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Psych - e - News
An Online Magazine from the
New York State Psychological
Association
Division of Psychoanalysis
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Beyond the Medical
Encounter
The
life of a patient isn't easy. First, there is the diagnosis--swine flu, cancer,
diabetes--words that elicit fantasies of what is in store for us, a mix of what
we know, what we think we know, what we fear. Then comes the treatment. More
anxiety. "Do I do something or just wait it out? Will my body be
invaded--medicine, shots, surgery? Or will it be held and nurtured--bedrest,
tea, plenty of sleep? Finally, the prognosis. Will I be cured? Will I die? Will
I suffer like this forever?"
Inhabiting a failing body stirs up
frightening feelings, including some we may not be aware of. We all use
psychological defenses to protect us from experiencing too many bad feelings.
But those that are outside of our awareness and remain vague or unconscious can
result in confusion and misunderstandings for the sick person and for those
around her.
Just being a survivor of a medical
crisis can cause painful or confusing feelings as we attempt to cope with the
ways we and our lives have changed. The
following articles describe three different lives that continue beyond the
medical encounter and illustrate some of the unexpected feelings that can
ensue. The first article paints a portrait of the inner life of a patient
post-surgery. It directly addresses the question, "What next?" and some
unanticipated reactions to being cured. In the second article, medical
intervention in the form of Assisted Reproductive Technology (ART) gives the
gift of life to a new generation. One mother, a psychoanalyst who conceived in
this way, addresses the feelings behind the question, "I have a real baby, but
am I really like other parents?" Finally, medical conditions have an impact on
loved ones, often in complex and bewildering ways. The third article tells a
real-life story of the effect on one little girl when her mother develops
problems the daughter cannot understand.
Maureen O'Reilly-Landry,
PhD
Ellen Luborsky, PhD
Issue Editors
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After Cancer Treatment: A Time of Questions
"What now?" This question, familiar to me
as a psychoanalyst specializing in medical conditions, has no simple
answer. It comes from my patient, a
young, single woman in her 20's. We are
trekking in the emotional terrain of post-trauma: She has just recently
completed her treatment for ovarian cancer.
It is a critical time. In fact, some might argue that the period
following recovery from a serious illness can be just as traumatic as
the acute
phases (diagnosis and treatment), although there's much less attention
paid and
certainly less activity. And while everyone's experience is different,
my patient's confusion today is expected. She seeks psychoanalytic
psychotherapy to
ease the dramatic shift from patient in the "world-of-sickness" to
person in
the "world-of-health." As with most cancer survivors she has a lot on
her mind.
"It all happened so suddenly," she
says.
First, there was the diagnosis. Then, surgery to remove her ovaries,
uterus and
fallopian tubes. Finally, the grueling treatment: chemo, radiation.
She's
endured searing pain, the loss of her silky dark hair, and drowning
fatigue,
among other indignities. She's been forced to make choices about what
would be done to her body, decisions she felt ill-equipped to make.
Many rallied around her. But others disappeared -- perhaps because they
could not tolerate seeing
her pain or perhaps because they imagined themselves in her shoes.
Her concept of time was skewed. "Mostly everything moved too swiftly, and yet
there were days when time passed at a snail's pace and waiting seemed
unbearable. I didn't have the luxury of
mourning then: My attention was poised on fighting for my life. I had no time to consider what any of this
meant in the moment or what it might mean to me in the future."
The question "What now?", then, is her
poignant commentary on how drastically life has changed and how she will make the transition from the cancer
ordeal to a semblance of her previous life. Now, mourning is on the
agenda. It's time to reflect on what
she's lost and time to salvage those things she put on hold. It's time to reconnect to her past with all
its daily, often mundane, challenges, and time to create a new future -- a
future that includes her experience with a life-threatening disease. Perhaps it's time to create new dreams,
strive for new goals she could not have imagined before her cancer. She wonders, what will her altered life and
"new self" look like?
It looks bewildering. When treatment ends, uncertainty, depression
and anxiety are not uncommon. So are loneliness -- and conflict.
"Everyone's thrilled to have me back," my
patient said in a recent session. "They're happy to be past the crisis.
And, of course, I'm happy too, but . . . there are so many ways I'm
not. I can't shake the memories. My
family and friends seem to think it's all over, or maybe they want it
to
be. I know it isn't. I can't go back, not now, not ever. Worst of all,
I can't really share it -- it
was so surreal. One minute I'm sad, next
I'm angry, then ashamed to be so ungrateful. I'm all over the place."
She tells me she's terrified of her
hard-won survivorship. Will she have the
stamina to keep up with her young friends? How does she explain her early menopause -- the hot flashes, the
irritability -- to peers? Will anyone be
interested in her as a sexual partner again? How does she cope with her infertility?
