brief psychotherapy for unresolved grief - a clinical example from later life

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Brief Psychotherapy for Unresolved Grief - a Clinical Example from Later Life Joan Hunter We see which way the stream of time doth run And are enforc'd from our most quiet shore (Shakespeare) It is remarkable that more than half a century elapsed before the subject of `The ` Applicability of Psychoanalytic Treatment at an Advanced Age' raised by Abraham (1919) was re-opened by King (1974). Certainly Freud (1904, 1905) had given his reasons for considering `old people are no longer educable', but Sandler (1978) has suggested that his view was coloured by personal anxieties and preoccupations about ageing. So it seems possible that the quotation may account for the lapse of time between Abraham and King. Since King wrote `Notes on the Psychoanalysis of Older Patients' (1974) a number of analysts have found that some older people can respond to this form of treatment. Psychotherapy for those in later life is still unusual, and as far as I know it is only Bellak and Small (1978) who suggest that brief psychotherapy may be of particular use to those in later life. Brief psychotherapy has been developed by Malan (1976) and colleagues, and criteria have been worked out by extensive clinical and research experience. The two triangle technique described by Malan (1979) has been extended by Molnos (1984) and I have found it a most useful conceptual framework. I first attempted brief psychotherapy with an older patient when I worked with an aged man suffering from unresolved grief (Hunter 1981). It was this experience which led me to attempt it again with the patient who forms the subject of this paper. I shall refer to the patient as Mary. She was sixty-eight and was referred as suffering from unresolved grief. There is extensive literature on the subject of grief but it is Tyson's ( 1983) paper which is particularly relevant to my work. He draws attention to the need to understand, from a developmental perspective, the effect of object loss on the narcissistic equilibrium of the bereaved and considers omnipotence, self-constancy and self-esteem the special components of this equilibrium. The other papers of special relevance are Freud's, ` Jokes and their Relation to the Unconscious' (1905) and `Humour' (1927), and Winnicott's ` The Capacity to be Alone' (1958) and `The Use of an Object and Relating through Identification' (1971). The author is an Analytical Psychotherapist in private practice. The paper was originally written for a Conference `Reassessment of Values in Later Life' organised by the Beth Johnson Foundation in association with the Department of Adult Education, University of Keele. Address for correspondence: 25 Eton Rise, Eton College Road, London NW3 2D1. British Journal of Psychotherapy, Vol 2(3), 1986 © The Author

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Page 1: Brief Psychotherapy for Unresolved Grief - a Clinical Example from Later Life

Brief Psychotherapy for Unresolved Grief- a Clinical Example from Later Life

Joan Hunter

We see which way the stream of time doth run And areenforc'd from our most quiet shore

(Shakespeare)

It is remarkable that more than half a century elapsed before the subject of `The `Applicability of Psychoanalytic Treatment at an Advanced Age' raised by Abraham (1919)was re-opened by King (1974). Certainly Freud (1904, 1905) had given his reasons forconsidering `old people are no longer educable', but Sandler (1978) has suggested that hisview was coloured by personal anxieties and preoccupations about ageing. So it seemspossible that the quotation may account for the lapse of time between Abraham and King.

Since King wrote `Notes on the Psychoanalysis of Older Patients' (1974) a number ofanalysts have found that some older people can respond to this form of treatment.

Psychotherapy for those in later life is still unusual, and as far as I know it is only Bellakand Small (1978) who suggest that brief psychotherapy may be of particular use to those inlater life. Brief psychotherapy has been developed by Malan (1976) and colleagues, andcriteria have been worked out by extensive clinical and research experience. The twotriangle technique described by Malan (1979) has been extended by Molnos (1984) and Ihave found it a most useful conceptual framework. I first attempted brief psychotherapy withan older patient when I worked with an aged man suffering from unresolved grief (Hunter1981). It was this experience which led me to attempt it again with the patient who formsthe subject of this paper.

I shall refer to the patient as Mary. She was sixty-eight and was referred as sufferingfrom unresolved grief. There is extensive literature on the subject of grief but it is Tyson's (1983) paper which is particularly relevant to my work. He draws attention to the need tounderstand, from a developmental perspective, the effect of object loss on the narcissisticequilibrium of the bereaved and considers omnipotence, self-constancy and self-esteem thespecial components of this equilibrium. The other papers of special relevance are Freud's, `Jokes and their Relation to the Unconscious' (1905) and `Humour' (1927), and Winnicott's `The Capacity to be Alone' (1958) and `The Use of an Object and Relating throughIdentification' (1971).

