytic literature on the subject cannot seriously be attributed to analytic patients’ having a lower mortality rate than the general population.

     Similarly, their analysts’ failures to regard them as proper subjects for reflection must be discounted as a factor that would explain the absence of pertinent literature.  The term “analyst” itself would seem a misnomer in a number of cases described by therapists who have made no attempt to adhere to the analytic model but have ignored it entirely or abandoned it early on in favor of psychotherapy.  Those authors who address themselves to the issue of the dying patient frequently make use of the thinking of Kurt Eissler, whose 1955 book, The Psychiatrist and the Dying Patient, reflects in its title alone (the psychiatrist, not the analyst), a significant choice of therapeutic models. 

     In this paper I intend to discuss several aspects of the Eisslerian approach to the dying patient, an approach I find superficial in its failure to comprehend psychoanalytic insights and perhaps unwittingly treacherous to those patients it purports to accompany in their last months and weeks of life.  I shall first state my major objections to Eissler’s models.  An examination of four contributors to the subject will follow, and in conclusion, I shall present a clinical case drawn from my own experience with a dying patient in analysis.

         The Eisslerian “credo” has perhaps been nowhere stated more eloquently than by Florence Joseph in her article, “Transference and Counter-Transference in the Case of a Dying Patient,” (1962):  “I believe that what is essential is that the patient not be left to his loneliness and despair while he awaits death; that in the case especially of the patient who has undergone analysis, he be in close contact with his analyst; that the path they had trodden together in analysis for so many months and years in intimate communication, often on the deep unconscious level, should now enable the analyst to bring comfort to his patient in his final extremity.” The notion of the analyst bringing comfort to the dying analytic patient is a noble one, perhaps, but it is unfortunately built on a shaky premise, namely that the unconscious is of little significance in the patient’s final days on earth.  We are in this way afforded just one of many examples of a certain intellectual confusion, for it is asserted time and time again that the patient unconsciously knows he is dying. If this is the case, then it is certain that on the deepest level no one can banish the loneliness and despair the dying patient must confront.  The “comfort” it is within the analyst’s power to bring to his patient differs, not only in degree, but in kind from the ultimately false reassurances the practitioner of the Eisslerian model hopes to purvey.

         The denial of the patient’s unconscious implied by this model has been shown to be reinforced by numerous attitudes, gestures and deeds on the part of the therapists who have provided the scant clinical material available to us on the subject.  The knowledge the patient possesses of his imminent death is consistently avoided by these therapists who thereby repudiate everything that is courageous in man: the impulse to breast the unconscious, to know the truth as far as one can know it, and to make as good use of it as one can.  To deny the model of psychoanalysis at this particular time in the life of the analysand, the time when one ought to adhere more closely than ever to the analytic process, strikes me as a double betrayal:  of the analysand on the one had, and of intellectual honestly on the other.

         Strictly speaking, the rationale implicit in much of the work on this subject is one which lends itself to destroying the analytic process in general, for we can always say (since we never know whether we shall be alive on hour from now): why not spare the patient loneliness and despair and make him more comfortable?  What is left unspoken is that we wish to make ourselves more comfortable as well.  In other words, where do we draw the line? Is a patient to be considered “dying” only when all clinical evidence available indicates that this death is imminent?  If we do not know – and we do not – I think it is essential in the interests of exploration of our being to garner what knowledge we can about the extreme regions of human life, about dying, insofar as our store of knowledge of human affairs is still rather meager.

         While it is not my intent to belittle the contributions of Eissler and the other courageous men and women who have dared to look at what remains, after all, a forbidden aspect of existence, I must strenuously refute their general stance.  The taboo against shedding light on the subject of dying, summed up in the dictum so often heard, “Do not interfere with the dying, let them die in peace,” is tantamount, of course, to that original interdiction on eating of the fruit of the Tree of Knowledge.  Curiosity is condemned, for we are to know neither of the beginning nor of the end of life.  As to the former, we have gradually succeeded in pushing back the frontiers of our knowledge but the cloak and aroma of religion continue to mask primitive anxieties linked up with the obsidian fingers of the death instinct, taken seriously only by Melanie Klein and her followers.

         Society has in the past assigned to the priest a role similar to that Eissler would appear to be recommending for the therapist of the dying patient, i.e., that of pipeline to the deity.  We must reject this sort of pretense and be saddened at the loss of opportunity for exploration that it represents.  Clinical experience has shown, moreover, that patients who are treated forthrightly do not wish rather to be fooled, but are genuinely grateful that an ordinary man, a psychoanalyst, is willing to go as far as man can, fearing neither the positive nor the negative transference.  There is in such an experience the sense of adventuring to the very edges of our inner universe: those who do so should be respected as the astronauts of inner space in the same way as we respect those men we have propelled through the far reaches of outer space.

         “The libido (of the dying patient),” Eissler (1955, p.141) writes, “is then totally drawn into the process of binding the death instinct activated in the pathological process, leaving no surplus to maintain those functions which, under ordinary circumstances, are fed by libido…but the accretion of sublimated libido from without apparently eases the patient’s struggle.”  With this citation I should like to present my second major objection to the Eisslerian model.  To begin with, the confusion in the use of basic psychoanalytic concepts is striking: what can it possibly mean to suggest that sublimated libido may be provided “from without”?  I would maintain, rather, that it is the interpretation of the conflicts of the patient (dying or not) as they relate to internal or external objects that results in a releasing of some libidinal forces with which to control the various manifestations of the death instinct.  If this is what we believe is best for the living patient who we feel will continue to live till tomorrow and no longer – an act we make on faith – I cannot see how it is less true for the dying patient.  Indeed anything short of this, such as avoidance of the truth as the analyst sees it, constitutes collusion on the analyst’s part with the patient’s destructiveness and can only hasten death.

     It is my conviction that, contrary to an “accretion of sublimated libido from without,” the patient’s struggle is eased by truth. 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, the summoning up of the most virtuous qualities developed by humanity in the course of its history.

         With these general remarks in mind, let us now turn to several concrete examples of the avoidance of truth, the collusion between therapist and dying patient, which, it would seem, the Eisslerian model encourages at every point.  In her article, Florence Joseph (1962) relies heavily on The Psychiatrist and the Dying Patient for confirmation of the approach she used with a young dying woman, Alice.  Though her article affords us numerous instances of the type of collusion I decry, my point will be perhaps better taken if I restrict my discussion to four interrelated aspects of it.