Will she be able to fully separate from her parents who took such good
care of her when she was sick? How does
she let go of fears of the cancer's return? What does she do with the alarming specter of her own mortality?
Slogging through this thicket, my patient and I explore her fears and
her feelings. They are expected. She is simply working through the
challenging process of mourning and transition. Yet, we acknowledge
that the going is tough. Cancer and its aftermath present
obstacles that no one should have to hurdle, especially at this age. We
have work to do.
On the practical side, I buttress my patient with tools: referral to a
support group of other young women who have battled ovarian cancer and
who are now on the "other side"; strategies -- journaling, meditation,
gentle yoga -- to help her process her experience, to
relax in the face of it, to reconnect with her body; exercises for
enhancing
memory clouded by the dreaded "chemo brain"; "role plays" that sharpen
her
skills for interacting with peers, family, work colleagues and the
medical professionals
she still visits as an out-patient.
Then, through the introspection of psychoanalysis, we use my patient's
dreams, reveries and reflections to restore balance as she swims deep
inside her life, before and "after." Together, we explore the betrayal
and invasion of her body; the loss of her once-innocent vitality; her
new, perplexing identity as a "cancer survivor"; her confrontation with
death; and,
now, her meeting with an utterly transformed life.
There is no easy path through this maze of recovery. Still, much can be
gained. Before long, like so many other survivors unraveling their
cancer trauma, she finds herself welcoming special pleasures, things
once taken for granted. She begins to write a new whole-life narrative,
one where cancer is just one of many chapters.
And while we have no simple answer to the "What now?" question, we
respect time. My patient feels lucky to have survived, and she uses
this time to understand what
she could not when she was so very ill. She goes on with her life and,
as she does, she continues to mine her cancer experience and find new
ways of understanding and being.
Ruth H. Livingston, PhD
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Life After Assisted Conception (ART)
Carly told me that she
felt she was the only mother on the playground with her secret. She had
been
hiding from the other mothers the fact that her own twin boys had not
been
conceived in "the normal way" because she feared rejection by "the
motherhood
club." Carly was so preoccupied by enormous self-consciousness and
sadness that
she hadn't noticed the other women in her neighborhood who had also
needed
infertility treatment. As she and I began talking about this, we came
to see times in her past that she had felt different from others. Those
earlier experiences had laid the ground for feeling so powerfully
isolated now. The deeper understanding of this aspect of herself helped
to reduce her self-consciousness, and her mood lightened. It gave her
room to consider the way she, and not "the motherhood club,"
experiences being a mother.
The psychological impact of infertility can last a long time, even
after the birth of a much-wanted child. The discovery and treatment of
infertility can strain coping mechanisms, leaving even the most
confident individual surprised by a profound sense of
inadequacy and failure. When the treatment is successful and a child is
born, the pain of trying to have a baby can now subside. But its
toll--feeling powerless, alienated from peers, and battered by the
losses--may linger. In the support groups I have run in my office for
parents who created their families with Assisted Reproductive
Technology (ART), men and women talk about unresolved feelings: the
unfairness of medical conditions, the mystery of
infertility, and regrets for waiting to have children.
Guilt, self-criticism, anger and despair related to infertility can be
confusing and disruptive,
particularly when projected onto others. Some parents worry, for
example, that their child will be stigmatized and not accepted as a
"real" part of their extended family or socially ostracized at school.
I help them to see that their own unresolved feelings are the source of
these worries. In order to move on, they must acknowledge and accept
these feelings, and let go of the idea of conception as they thought it
"should be."
Assisted conception represents a "final frontier" in social and
scientific terms. Parents using it today are adventuring into unknown
terrain and can feel lost and alone.
Although thousands of children are born through ART every year,
assisted conception often remains hidden.
Conception occurring outside of the womb is commonly referred to as
In Vitro Fertilization (IVF). IVF may use the parents' own ovum and
sperm to conceive, or one or both can come from a donor, with the
possible addition of a surrogate mother to carry the embryo as it
develops. Gamete (ovum or sperm) donation is a complicated and
sensitive
psychological experience for both men and women. For example, a woman
must accept both the loss of a genetic connection to her child and the
addition of an ovum
from another woman. This mental adjustment strains her sense of self,
identity,
and physical integrity. Each of these areas is vulnerable to the
influence of past traumas, and the legacy of the woman's own early
family experiences. For men, the need for a sperm donor may be equated
with inadequate masculinity and provoke a similar crisis. Some women
feel the most discomfort as they search for a donor like themselves,
reflecting a desire for sameness that may be impossible to satisfy; for
others, worry about the donor's otherness increases during pregnancy or
heightens post-partum depressive
feelings.