The author is an Analytical Psychotherapist in private practice. The paper was originally written for aConference `Reassessment of Values in Later Life' organised by the BethJohnson Foundation in association with the Department of Adult Education, University of Keele.Address for correspondence: 25 Eton Rise, Eton College Road, London NW3 2D1.

British Journal of Psychotherapy, Vol 2(3), 1986© The Author

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The Background

Mary was referred by the social worker from Camden Old People's Welfare Association.She had been widowed eleven months previously, and had been seen by a counsellorattached to the group of general practitioners with whom both she and her late husband wereregistered, but had asked the counsellor to stop coming. She had also attended the meetingsof Cruse (the National Organization for the Widowed and their Children) over the last year.It was the frequent and sudden outbursts of weeping with which Mary was still overcomethat led the social worker to think that more help was needed.

When Mary came to see me at the end of October I was struck by the speed at which shecame along the passage to my consulting room - a small neatly-dressed woman with tintedglasses. Facts about her background gradually emerged - she spoke incessantly and weptspasmodically. She was the only child of her parents although she understood that hermother had had several miscarriages before her birth. Her father had worked with CharlieChaplin, and although he served in World War I he was discharged home after being gassedand resumed his previous employment. She remembered playing beside him with her doll'stea-set and he remarked that it was funny the tea did not come out when the cups wereturned upside down. When she was three he died suddenly in the office. After his death hermother had let the house and boarded Mary out with various aunts. But her motherconstantly quarrelled with them moving Mary on each time so that Mary was at 28 differentschools. When Mary was eleven she went into hospital for three years with chorea, andwhen she was due to be discharged her mother did not turn up to fetch her, but eventuallyone of her aunts came. She was soon to start work from this aunt's house as a trainee courtdressmaker and it was in this house that she met her first husband, Charlie, who was thegrandson of her uncle by marriage. They were married when eighteen and had eight years ofhappy married life. Charlie was in the Royal Navy and his ship went down in World War II;he was `missing presumed killed' and the Admiralty advised her to wait seven years beforemarrying again. He had always called her `little fish' whereas her second husband called her`little Mick'. She contrasted the two bereavements. `As soon as Chamberlain declared thatthere was going to be a war I knew I would lose Charlie.' She also said `Somehow it waseasier to get over - I was working and anyway I didn't feel the same about him as I did aboutTed'.

As she spoke of Ted she wept and went into a lot of detailed information so that it wasdifficult to understand the stages of his illness. It became clear however that her latehusband had become ill at the end of June and died on 11th November; it was in theSeptember before his death that she knew he was suffering from cancer from which he hadno hope of recovery. She recalled her husband saying shortly before his death `You haveknown this all the time', and she had replied affirmatively. As she wept she rememberedtheir last Christmas together and how she had remarked that it would be their last. `I wondernow if I wished him dead' she said, as if she lived in the fear of the power of her ownmagical omnipotent wishes.

She spoke a lot about her many voluntary activities and it as clear that she kept herselfvery busy. I was very impressed by the firm t kind way she had handled a very difficulthandicapped woman whom she had volunteered to take on

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holiday. In fact, despite her disturbed childhood, she showed remarkable strengths and I sawno contra-indications for brief psychotherapy. So I said that I was willing to offer treatment,but if she decided to accept she would have to set aside two days a week for coming to see meover a period of time we arranged, which would be several months. She replied 'If it's going todo me good I'm better coming here'. She explained she would need a week to rearrangethings. So we met the following week and arranged that she would come twice a week until1st March with a break from 22nd December - 5th January for the Christmas holiday.