         The first aspect of collusion concerns the giving of gifts to the analysand.  Joseph regards such comportment as not only justified, under the circumstances, but as desirable.  She remarks that “spontaneous love without thought of obligation or return on the patient’s part is a kind of antidote against death,” (p.27).  Similarly, she notes that Eissler has written: “Then the gift will be experienced by the patient as a physician’s giving him part of his own life, and the dreadful stigma of being selected for death will be converted into a dying together” (Eissler, 1955, p.139).  The beauty of such a sentiment is, I am convinced, entirely illusory.  The notion of “a dying together” must be seen for what it really is: a well-intended device which unfortunately adheres to neither internal nor external reality but ends by duping the patient – and reassuring the therapist.  But the patient is not really deceived:  he knows at some level that the physician is not giving over part of his own life, nor would he, and that “dying together” is, of course, a phantasy which, like all such phantasies, is one of omnipotence, a denial of the helplessness he is subjected to in his moribund state.

         Again, it must be stressed that the “antidote against death” which Joseph misguidedly seeks in proffering gifts to her patient can be found only in the replication of reality.  For, as Freud’s genius discovered, the death instinct we are to combat, even in its physical manifestations, may be neutralized by such infusions of truth (and thereby of libido into the mental economy) as interpretations can accomplish.  Our task, in other words, is no different for the rapidly ebbing than for the slowly, imperceptibly dying patients that are the work of our everyday analytic practice.

         Joseph’s account of her treatment of Alice itself contains the very evidence one could make use of to support the contention that the patient knows very well he or she must die alone, that the therapist’s “generosity” is ultimately of a rhetorical sort.  Joseph ceased taking payment from Alice and brought her flowers on her weekly visit to her bedside.  Her patient “laughingly scolded” her one day: “Freud would not approve of you at all.” Indeed it may be asked: had the therapist the right to deny her patient her reparative gestures which went so far in recognizing what it cost the analyst to come and work with her and which, perhaps more importantly, represented a grand acknowledgement to her internal objects, those objects which, if not reinforced can only keep the patient depressed, quiet, anxious – even if possibly covered by manic denial? What then will be the toll upon the patient’s state of mind – and upon her body?  By refusing Alice’s check, Joseph unwittingly deprives her of her feeling of potency, or richness, of capability, and tosses her into a state of weakness.  She aids in this way the processes of deterioration, hastening death in her patient. The Eisslerian model, which effectively leaves little or no room for such reparative gestures, must subtly but surely speed up the dying process.  While it might be argued that my position is cruel, it cannot seriously be denied that our existential situation is cruel and that there is nothing to be done about this state of affairs except to face up to it, and deal with it as best we can.  The analytical model is realistic, whereas the Eisslerian one would appear to hinge on the religious, seeking to bring comfort in extremis, ignoring the analytic tools that Freud passed on to us.

         Nothing, moreover, is gained, in terms of expanding our knowledge about dying, by such collusion.  No significant information comes out of Joseph’s experience at least, although she appears to believe differently when she tells us that Alice’s behavior could be interpreted as regression to a pre-oedipal infant-mother relationship.  That a state of regression might exist in a dying patient does not strike me as out-of-the-ordinary.  Have we really been enlightened as to the process of dying by this information?  I hardly think so.  What analytic patients are not in some state of regression?  And isn’t the same true of many post-analytic ones as well?  Indeed it might be plausibly argued that in all of us such states exist.  Any threatening situation that renders us helpless immediately lands us in states of phantasized omnipotence, which are pre-oedipal states most often arising in relation to the mother, vis-à-vis whom we suffer our helplessness most intensely, when we are ill-equipped to cope with it.  Thus Joseph’s description of this sort of regression in Alice scarcely adds to our knowledge of dying.*  It is my conviction that the avoidance of truth with respect to the patient’s unconscious has an inevitable repercussion upon the acquisition of truth in the domain of dying in general: to deny the unconscious results in intellectual stasis and prohibits accession to the truth.  Indeed, the question of the regression of the dying patient has not been adequately treated by Joseph or even Eissler, who perceives it in a possible longing for a past pleasure, the mother-child relationship.  Merely to state that this is the last, the most intense, the grieved-for hope is insufficient.  Perhaps we must look beyond the Oedipal situation, beyond the maternal-infant duo to glimpse a process of a completely different order: a maturation process which might be entirely desirable. Our minds must be open to this possibility and not be saturated with clichés so debased as to be meaningless to any reader or listener.  I shall say more about this maturation process at length.

         A third aspect of collusion in this area is related to the patient’s dreams and the therapist’s interpretation, or, as in Joseph’s case, lack thereof.  While admitting that Alice unconsciously knows she is dying, Joseph abstains from interpreting her patient’s dreams of being the only passenger escaping from a sinking ship and from a burning, doomed airplane.  Joseph explains her silence this way: “But never did she ask me to interpret her dreams, nor did she attempt to do so herself, although she was well-versed in dream interpretation and must have understood the symbolism” (p.29). Instead, the therapist’s comment: “Oh, Alice, people do dream such horrible dreams under sedation” illustrates her attempt to deny the patient’s unconscious knowledge, a denial with which Alice does not hesitated to collude.  As we often see when a young analyst makes a wrong interpretation, the patient is quite ready to please himself or herself and the analyst by agreeing.

         Finally, what is the outcome, for the therapist, of the Eisslerian approach to the dying patient? In Florence Joseph’s case, it was, paradoxically, an enormous sense of relief after the patient’s death.  “It was scarcely a week after Alice died,” she writes, “that I began to feel as if a burden had been lifted from my shoulders and shortly thereafter began to feel happy as I had not felt for months.” (p.33).  From this she infers that she might have resented the drain on her emotions and on her time and energy that dealing with Alice represented.  I would suggest that such a drain must be the consequence of not hewing to an analytic model in the treatment of the dying patient.  Briefly stated, the analytic model, by its refusal to encourage corollary demand on the analyst’s energy, is as healthy for us as it is for the patient – which, if anything, again attests to Freud’s genius.