ART families are both similar to and different from families
created through adoption or sexual intercourse. I encourage couples to
define family for themselves and use this
idea to think about genetics, biology, and environment. While genes
matter, their significance is mysterious and intricately connected to
the context in which they merge. Truths arise that may seem
contradictory: Donors contribute genetic material, but they are not
parents to the child conceived with donor gametes. Healthy families
created with ART learn to balance what they know about and what they
can only guess.
When should I tell my children? What if I have very little to tell
them about the donor? Will they ask me if I'm still their mother or
father? What should I say? What will it mean to me if they want a
relationship with the donor? Most parents seek help with these
questions as their children reach preschool age. At this age, some
parents also admit to pain about feeling different from their
children--in appearance, talents, or personality. In general, men and
women are relieved to come together to talk about the simple pleasures
and complicated realities that shape their lives thanks to the
possibility of assisted reproduction.
Talking about conception with a child is also a way of talking about
sexuality, and parents may bring the same discomfort and inhibitions to
both topics when discussing them with
their child. One parent began by reading her four-year-old daughter a
storybook about ovum donation and asked me in amazement, "Is everything
okay if she doesn't ask a lot of questions?" This mother had expected
her daughter to want to know more about her
donor, but found instead that her little girl enjoyed the story and
treated it like any other book she liked: She asked to hear it over and
over again. The mother's anxiety betrayed both her wish and her fear
about talking with her daughter. Both benefited when mother was able to
consider in advance what she wanted her child to know, aware that the
two of them will say more and more over time.
Recent studies (notably the work of Susan Golombok in England) show
that families
created with donor gametes are doing well; families who disclose
information
about the use of donors may be doing even slightly better, with more
openness
and less conflict reported between teenagers and parents. In my
professional work with families created with ART, we find ways to speak
about donor gametes and the meaning of family and genetics, so that the
families created with assisted conception can accept
the ambiguities involved, and thrive.
Nancy Freeman-Carroll,
PsyD
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"Too Tired"
Chronic Fatigue in a Preschooler?
How can you tell the difference between a physical and an emotional
problem? In
a variety of illnesses the symptoms may be all too similar. If that can
be challenging
with adults, what about with a child? This story follows the trail of
discovering the meaning of chronic fatigue in a young child.
"Emmy hasn't been to school in over a month." The director of the
nursery school met me at the door. "She'd been doing great, then all of
a sudden she wanted no part of it."
I
stuffed my gloves into my pockets and unwound my scarf. The inside air
was hot compared with the February chill on the other side of the door.
Her parents were waiting for me inside.
"Emmy says she's too tired for school," her mother began. "She lies on the floor with her pillow . . . "
"But we get her to bed at night," her father pointed out.
What would make a three-year-old so tired?
They took up my unspoken question. The pediatrician had tested Emmy for
Lyme disease, mono, the works. It all came back completely normal.
"She's manipulating," he had concluded. "Put your foot down, and send her back to
school."
"I couldn't do it." Her mother shook her head.
I imagined a small child lying listless on the rug. Something was not right.
"Any changes in her life?" I wondered.
"Nothing, except . . . " She squinted. "That's over."
"What was that?"
"My legs kept wobbling whenever I started walking. Tried to go out for our anniversary . . . " She bit her lower lip.
"She ended up in the hospital . . . " Emmy's father looked at his shoes. "Multiple
Sclerosis . . . It took a week before they figured that out."
I felt my eyelashes blinking moisture away.
"When they finally let me go home, I was too tired to do anything but lie in bed. I had to
get sitters to pick her up from school and keep her busy."
"Did Emmy know what was wrong?"
"What can you say to a three-year-old? We told her Mommy hurt her legs. But I'm a lot better now. It's her I'm worried about."
I nodded, and I almost smiled. Here Emmy's mother had been diagnosed
with a disease that, as far as I knew, didn't have a cure and would
only get worse, but it was her little girl she was worried about.
Her parents agreed to bring Emmy to school the next Tuesday so that I could observe her.
That was also the day she turned four, so the lure of cupcakes got Emmy into
the classroom.
As
I opened the door, I spotted them over in the corner. Her mother was
attempting to read a magazine while Emmy stood close by. She clutched a
brown plastic horse in her fist, her green eyes wide as she stared out
at the classroom. She inched out to grab more horses, until she had her
own corner stash.
The tables were already set with small cupcakes on paper plates. The
teacher walked over to invite her to the birthday table, but Emmy clung
to her mother's sleeve.