The Phase of Confrontation

When she came for the next session she said that the thought in her mind as she entered thebuilding was 'I wonder if she'll be there for me', clarifying her need for reliability as acorrective emotional experience in the relationship. In this phase of confrontation it was myaim to enable her to experience as much of her true feelings of grief as she could bear, andour task was facilitated by the fact that the anniversary of Ted's death was approaching. 'Inever seem to have thought of that last week before' she said, and in many ways she seemedto be experiencing the symptomatology of one recently bereaved.As I sought to hold her to the expression of her true feelings the significance of Ted'srelationship to her became clearer. 'If I had committed a murder I know that Ted would neverhave left me' was said more than once. Self-constancy, a component of her narcissistic status,(Tyson 1983), had clearly been seriously undermined by Ted's death.She also said that when she was alone in the house she would hide from Ted when she heardhim coming home and would let him call 'Mick, Mick, where are you?' for a time before shecame out of her hiding-place. This behaviour suggested that she had not been able torelinquish infantile omnipotence and Ted appeared to collude with this. She also said 'I usedto feel for him in bed at night to see if he was there - I used to put out my hand and touchhim', showing her infantile insecurity. She mentioned that since childhood she hadsleepwalked saying 'They used to put a bowl of water by my bed ... Ted used just to lead meback to bed'. Presumably if she knew this they had discussed it and it seemed that Ted hadprobably helped to lessen the dissociation which Winnicott (1945) thinks is manifest insomnabulism.Throughout this period of confrontation the most regular and persistent defence wasfacetiousness. Even in talking of Ted's funeral she said 'I remember my flowers from theflorist very nearly didn't arrive, and I thought if the widow's the only one not to send flowersthat will be funny' and she laughed. She also said 'Ted always liked my laughing' and went onto mention how when he went into hospital for the last time he remarked that the hospital hadput him in the right ward 'King Edward's Ward'. She also said 'Dying on Armistice Day hemust have wanted to be remembered'.However, on the exact anniversary of Ted's death there was evidence that acceptance ofreality was beginning as well as an ability to bear intense pain. 'Well, I was expecting it to bebad and it has been, and I remember thinking I will live for a year and then I'll take my life -rather a dreadful thought, but I think now it wouldn't be right and anyway I don't know if I'dbe nearer to Ted if I did -

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because you don't know do you.' She told me she had given up ringing the bell three timeson arriving home which used to be the signal for Ted coming downstairs to meet her. Shespoke too of a friend who had spoken with her dying husband of his dying and said `I thinknow perhaps Ted and I shied away from it', and she recalled again how Ted had said near tothe moment of his death `You've known all along'. She continued to be tearful and clearly ingreat psychic pain in sessions, and when she said `There's no future now to look forward to' Ithought she was truly experiencing the reality and depth of pain of the separation from Ted.Yet defensive jokes did still occur and I drew her attention to this. She said that she hadbeen at the Day Centre the previous day and had been reprimanded by the server at lunch forpiling up the plates. She went on with a laugh `You know, I'd been quite happy and wentaway unhappy and thought about it all evening'. I put it to her that it sounded as if it was nolaughing matter, speaking to her as a parent to a child who has been the victim of injustice inthe hope of encouraging the emergence of the true feeling.

Soon after this session she began to talk of different people very rapidly withoutstopping to explain to me who they were, so that I became confused and experienced anger,which I felt in part belonged to her, and I put this to her. `Oh, yes' she said `I have to watchmy temper', and there was evidence of the emergence of anger both in this session andothers following. She spoke of Ted's first wife and of her own loss saying `I do feel bitter -why me?'. She also spoke of the irritating husband of a friend. At the beginning of Decembershe came to a session having had to leave home before the arrival of a friend, Clara, whomshe was expecting. Her anger reached the necessary climax and turned on me. I suggestedthat her true feeling was anxiety about Clara, and she kept denying this again and again.Towards the end of the session she said `I nearly forgot with you going on about Clara'. Shetold me that she had had an invitation for her birthday in midJanuary which she could notaccept unless we changed a session. She went on to explain how her last birthday had beenspent with a very provoking woman from Cruse to whom she had eventually said `You're abloody nuisance'. She went on `It was dreadful swearing like that, Miss Hunter'. I pointedout that this was her true feeling and that was what I wanted her to express here. As shewent out of the door she said `Well, if Clara isn't there when I get home, I'll feel likeknocking your block off'. Expressing anger and directing some at me had introduced a newphase in our work for the anger was presumably her reaction to abandoning resistance.

The Working- Through Phase

In the very next session she told me of a dream. `I remembered it at the time and now it'sgone - really I can only remember there was blood around and a black bear that got on top ofme.' In discussion she mentioned that her periods had not started until she was 18 and thather mother at some point earlier had asked a Matron friend to talk to her on this subject. `You will see blood one day on your knickers - it's nothing to worry about, it just means you're becoming a woman' the Matron had said. I wondered, was she becoming a woman in thetreatment situation? She recalled missing two periods but did not tell Charlie. He hadsuggested in fun having a race with her up some steps which resulted in her

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having terrible pain and haemorrhage. When they both went to the doctor they were toldthat a baby had been lost. She spoke of this carefully but without emotion. She also said thather mother had always been against her having a child as she had suffered from chorea, butthat she had had occasional intercourse with Ted although he was not much interested insex.