          What, then, is the temptation of the Eisslerian model? Might it not be the inability, on the part of many therapists, to recognize in themselves those very same primeval anxieties with respect to death that haunts their patients?  The Eisslerian model alleviates such anxieties by joining therapist and patient alike in an alliance of omnipotence. Comforting the despairing, lonely patient, giving him gifts, refusing to give credence to his dreams, “dying together”: these and similar notions reflect the extent to which primitive anxieties retain their hold over us.  It cannot be recommended strongly enough that these anxieties be recognized at least intellectually by the therapist if he has not had an analysis of them.

          Society, too, encourages adoption of attitudes favored by an Eisslerian type model: it is impressed upon us, early on, that solitude is dangerous.  Everyone ultimately lives alone just as everyone dies alone, yet the attractive though meretricious clamor of modern-day life serves constantly as a barrier to solitude.  To be alone is to be lonely, or so we are led to believe.  Groups, of which we seem never to be free from birth on, the family, school, profession; the propaganda of “sociability”; the cry of “learn to get along” – in all of this we can perceive the difficulty confronting the individual, the quasi-impossibility of attaining not the solitude of the hermit, but those stretches of aloneness that must be endured if one is to have any idea of his own world.  So it is with dying: even in the extreme regions of life the individual is to be “spared” the confrontation with his lone self; a “dying together”, in this perverse logic, must follow what amounts in most existences to a “living together” that has too often masked the truth. It is unfortunate that the author of the communication under discussion chose not to give us a more complete description of the therapeutic services themselves.  This is, regrettably, too often the case in the analytic literature available to us: an absence of precisely that clinical material without which our knowledge of this area must remain inadequate.  Illuminating this last part of living might shed similar light on the first part, though this latter area is increasingly open to our scrutiny no doubt because of the optimism associated with the study of an organism that has exhausted its potentialities or has not fulfilled its promise, stirs up uncomfortable feelings in most people, analysts being apparently no exception to the rule.

          To what extent these unacknowledged anxieties may be responsible for the lack of clarity one senses in an article such as “The Dying Patient”, by Lawrence J. Roose (1969) is open to conjecture.  The etiology of the author’s confusion apart, it behooves us to expose his mistaken ideas at once.  Roose states his premise thus: “Assuming a minimal interference from counter-transference factors, the manipulation of the transference offered the patient a more promising way out of his dilemma through the facilitation of more primitive defense mechanisms in pursuit of the quest for the good mother through regression to the fantasy of reunion”.  The success of his approach to a dying patient he proclaims in these quasi-religious terms: “Death was miraculously transformed into ever-lasting life”.  The latter statement, it will readily be seen, closely parallels the earlier mentioned “dying together” phantasy in its evident emphasis on omnipotence.  But it is chiefly with Roose’s former statement that I must now take issue.

          It seems to me that a certain ambiguity is apparent in Roose’s text, for at the outset of his article, the author claims that ‘the psychoanalyst, with his special training and skill, is in a unique position to demonstrate that the use of psychoanalytic theory may extend beyond its strict application to those in psychoanalytic treatment”. (p.385)  Does he really mean this?  Apparently not, for Roose immediately qualifies his remark by adding that it is not “classical psychoanalytic procedures” which he has in mind.  Rather he feels no psychoanalyst today can “rigidly restrict himself” to the latter. Roose concludes that he has envisaged such a liberty as “manipulation of the transference”.  It may be wondered what is meant by use of the term “psychoanalysis” in this article if the “manipulation of the transference” in which Roose indulges is to be taken seriously.  How does such a manipulation manifest itself?  Chiefly through the therapist’s failure to respect the patient’s unconscious – and indeed, at times conscious – knowledge of his imminent death. The patient, a doctor wavering consistently between acceptance of the truth and denial of it, was virtually begging Roose to help him come in contact with what was essential to him when he asked him, for example, whether to give up his professional phone.  To have encourages him to do so, to have in this way confirmed what he unconsciously  knew, namely that he was no longer the doctor but the patient, the dependent one having to confront his essential reality rather than flee it as he had done with partial success for so long, would have constituted, in my view, the analyst’s imperative task.  Instead, by helping his patient to decide the issue in the negative, Roose further abetted his denial of the truth.  The patient died as he lived, in a state of falsity.

          The question of denial as raised in the article under consideration merits some clarification.  it is not accurate that denial and consequent repression ultimately lead, as Roose appears to believe, to a phantasy of bliss, of reunion with the good mother.  Why should the very real possibility of reunion with the Bad Breast – obviously represented in Roose’s patient’s case by the sister, the many unsatisfactory housemaids, and, before the, the mother herself – be so imprudently excluded? Indeed the good breast to this patient must remain, for the reader of Roose’s article, a mystery, unless one conjectures that is was he himself he phantasied as the good breast, who need no other person (internal object) and who later, by becoming a physician, could feel that many other people needed him.  In any case, nothing assures us that a phantasy of a nature diametrically opposed to that Roose has suggested as the outcome of “successful” denial could not have resulted from such manipulation of the transference.

          Finally, it is at best misleading to shore up one’s arguments in favor of such departures from the analytic model by citing other authors with respect to reunion phantasies.  They tell us nothing if more extensive clinical material has not been made available to us, as it has not in Roose’s article.  Freud’s remarks on death, moreover, serve no purpose here: the issue is not death, but dying.

          It is perhaps only in Janice Norton’s account (1963) of her treatment of a dying patient that we may discern the ideal lineaments of the Eisslerian approach.  Norton’s is a story that combines the insight of the analyst with the care of a nurse, the practicality of an internist, the concern of a friend and the love of a mother.  We could, without doing an injustice to her test, subsume it under the heading: “Analyst counter-transference reactions to a baby in extremis”.

          Norton’s article raises once again the question of the extent to which strict adherence to the analytic method should be observed. The description afforded us of the dying patient she was working with must, however, give us pause: so much unfolds, in the treatment of this particular patient, that one would expect and hope for in the development of any analytic therapy, that the analytic model as such may indeed have been unnecessary. Mrs. B., Norton’s patient, appears to be so open, so capable of verbalizing her mental states that we wonder whether such terminal conditions as hers lessened the resistances ordinarily met and struggled with or whether there exists an – as imperious as that existing in salmon homing up rivers whatever the perils or price – an urge in a human being when dying to fulfill his potential, to complete something (his life? his personality?) in a manner esthetically satisfying.  As we experience with music, literature, painting, so do we perhaps seek to feel with respect to our lives: “that’s the only way it could have ended,” a feeling of esthetic rightness.  Or does the need for such a maturation process waken in relatively few dying patients, much like the very few who come to us for psychoanalysis when all other ministrations have failed?  They approach us still hungry, still searching, driven by elusive truth.

