Psychoanalytic understanding of the request for assisted suicide.

The legalisation of assisted dying, including euthanasia and physician assisted suicide, is increasing in countries across the world and constitutes a key contemporary debate, reflecting social changes, in which two views of suicide conflict; that (1) rational reasons justify assisted suicide, providing dignity and control of terminal illness and (2) suicidal wishes are driven by unconscious and disturbing internal conflicts. In this paper we explore the unconscious motives and meanings of requests for assisted suicide. Although there is a paucity of psychoanalytic literature on the subject, and an absence of practice examples, we make two links, firstly, with the literature of palliative and end of life care, and, secondly, with psychoanalytic understanding of suicide, in order to develop the view that unconscious factors are crucial to understanding requests for assisted suicide. We provide an illustrative case example of psychodynamic psychotherapy with a 94-year-old woman, drawing out theoretical and practice implications. We show that unconscious factors and motives lie behind apparently rational requests for assisted suicide, and attention to these through psychoanalytically informed treatment can bring about therapeutic change.

Narcissistic mortification of ageing men.

The development of a male gender identity involves the task of relinquishing the identification with the female primary object. If this separation is experienced as loss or expulsion, and responded to by the development and libidinous cathexis of phallic-narcissistic characteristics, a specifically male narcissistic vulnerability emerges, which can, particularly in ageing men, escalate to critical proportions. However, phallic-narcissistic crises in the ageing process also contain opportunities for development, provided the losses of age can be faced with mourning. The author sets out the statements on the subject of old age in the myth of Narcissus and makes use of the concepts of developmental psychology. He outlines clinical examples illustrating this problem. Finally, he brings to mind the narcissistic plight of the aged Oedipus.

Permeability and demarcation in the psychoanalytic process. Functions of the contact-barrier.

Introjection, identification and projection are concepts that designate processes in which something is being put into or taken out of something else. These processes presuppose the overcoming of some form of separation between two entities. The permeability or impermeability of a fictive boundary between the representations of subject and object set the emotional tone of their coexistence. There are moments of complete diffusion, in which subject and object can no longer be differentiated, and moments of autistic enclosure in which the individual can no longer be reached at all. Permeability and demarcation result from the processing of stimuli carried out by the 'contact-barrier', as an ego function. Stimuli of internal, libidinal or aggressive origin, as well as 'impressions' of external origin, are classified and processed with the aid of various kinds of factors arising from coagulated object-relational experiences. Whereas for Freud the contact-barrier regulates the quantity of energy and found a topographical structure, Bion understands the contact-barrier as a psychic function that simultaneously regulates boundary demarcation and making contact. In the psychoanalytic process, the contact-barrier created by patient and analyst regulates the events in the transference and countertransference. An awareness of the struggle for contact and demarcation at the dynamic boundary representations that are constantly being recreated by both partners in the analytic process may be helpful in our clinical work. The author presents an examination of the ways in which patient and analyst make contact and demarcate the boundaries, which provides a better understanding of the dynamics of transference processes. He demonstrates this in relation to clinical material.

[The nursing relationship--psychodynamic aspects]. / Die Pflegebeziehung--Psychodynamische Uberlegungen.

The relationship between nurses and their patients is influenced by subtle and often unconscious emotions which influence proper nursing. In this paper psychological concepts of development from psychoanalysis, baby-watching and attachment theory are enlisted to understand more deeply emotional situations in nursing relationships. After considering anthropological basics of nursing relations with the elderly and the mutual dependency of nursing and nursed persons are discussed. The limits of comparison between early childhood nursing and professional nursing relationships are mentioned at the end.

"Without being in psychoanalysis I would never have dared to become pregnant": psychoanalytical observations in a multidisciplinary study concerning a woman undergoing prenatal diagnostics.

As is well known, Freud described the clinical practice of psychoanalysis as the 'loam' of his cultural-theoretical work, an assessment which is shared by many psychoanalysts up to the present, including the authors of this paper. The complex interplay between unconscious phantasies on the one hand, and the real experiences arising from the new possibilities opened up by prenatal diagnostics on the other, is described with reference to a report of an intensive, long psychoanalysis with an analysand from a family burdened with a genetically transmitted illness (haemophilia). The holding and containing function of the analyst enabled this analysand, despite traumatic experiences with the miscarriage of a healthy child triggered by a prenatal diagnosis and the later abortion of a haemophiliac baby, nevertheless to have the courage to go through another pregnancy and give birth to a healthy girl. The intensive clinical investigation of the unconscious phantasies, conflicts and traumas around the prenatal diagnostics proved to be not only therapeutically fruitful for the analysand, Ms F. It also facilitated insights into those individual chances and risks which appear to be an integral part of the opportunities presented by todays prenatal diagnostics and, through them, it lead to a cultural-critical look at the ambivalence of medical-technical progress. These insights, which are only attainable through psychoanalysis, can represent a distinctive contribution of psychoanalysis to a multi-disciplinary dialogue with medical practitioners, geneticists, ethicists and health policy-makers. By referring to a large EU study on 'Ethical Dilemmas due to Prenatal and Genetic Diagnostics', this paper gives a practical example of such a discussion. Ms F. was psychoanalytically interviewed as part of this study, 16 years after the conclusion of her analysis. The summary of these interviews, which is set against the account of the treatment, offers an impressive insight not only into the long-term effects of a psychoanalysis under very particular personal circumstances, but also into the lasting consequences of decisions made in the context of prenatal diagnostics. Finally, the results of the individual case study are brought together with the clinical outcomes of the EU study, and some considerations are formulated concerning the protective and risk factors facing women during and after prenatal diagnostics. The paper is an appeal to psychoanalysts, with their specific competence in dealing with unconscious phantasies and conflicts and their high level of professionalism in dealing with traumatised patients, to get involved in fresh dialogue with prenatal diagnosticians and their patients.