At this time the Christmas holiday was approaching and I asked how she felt about it.She replied crossly `Well, you need a holiday and I need a holiday'. Yet in the next sessionshe talked of her experience of separation. `It was before Christmas just about this time in1963 ... my mother went off before Christmas, she waved good-bye and she did not comeback; and the Insurance man said "You'll have to find out", and then I found out fromSomerset House that she was dead'. At this time in the treatment she told me she had newsof the sudden death of the husband of a great friend, and as she told me of this she wasclearly upset. She spoke a lot about this: she wondered why this had to happen just beforeChristmas and referred to talk of `depressing things'. I said `Perhaps you feel that here?'. Shesaid `Well, I'll be honest, I do but I agreed to come'. She spoke of questions her newly-widowed friend was being asked saying `I wouldn't like to be asked questions'. I said `Doesn't that happen here with me?' To which she replied `But you ask questions for mygood; they ask questions to satisfy their curiosity'. I experienced her still as the compliantchild having to deny feelings, although as she left that session she said `You know, when Istop coming here I'm going to have to get used to not coming here'. She bumped into one ofmy chairs as she left, knocking it over, and said `Oh dear - I'm going to take this with me'. Ithought this showed her anger about the prospective separation and her wish to comfortherself by taking something of mine with her - like a transitional object (Winnicott 1951).

In the next session, last but one before Christmas, I realised that she was planning tocome back from her holiday later than 5th January when she knew that I started work.When I pointed out that this would mean missing a session she said `Well if there's anyalteration I can let you know when I'm on holiday'. I said `I will want to know before you gowhen we are to meet again'. She then said `Would you rather I didn't come back afterThursday?'. I thought she had to reverse the transference as it was too painful for her to bethe child. So she enabled me to feel as she had as a child while she behaved as her mother. Ialso thought that she was inviting rejection so as to avoid experiencing the true feeling. Ifelt it was important to sustain her rejective or destructive attack to enable her to use me inthe Winnicott (1971) sense. Later she spoke of visiting a friend's house and being really gladto get away. I said `It would be understandable if you felt glad sometimes to get out of here'.She said 'To be quite honest I am, especially last Thursday - it was terrible that day'. Thiswas the session described in the previous paragraph.

In the last session before Christmas we had the first silence - as if the capacity to bealone might be starting (Winnicott 1958). She had come in telling me that she would be ableto keep the appointment on 5th January. Then she started talking of the school in theMidlands where Ted had been caretaker and where she had sometimes deputised for theMatron. She mentioned that if any girl told her she was not feeling well she advised her togo to bed, saying to me `You see, I did not

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know so I thought that would be safe'. I suggested this playing for safety was like her motheradvising her not to have a baby and it was at this point that the first silence occurred. Shebroke it after a minute or two saying that she quite liked silence and that this used to happenwith her and Ted. She spoke of the happy days at that school `until mother (who had stayedfour years with them there) packed up and went'. I said `You didn't know when she'd be backbut now I know when you're coming back'. In the hall as we shook hands and said 'goodbye'she asked me whether a group she knew I was running had finished. I felt she was wonderingwhether the therapy like the group might have finished. In the transference it was clear shemight experience me as a disappearing mother, so it was important that I should leave herand come back in a predictable way.

The Final Phase

The last stage of treatment which began on her return was a difficult time for Mary,when her level of anxiety was often very high although she was becoming more in touchwith her true feelings. On her first day back she said `I really missed not coming here onThursday'. She went on to explain that she had been made welcome by the friends withwhom she had stayed over Christmas, `but on the Thursday I did miss coming here'. TheThursday was in fact Ted's birthday as I pointed out to her.