          The wisest of men, Socrates, condemned to death by the cancerous hatred of truth in his society, was occupied with adapting Aesop’s fables and the Prelude to “Apollo”.  Let him speak in his own words:  “I did it in the attempt to discover the meaning of certain dreams, and to clear my conscience, in case this was the art I had been told to practice. It is like this, you see.  In the course of my life I have often had the same dream, appearing in different forms at different times, but always saying the same thing: ‘Socrates, practice and cultivate the arts’”.

          A sentence of death failed to change Socrates’ dream. The fundament of his personality remained secure, and he was at work in his last days interpreting his dream and, what is more, putting it into action in the present, where he seemed so capable of being, though not without a capacity for speculative thrusts into the future.  We, on the other hand, cannot interpret the dream except to note the obtrusiveness of the day residue and the exquisite alliance of his dream life and his waking life. Indeed, it would appear to us that Socrates always practiced and cultivated his art.  Would we, moreover, be guilty of too freely practicing our own art if we stated that the entire Phaedo could be taken as the free association to this dream?  We would all be at liberty to select from the discourse whichever theme strikes us as being the iron core around which all the filings arrange themselves.  For my part the following paragraph would best illustrate the latter:

          “Ordinary people do not seem to realize that those who really apply themselves in the right way to philosophy are directly and of their own accord preparing themselves for dying and death.  If this is true, and they have actually been looking forward to death all their lives, it would be absurd to be troubled when the thing comes for which they have so long been preparing and looking forward to.”

          I quote from the Phaedo because it is here that Socrates confronts us with both the idea and the illustration of doing what he has always done, namely, be a philosopher. In his bones, in his soul, waking or sleeping, married, the father of children, questioner of men, expositor of truth, betrayer of deceit, citizen of the republic, soldier, victim, he was not like a philosopher but a philosopher.

          Norton’s patient was an exceptional woman whose courage in the face of death Norton describes as “extremely impressive”. Little did it matter, then, that the analytic model was passed over.  Mrs. B. functioned on a very high plane and would no doubt have succeeded in being analyzed regardless of the therapeutic model applied.  Typical of this patient’s basic personality structure was her liking for two psalms, both of which would appear to indicate a person with confidence in a kindly internal object called “the Lord”.  Norton’s work may thereby have been greatly facilitated. So many of our patients unfortunately operate at lower levels of mental functioning, impelled by early infantile anxieties, bizarre part of objects, “beta elements”, unlike this woman who appeared to have reached the calm waters of concern, care and trust, as expressed in Psalms 23 and 121.

          It is clearly to patients such as Mrs. B., to relatively well-constituted human beings, that Eissler’s comment, duly cited by Norton, may pertain: “It is conceivable that through the establishment of transference, through an approach which mobilizes the archaic trust in the world and reawakens the primordial feelings of being protected by a mother, the suffering of the dying can be reduced to a minimum even in the case of extreme physical pain.” (Eissler, 1955, p.119)

     In these specific instances only can some measure of success then be expected from the Eisslerian model.  Far more frequently, it seems to me, the success, if such there is, of this model would have to be of an entirely illusory nature.  For Eissler himself admits that his approach ideally requires of the therapist an impossible degree of psychological agility. “One of the greatest difficulties,” he states, “seems to lie in the necessity for the psychiatrist to activate attitudes which seem contradictory.” (p.151) These attitudes are the following: (1) The therapist must give to the patient sublimated love in the form of affection, but “this affection must not be ‘realistic’, as it would be when the physician loses a loved person of his own private orbit”; and (2) the physician must be fully aware of the “dread involved in the certitude of death for this particular individual,” yet he must not forget that such a death is an “organic event per se, deserving no other response but the one with which we bow to all other necessities of life.”  The therapist’s failure to “balance” these contradictions can spell danger to the patient who will feel unloved, rejected or be drawn toward extreme acting out, says Eissler.

          I could not disagree more.  We should ask not only how such contradictory attitudes can possibly be maintained, but why they should be.  It is not the therapist’s role to regulate the intensity of an emotion, be it sorrow, pity or affection for the patient, but to put all such emotions, along with the patient’s associations, to use in the furthering of the patient’s self-knowledge.  The goal of analytic therapy cannot be other than this. And why should the ego voluntarily tolerate such contradictions as Eissler deems necessary?  He appropriates Hartmann’s view of the ego as “organizing principle” to bolster his shaky arguments in this connection.  Indeed, Eissler openly acknowledges the existence of irrationalities behind these contradictions, but fails to come to terms with the logical consequences of this admission by citing Hartmann with respect to the adequately differentiated ego’s capacity to tolerate a certain degree of irrationality.  What Eissler is in fact recommending for the therapist of the dying patient is none other than the high art of the actor.  This pose must be unqualifiedly rejected.

          The therapist’s task is not to delicately balance contradictions, an unhealthy, impossible proposition, but rather to undo contradictions and expose behind them the irrationalities which Eissler unfortunately seeks to accommodate.  It is finally this evasion of the truth which mars Eissler’s book throughout and to which disturbingly little attention has until now been paid.  In The Psychiatrist and the Dying Patient (1955), the most elaborate rationalizations, parameters, implausibilities are brought forward as their author contradicts himself time and again in the case histories.  In addition to having lost valuable opportunities for exploring this little-known segment of life, the esteemed analyst, Kurt Eissler, in this book has set the example for generations of analysts to provide the same sterile reason for not furthering our knowledge of dying.