"Go ahead," her mother encouraged. She accepted her teacher's hand. After
licking the icing off her cupcake, she retreated to her mother again.
"Have a boo-boo." She pointed to an invisible spot, mid-calf. Her
mother blew it a kiss, and Emmy returned to the table. Briefly.
After cupcakes, the other children gathered on the rug for a story, but Emmy stayed
in her corner. With a horse in each hand, she pranced them along the shelf, right behind her mother's shoulder.
As I watched her, my right calf went numb. Emmy's horses kept prancing
in duo, doing small leaps in their hiding space. That's Emmy and her
mother, I thought as I rubbed out my numb leg. They had been prancing
together until her mother got sick.
This may not count as a medical illness, but it was still very real.
Emmy was too tired and her leg hurt, just like her mommy's had. You
could call it a version of empathy. Just in case I didn't get how that
could happen, my own leg had just joined in. I tried out my tingling
foot on the floor. It was worth that strange feeling to "get the
message."
The nursery school lent us an empty classroom for our next meeting. We
needed Emmy in on this. She discovered a plastic barn in the corner of
the room, filled with pigs, sheep, and horses, and settled down to play.
Her mother and I talked about what they had been through -- the endless medical tests, the
ten-day hospital stay. "When I finally got home, she ignored me. She went off with the sitter like I wasn't even there."
Was she paying her mother back for disappearing? I tried out a
child-sized version of my thought. "When mommies go away to the
hospital, some kids get a little bit angry."
A low growl came from Emmy's corner. "A lot angry!"
"A lot angry." I stood corrected. "But they still can miss their mommies."
Emmy gave her mother a dark look, while clutching a rubber pig. Her mother gave her a smile.
If her mother understood how Emmy felt, then Emmy might not need to say
"I missed you"
through chronic fatigue. If it was okay to be angry, she could "take
the lid off" her feelings. Her symptoms were turning back into the raw
material that inspired them in the first place.
I took a look at the classroom after they left. Stray horses and pigs were strewn around
Emmy's corner. I sat down among them to restore order to the room. After putting
the animals back in their barn, I turned off the lights in the classroom, empty again.
I checked on Emmy one morning, a few weeks later. I spotted her over in
the corner, making the horses prance. Only now she was back at school,
no longer "too tired."
Ellen
Luborsky, PhD
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About our Authors
Nancy Freeman-Carroll,
PsyD, is a member of the Division of Psychoanalysis of NYSPA, and the
Education Committee of the Mental Health Professionals Group of the ASRM.
She works in private practice with adults, children, adolescents and
families in NYC, and conducts groups for families living with
assisted reproduction. She teaches courses on
psychoanalytic process, and the impact of infant research on psychoanalytic
theory and practice at several institutes of psychoanalytic training. She
is a Supervising Analyst at the William Alanson White Institute. She and her husband created a family with the help of
Assisted Reproductive Technology; they are the proud parents of twin boys.
Ruth
H. Livingston, PhD,
is
the Director of the Living with Medical Conditions Clinical Service at
the
William Alanson White Institute, where she is also a Supervisor of Psychotherapy and the
Executive Editor of the Institute's journal,
Contemporary Psychoanalysis. She holds a Certificate in Bioethics and
Medical Humanities from the Albert Einstein College of Medicine and
Cardozo Law
School/Yeshiva University. Dr. Livingston maintains a private practice
in NYC
specializing in treating persons with acute and chronic medical
conditions.
Ellen
Luborsky, PhD,
is a
clinical psychologist in private practice,
who integrates
psychoanalytic thinking with an understanding of attachment and early
development. She has been doing
consultations in early-childhood settings for over 25 years. This story is part
of a collection in process about that work. She has also written articles and
given talks on the ways play and behavior speak, including "'No Talking': The
Possibility in Play" (Journal of Clinical Psychoanalysis, 2001). With her
father Lester Luborsky, she is co-author of Research and Psychotherapy: The
Vital Link, published in 2006, and co-author of a textbook chapter on
psychoanalysis in Current Psychotherapies with Maureen O'Reilly Landry and
Jacob Arlow, published in 2010.
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Susan B. Parlow, PhD, Editor-in-Chief
Maureen O'Reilly-Landry, PhD and Ellen Luborsky, PhD, Issue Editors
Roanne Barnett,
PhD, Don Greif, PhD, Maureen O'Reilly-Landry, PhD, Janet Tintner, PsyD, Ruth Vogel, PhD, Editorial
Board
NYSPA,
Division of Psychoanalysis
With special thanks to the Psychoanalytic Society of
the Post Doctoral Program in Psychotherapy and Psychoanalysis at NYU, for
initial funding.
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