A Dying Patient in Analysis

          The patient had come to me recommended for psychoanalysis after several failures in psychotherapy.  She was twenty-seven years old, small in stature, and dark hair covered her brow.  She had a dirty look to her, and her dark bright eyes darted glances around the room. I was persuaded by the intelligent eyes, despite an obvious massive emotional illness, to undertake the analysis. Soon, as we all discover, sometimes to our chagrin, and sometimes as we expect, other symptoms came to be revealed. One was picking her nose uncontrollably until bleeding.  In fact, this occupied a larger part of the analytic work than her phobia with paranoid reactions filling out the interstices of her personality.  There were problems with her children, with her husband; terrors of unknown origin which would sweep her away; car accidents in which she narrowly missed death.  There is no way to recount ten years of a psychoanalysis in this brief resume, but one important fact became evident, and that was her tenacious wish for health, her determination to learn about herself no matter what the cost. It was this aspect of her personality that helped see her through the darkest miseries of her life when no relief seemed in sight, and when she would be stunned as other parts of her personality, unknown to her, landed her in predicaments which left her humiliated and hating herself.  In time the dirtiness that was obtrusive, and on many occasions the smell of flatulence which soaked the room (for she lived almost exclusively in her bottom) also lessened and disappeared.  She had been born and reared in New York of Jewish parents, and, as one so often hears, the father was kindly, reasonable, and loving in contrast to an argumentative, never-satisfied mother.  She was the eldest of two children, her brother, Sy, being two years her junior. She did well in school but could not afford college, so her way was that of the business world.  The family moved to California where she met and married her husband, who became a very successful businessman.  The symptom which brought her to therapy was her fear of everyone, a fear so pervasive that she would spend her days peering through the curtains of her home, never showing herself.  By this time she had two children, a girl and a boy, and there were problems with them already.  She could be described as a borderline personality, or a severely obsessive-compulsive, with borderline features or a schizoid personality with depressive anxieties, depending on one’s viewpoint; any one of these could front for the thing itself.

          It was clear, after a piece of psychoanalysis, that Mrs. A. was infantile, was as ignorant about the realities of everyday life as she was about her children or her husband or about marriage, and, the key to it all, was exceedingly ignorant about herself.  The task of psychoanalysis was no less than a construction of a personality for which she had substituted a life through omnipotence. By this I mean a life of infantile helplessness when confronted with the tasks which were simply beyond her capacity. We negotiated two suicide attempts in the course of a ten-year analysis.  Never were any parameters used, nor was there any hospitalization. Psychoanalysis in its usual form was adhered to, that is, interpretation of the material, of whatever nature, even to the very end of her life. It is germane, I think, though it cannot be part of this discussion, * that the patient’s daughter committed suicide one year before Mrs. A. returned to me, thinking she was paying for the guilt over her daughter’s death by psychosomatic symptoms.

    A thorough examination of her physical symptoms revealed a carcinoma of the ovary.  Surgery was performed, and chemotherapy as well as X-ray treatments were administered.  In the course of events, she wanted to see and resume her analysis with me.  I think it to be significant that the carcinoma struck this particular system, that is, the reproductive system, because I have rarely seen a patient with Mrs. A’s intense hatred of sexual intercourse, by which I mean ultimately that of her parents.  It is also noteworthy that so central a theme should have occupied her last days, but with quite a different feeling tone.

          If I am correct in believing as I do, and as I suggested to Mrs. A in the second session, that she remembered with a part of herself – a fetal self – the sexual coupling of her parents and was terrified by the muffled noises, it is significant, then, that “sexual nightmares” (see below) – preoccupied her all her life until her death.  I do not believe this to be a phantasy, that is, an event merely mental and/or imagined, but a reminiscence of a real event. 

          This complex of feelings was the central fact of her personality, and, though greatly attenuated by the psychoanalysis so as to enable her to live a more than tolerable life, never was forgotten.

          In the closing phase of the analysis, it was apparent to her, and she commented on it, that her marriage had become much happier, and she and her husband were able to take vacations together, away from home for the first time.  Her attitude to her mother had changed; by this time her father had died, and she was able to help her mother, in whatever way she could.  She had become an outgoing woman, active in many areas, in civic and community affairs, in politics, and participated here at the local level in the part of her choice.  She painted, played tennis.  She had many friends, both male and female, and we both thought that the analysis had been sufficient and that terminating it was the right thing.

          What follows is a transcript, reconstructed out of my notes, of several sessions with Mrs. A. a few years ago, during the last days of her life.

Transcript of Sessions with a Dying Patient in Analysis: 
First Session*

          MRS. A: Something is strange.  I think I am dying.  They keep saying I’m courageous, I’m brave, but it’s not me. I’m not.  I know it’s not me.  The doctors and nurses at the hospital would say that.  But I’m a coward.

ANALYST:  It seems to be important to have people confirm what one feels one is.

          MRS. A: I sweat.  The nurse wraps me in towels.  It’s awful.  I remember what my mother used to say, that if you sweat, you’ll catch cold, if your resistance is low, and die.  And I seem to sweat a lot now.  I get insulin.  They test my urine.  But I am afraid.  It seem to be in a different world from everyone else.  It’s as if I’ve let go.  There’s a feeling of a plate glass between them and me.  I’d like to hold on to that picture they have of me, but it’s not me.

          ANALYST:  The fear is, if you let go – who are you and what are you?  It is as if you were the infant who didn’t know.  In addition, what you always feared has come true – that mother was right.  You have caught that kind of cold so there seems to be a very punitive mother and a very guilty you.

          MRS. A: I used to read, watch TV.  But I don’t anymore.  I lost all interest.  I’d see a little boy fall or a man about to get hurt on TV and I’d feel it as if it were happening to me.

          ANALYST:  You feel as if you put yourself into them and could feel them, be them.

          MRS. A: My mother was supposed to come Friday. She hasn’t seen me in two months, but I was sweating so I called and told Sy I just couldn’t see her.  What shall I say – that I’ve got cancer?  My mother used to have pains.  She used to tell me all about her pains.  Now it’s as though I’ve got them.

          ANALYST:   You feel as if you’ve put your pains into your mother, as if you were the infant with all those pains, trying to get rid of them.  You felt responsible for your mother’s pains and now they’ve been returned to you.

          MRS. A: Jean and Kay (her friends) came over and cooked some soup.  But I can’t eat anything or drink anything.  They also made some rice.  It smelled so good that I wanted some, so I took a bit – but it hurt me.

          ANALYST:  You felt the food was taken in and caused you pain – like mother’s pain caused pain – and any food would be painful to take in.  This would make physical pain worse.

          MRS. A: Oh, I’ve forgotten what it was.  A couple of months ago – my mind – I tried to hold on to my mind – I felt I couldn’t….

          ANALYST:  It’s paradoxical to say, “to hold on to one’s mind”.  What does that really mean: as if the mind were some material, substantial thing one could actually hold.

          MRS. A: I mean my sense of reality.

          ANALYST:  Ah, then the mind – whatever it was – would be important, as important as infancy, and then there would be great difficulty, for you’d not have had much experience with your sense of reality then.

          MRS. A: My eyes hurt, maybe it’s the light – my left one more than the right.  I don’t know.

          ANALYST:  That’s a way of saying your “I’s” hurt, as if you were the infant just bringing these things into you – the things of external reality and internal – and they were painful.

          MRS. A: I’m not brave.  Instead I’m a coward – I do what I have to that’s all. I’ve no choice.

          ANALYST:  Perhaps that’s what courage is, after all; being a human being who does what she has to.

          MRS. A: I feel I’m being pushed into a corner – with no chance of escape.  At least if one’s in jail there’s always a chance of pardon.  But I feel more and more pushed into a corner.  Dr. A came and removed fluid from my chest – 1400cc. It felt as if my chest were being crushed.

          ANALYST:  That’s strange, isn’t it, when in reality there might be a feeling of more room in the chest. 

          MRS. A: I know, but yet somehow I feel it’s the other way around.  But today I don’t have that feeling, of being crushed.

          These last two weeks in hospital have been strange. I keep thinking and dreaming of life, death, babies, and I keep being afraid.

          ANALYST:  Perhaps that’s what babies keep thinking of, in their way: of life or death, of how to survive, and being and feeling afraid, unlike all those stories of how much paradise infancy or childhood is!  It fits in with your lack of interest in the things of the world, like playing Scrabble or watching TV or reading.  There’s all the work of coping with life or death.  Others may fool themselves.  But you’ve had enough analysis to feel how difficult it is to do that to yourself now.

          MRS. A: (nods)  No, I don’t fool myself.  I can bear the pain of fluid drained out of my chest.

          ANALYST:  That’s bearable – it’s finite.  But to bear the chronic mental pain of dying every day – to tolerate it – that too is part of the courage of everyday living for you even though, as you say, you have no choice.  And to do it without screaming and yelling – like the nurses say other patients often do.

          MRS. A: I used to talk to myself.  As if I were the observer in my dream.  And when I’d open my eyes the nurse would laugh or Tom (her husband) would laugh.  I’d be saying-“Take care of the Baby”.

          ANALYST:  It’s as if you were both the adult and the baby at the same time.  Now you can say it but then you might only have been able to cry.  As a baby you would have been hoping mother would understand what you meant.

          MRS. A: All I thought about or dreamt about was life – death – babies.

          ANALYST:  In the beginning that must be what one feels about. Perhaps in the end too; what to choose, except there is no choice now….

          Would you like to talk again with me?

          MRS. A:  Yes, I would, unless something comes up.  (We both knew she meant death)

 Second Session

           MRS. A:  (in a very low voice) Well, the week hasn’t been a bad one physically.  I’m pleased with the progress I’ve made.  They removed the subclavian I.V.  But I feel like I’m in two worlds.  I speak as if I were in a little room and no one hears me and the sounds are muffled and no one can answer me.

          ANALYST:  I would agree that you’re in two worlds.  One is the world of reality, that you’re in right now as I talk to you; the other is the world of the womb in which you are remembering your parent’s intercourse.

          MRS. A: And I am full of fears.  I had sexual nightmares during the week.

          ANALYST:  What do you recall of them?

          MRS. A: They were all along the same line – In this one:  Dr. Jones and his wife said I had to urinate before one.  I woke up terrified.

          ANALYST:  Of whom or of what are you afraid?

          MRS. A: I’m afraid of nausea.  I had several attacks yesterday.  They come on suddenly, there’s no way to know when or why. They’re “dry heaves” and they are so painful.  I had several during the week as well.

          ANALYST:  Who is Dr. Jones?

          MRS. A: I have no idea.

          ANALYST:  It would seem that one point is not so much the command to urinate, but I feel it has to do with a time of your life when you couldn’t control your bladder, and you had terrible anxiety about your excretory habits.  After all, nausea is or may be a prelude to vomiting – as if to get rid of something…obviously food, whatever else food might stand for.

          MRS. A: I was able to urinate by myself yesterday.  I’m very pleased with my progress – I could drink the tea – (she sips).  I have to let it flow down so slowly or else I can pay for it for twenty minutes with pain.

          ANALYST:  It seems as if the dream contained a punishment.  If you did wet – then the punishment would be nausea or ultimately – no food – if one follows out the train of thought. 

          MRS.A: I wish I could remember what you said and think about it.

          ANALYST:  What need is there of that?  Unless you didn’t understand what I said at the time.  It would be like bringing up old digested food already used up – to redigest when all the food value was gone already.

          MRS.A: No, I did understand what you said when you were saying it, but my mind slips.  I can’t read or concentrate and I can’t hold onto things…..My mother came – finally.  Chris told her on the way about the cancer – so that was a relief.  Mom stared at me, then sat and held my hand – kissed it – kept kissing it.

          ANALYST:  Like a mother would a baby.

          MRS. A: She didn’t make any fuss, she didn’t cry, she just sat there quietly the whole time.

          ANALYST:  You have just painted for me a picture of your mother we never saw in the whole of your analysis, quietly kissing away your pain. (Patient cried. Analyst waited, then continued) When were you nauseous?

          MRS. A: Well, I couldn’t see Mom Friday last. I got too sick and had to cancel.

          ANALYST:  It was as if there was something you wished to get rid of and couldn’t.  Something you didn’t want mother to know or to burden her with.  Of course, I am not denying the tube in your nose or the illness itself, but I do want to call attention to these other reasons which I feel are so important in helping us understand the psychological contribution to your nausea.

          MRS. A: And there is always this feeling of no control, of not knowing when I am going to get this way and feeling utterly helpless about that state.  When I get up I want to push away the nurse.  I want to do it by myself.

          ANALYST:  Well, we know from the past analysis how you feared helplessness and vulnerability – and yet what would a child do?  An infant?

          MRS. A: It must be awful…I watch Tom eat Chinese food, or I see someone eting on TV.  I’m afraid of it and yet I want it so much.

          ANALYST:  This reminds you of the time you’d watch Sy at mother’s breast – and lose control, as you once, more than once, told me, of how you ran up and began to hit Sy at that time.  By the time you’d get through hitting Sy, not only would he be feared, but the milk – the first food you ever had – as well as its container would be feared; and yet at the same time wanted.

          I think we can link the dream to the loss of control of your bad urine with which you attacked the mother and your feeling that the breast was taken away from you because of it, about which there was so much in the analysis (She had had to be suddenly weaned at the age of three weeks when her mother developed an abscess.)

          MRS.A: You’re right. I did feel it like that. These dreams I had were nightmares…I wish I could eat.  If I don’t make it I’ll be sent back to the hospital.

          ANALYST:  Even this you feel would be a punishment – like the time you and Sy were sent to a home so as to gain weight.  You felt it was a punishment even though you felt you went along to help and be with Sy. It’s obvious it would be felt again today as a punishment.

          MRS.A: If this is like infancy, I can’t tell you how horrible it must have been to be perfectly still-full of fear physically, and mentally afraid to make a move for fear something terrible will happen- there is no way for me to be free enough to use anything.

          ANALYST:  I do feel this is as close as one can actually get to knowing something about these states of mind now forgotten.  There are two things we ought to notice about your last remark: (1) it illustrates that mother had become a thing; you said “anything” and (2) she wasn’t able to contain your pain, physical or mental.  And you had to lie perfectly still because you couldn’t contain your pain and indeed were terrified by any hint of it.

          MRS. A: I look at myself in the mirror and Harry (her son), when he saw my hair fallen out was shocked.  I was shocked, too, when I saw myself in the mirror, but I can’t deny it – that’s me – I can’t run away from it.

          ANALYST:  I’m reminded of how you earlier tried to run away from your personality as we discovered before in your analysis.  How you tried to run away from what you thought to be monstrous in it, which seems today to be something like a terrible punitive part if you don’t do something-physically control yourself.  Or aren’t you really talking about mental control:  controlling your feelings which were ones of rage at the situation of helplessness when Sy came along, and at the parental sex that made you both.

          But there is no running away from these monstrous feelings – or from your personality – instead, to be aware of it will help you cope not only with it but with your external world as well.

          The fact of the matter is that today you can contain your personality such as it is and do take responsibility for it.

 Third Session

                    MRS.A: (She spoke at length of her physical state)  I just woke up at nine to get ready for you.  (She was being a bit more sedated)  I’m getting Compazine every three hours so I don’t have any nausea but I’m so sleepy. I tried to read by everything is so full of murder and bad things that I’m beginning to read The Time Machine which is trashy, but the other books upset me too much.  I tried to think of what we talked about last week, but it was hard to recall.

          My mother came Tuesday, with Sy. (This was related with a smile)

          ANALYST:  Why are you smiling?

          MRS. A: I don’t know why….my mother worries me. She’s going to be a problem.  She comes and looks at me and says, “You don’t look better.  Your throat is sore, why don’t you gargle?  What’s to become of you?”  Anyway, I was so bad that even though mother wasn’t here for very long I asked Sy to take her home.  I feel sorry for Sy because he wanted to stay. Tom’s mother stayed and watched TV with him until quite late.

          ANALYST:  I wonder if you smiled just before in irony, was it a wry smile?  Because this is not the kind of mother who helps, the one that was here the other day, but one who hinders.  It’s like the books, full of murders.  But I was thinking: The Time Machine was your body, which you’re reading, which you now feel is trashy.

          MRS. A: I was so worried last week, I was so grateful that you’d talked to me.  I felt you saved me.  I could hear the nurses talking and I was afraid they’d both leave.  I could only hear the murmur of the voices.  It was holiday and I thought both would not be available – and it was frightening.

          ANALYST:  It was comparable to being the infant, feeling the mother would go away.  Who then would look after you?  Or it is even more primitive: the two breasts (the nurses). According to what we know, you did lose the breasts when you were three weeks old due to mother’s infection.  The anxiety could be that of dying.

          MRS.A: I can understand that.  It was terrible-terrible enough to feel these things today.  I must make peace with my stomach, but how?

          ANALYST:  It is as though the stomach were the heart of you and you have to find out how to make peace with it – it’s as if it got a bad meal, and were in pain, trying to reject the bad meal.  If the meal were good, then there’d be no problem.  This is in addition to the physical problem today, which I don’t want to deny, the actual chemotherapy and its effect on the body, which is real enough.

          MRS.A: I just got another injection on Tuesday – a chemotherapy injection.  Tuesday was the day mother came, too; Tuesday, New Year’s Eve.

          ANALYST:  All came together then, Life and Death.

          MRS.A: I just got a picture in my mind of my mother: a long needle, standing up – with a huge eye.

          ANALYST:  You feel your mother comes and needles you instead of being a mother who can take away your hurts and pains, a mother who gives you bad milk, to put it in primitive terms.  And I am felt to be a long needle, as well.

          MRS.A: My mother has big eyes – you know, seeing everything.

          ANALYST:  Indeed you are also putting forward that these big eyes (I’s) are capable of not only taking in a great deal but also of pushing out a great deal, pushing it into you. And it’s very painful.  And my big eyes, seeing everything, reflecting everything – also pain you greatly.

          MRS.A: There’s nothing I can do about my mother.  She won’t change.

          ANALYST:  I agree. But you have changed.  There’s a great difference between the way you were as an infant – so helpless, and yourself today with all your knowledge. And this may enable you to cope with your condition such as it is today.

          Indeed it is as if Sy, your brother, neutralizes your mother.  The problem is how to get more of Sy, figuratively speaking, and less of that mother- more good, less pain.

          To sum it up, considering the totality of your feeling, I think there is a positive aspect as well in this discussion.  Not only is this needle and eye a part of mother or myself or yourself – but it should be understood to be able to see everything wrong and to sew up the cares of the body and of the spirit.  I want to remind you of the mother who, learning of her daughter’s impending death – sat quietly, held and kissed her hand.

          MRS. A: Well, I know our time is up now, Do I need to call?  Will you come?

          ANALYST:  I’ll come next week.  There is no need to call.

Conclusion

 Mrs. A died several days after her last session with me.  She had been calm in the final days of her life, according to her husband. She had, on the day of her death, expressed interest in his work.  As they conversed, her blood pressure suddenly fell, she felt weak, and asked her husband to get the doctor.  Then she died.

           The following material transcribed here in a somewhat compressed form from my notes, relates to the dream Mrs. A. earlier reported. This dream was highly condensed and offered myriad threads to be sorted out for interpretation.  I ultimately came to view the latent content in these ways:

          (1) the command to urinate could be taken literally in terms of an evacuation which would be essential in ridding her of her dying as well as her destructive parts.

          (2) The patient’s mother had prided herself on the fact that her daughter was toilet-trained, bowel and bladder, before the age of one.  This clearly ties in the peculiar formation: “Dr. Jones and his wife ordered me to urinate before one.”  In reality, the patient had had to control her excretory functions before one year of age; in the dream she had to be able to let go. The reversal thus operated would create anxiety, for to urinate as commanded would doubtless arouse Mother’s anger.  The reversal affects, too, the major figures, Dr. Jones and his wife, who no doubt represent the analyst, that very analyst who had “saved” the patient’s life precisely by allowing her to rid herself of her destructive parts in the analysis. The relief the patient had felt when she understood that the analyst could contain the bad things she projected into him is transformed in the dream into anxiety.  The good analyst has become the persecutor, forcing her to risk angering her mother by urinating.

           The peculiar formulation “before one” raises the questions: can this “one” also be viewed as the equivalent of “one of us” since the command is given by the couple, Dr. Jones and his wife?  Or does the “one” suggest copulating, sexual couple, i.e., “You must urinate before our couple (- one)”?  The parental couple’s intercourse, having aroused such terrible feelings in the patient, her anxieties with respect to urinating in this dream can perhaps be better understood if we follow this train.  To urinate is to destroy the parental intercourse. The damaged parental couple become persecuting objects taken into the patient’s personality and she must get rid of these objects somehow.  The very course of action she undertakes to save her life – getting rid of her destructive parts – is precisely that which threatens the parental intercourse.  She must harm her good objects to disembarrass herself of her bad ones, hence the terrible anxiety she associates with this dream, which she refers to as “a sexual nightmare”, one of many she claimed to have had around the same time.

           (3) The association to the “dry heaves”:  these must be viewed as her valiant attempts now to get rid of her bad urine so as not to harm the parents.  Yet the “dry heaves” also indicate her incapacity to project the dreaded substances (feelings) and persecutory objects out of herself.  On perceiving the parental couple, who are capable of a sexual life, in the dream she responds with urinary soiling, but she also wants to evacuate this bad part of herself and cannot, just as the infant cannot stop his own phantasies.  She knows she herself will be hurt by it if she can’t somehow get rid of this bad urine: she will then have the damaged parents within her. It is not a person she fears but feelings.  The “dry heaves” can easily be imagined to have a sexual meaning as well.

           (4) A literal interpretation of “before one”, taken again to mean “before one year old”, might allow us to view the patient’s terror in relation to this dream as the terror connected with the task before her; how to be “trained”, how to control herself in a given, limited period of time – i.e., the time remaining in her life.

           (5) Dying is felt to be a humiliation and a punishment. If the patient identifies with the parents, she fears she must suffer their fate, which is to be subjected to her burning attacks on them.

           (6) The exhibitionism contained in this highly condensed manifest content of the dream can be linked specifically to the anxiety experienced by the patient in the early and middle phases of the analysis during which time she lived an extremely private, almost secretive life, including, naturally, its infantile components.

           I was privileged, in the treatment of this patient, to reflect on the significance of the material she provided, exclusive of its use in the therapy.  Though the content ultimately differed little from what one hears in other analyses, its intensity, to the analyst, is immeasurably greater.  With a patient confronting imminent death, it is really only the analyst who must defend himself against that fact.  Re-reading these transcripts today I am aware of the insufficiency of my interpretations on some issues, a fact which I attribute at least in part to the impact of the situation upon me.  Yet the sessions do, I feel, give us an idea as to what a dying person is occupied with, as novelists and poets have tried to render imaginatively.

           The study of dying is an attempt to give meaning to death as it is an attempt to give meaning to life.  We are creatures who, consciously or not, insist upon such meaning. If history is, as it has been called, “an illustrious war against death”, what more noble undertaking can there be than to investigate a personal history even if that one, under our tremulous glance, is already at an end?  If the dying person seeks to know, who then may cavil at such a request by thinking “of what use is it”?  As psychoanalysts we do not question what use a person makes of his death.  The choice we have with the dying is the same as that we have with the living, prospective patient: we can refuse to participate in the analysis.  In this we do not treat a body or a soul alone, but a whole life.

           The dying patient gives us anew the gift of solitude. We as analysts can only give back to each analysand his life.  His living and his dying must be centered in himself.

           Psychoanalysis must be the fusing of two solitudes: the analysand must be able to be centered into himself so that he can be fused into the solitude and authenticity of the analyst, but only for the duration of the analysis.  Afterwards, the solitudes must again be separate.  Man in a group, paying heed to the group alone, is no better than an animal ceaselessly surveying its environment, unable to withdraw to contemplate his life.

           As analysts we are privileged to come constantly into intimate contact with a segment, however short, of human life.  We can reconstruct the beginning and childhood, and with luck we may be there at the very end of the patient’s life.  How, it may be asked, can we truly understand a life unless we can see it and be in it at the very end?  Just as one age cannot be adequately understood unless we know and understand the previous one, a life cannot be understood unless we know it in its entirety.  And here we are just beginning.

* A minute examination of analytical material might well help the physician in ascertaining those emotional assaults which cannot be contained mentally, thus breaching the mind, attacking the body and destroying it.
* A paper reporting on this phenomena is in progress.

Copyright © Bernard W. Bail, M.D. 2005
August 1977
(WB2005)

 References:
Eissler, K (1955). The Psychiatrist and the Dying Patient, New York: Int. Univ. Press.
Joseph, F (1962).  Transference and Counter-transference in the case of a dying patient, Psycholanalysis and the Psychoanalytic Review, 49, 21-34.
Norton, J (1963), Treatment of a dying patient, Psychoanal. Study Child 18, 541-560
Rose, L.G. (1969) The Dying Patient, Int. J. Psycho-Anal., 50,385-395
Young. W.H. (1960) Death of a patient during psychotherapy, Psychiatry, 23, 103-108