She often felt low and one day she said `I wonder if it's worth carrying on?'. I said `I'mwondering if you sometimes feel that about coming here?'. She replied `Well, people say "Isit doing you any good?" But you know when I was away I wished I'd been coming so it mustbe doing me good, mustn't it?'. Later she spoke of a man whose wife had died and thought hemight feel guilty. When I asked if she knew that feeling she said she did and wondered if sheshould have looked after Ted better and talked with him of his dying. She said `I think if hecould only come back for half an hour I could ask him all these things' adding `but you don'tknow do you?' I said `Well we know we're going to be working together until 1st March'. Shesaid crossly `You're always saying that - do you want me to go before?'. I thought she wasagain reversing the transference and I was the child with the feelings she had had while shewas her mother. Further I thought she still needed to invite rejection to avoid the pain ofseparation, and it was my hope that she would experience in the treatment separation that didnot mean rejection. In addition I wanted to be the object that could survive destruction andso be outside her omnipotent control (Winnicott 1971). She went on to say how unsettling ithad been coming back after Christmas, and I said `I'm wondering if you feel that a bit here?'.She replied `Well, I wanted to come back but sometimes I feel it's going over and over thesame things again'. I felt I must stay with her in this situation while she felt herself into boththe ending and being on her own afterwards, so that she had the experience Winnicott (1958) has referred to in his paper `The Capacity to be Alone'. He writes

Although many types of experience go to the establishment of the capacity to be alone, there is onethat is basic, and without a sufficiency of it the capacity to be alone does not come about; thisexperience is that of being alone, as an infant and small child, in the presence of the mother. Thusthe basis of the capacity to be alone is a paradox; it is the experience of being alone while someoneelse is present. (p.30)

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That this was on her mind seemed confirmed when she went on `You know, I wish nowthat Ted and I had talked about it on that last holiday' adding that he said `You knew all thetime'. Then she added `I think he might have wondered how I could manage without him'.Then she continued `I always thought I'd go first'. I said `and here we know the date and Idon't think you like me saying when it is'. `Well' she said, `sometimes I think of this and wishI could always keep on coming and other times I think - well, I'll have more time when I don't go to Miss Hunter'. It appeared now she was thinking herself into the position of separating.

Her birthday was in the second half of January and although this anniversary was painfulfor her and she wept in the session, she said `You know I think I've been running away fromthings'. Later she spoke of an appeal on television for the organs of a dead child to be givento save another child's life - as if this symbolised the possibility of new life arising from thedead past. Despite the high level of her anxiety she said `I sometimes wonder how I'llmanage but then I think of things I'll do'. She was able to tell of things she had done and wasgoing to do whereas before she would have relied on Ted. In this, period she spoke again ofknowing that even if she had committed a murder Ted would forgive her, and she repeatedthe story of the woman from Cruse whom she had called `a bloody nuisance' emphasisingthat it had in no way fractured her relationship with the friend who had introduced them. Itseemed as if she was now able to tolerate memories of herself in different situations and hada greater sense of self-constancy and selfesteem. In this same session when I again askedabout her feelings regarding 1st March, she said `Well to be quite honest I feel sad' as if now,for the first time perhaps, she was able to allow herself to have sad feelings in a relationship.

Silences were becoming more frequent in sessions. She did not so often have to keep theconversation running and I thought this was probably reflected in her life situation now, forshe said `You know I don't have to keep running out', and after referring to a Sunday at homeshe said 'I thought, well I must get used to being on my own by myself and not just keeprunning out'. There was another occasion when she referred to people dying and said `Whenthey seem fine they just go', and I said that I wondered whether she felt that here when, justwhen we were getting to know each other, we were going to end our work. She said `Yes, Ido feel that - I do feel sad but then it can't go on for ever'. Although her sadness was clearlypainful she could now bear to experience it. It was interesting too that she found herself ableat this time to speak her mind freely in the outside world - something she said she had notbeen able to do since Ted died.

In the last fortnight of her treatment there was an upsurge of anxiety. As she came intoone session she said `You know, when you think you've got so much time there's hardly anyleft'. Yet she spoke of positive experiences outside, such as a shopkeeper trusting her whenshe found she had not brought enough money. She spoke too of the pillar-boxes being openagain (after a strike), and I suggested that things that had been closed to her were now open.

She was able to open up more in herself and she could enlarge on painful times she hadonly been able to refer to briefly before. She spoke of the terrible last three months of 1963when she had a hysterectomy and a stitch went septic, and of how her mother who wasstaying with them had no idea how to care for her or take her frailty into account, of how thevicar left, her doctor left and then her

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mother left after causing much unpleasantness never to return. It became clear that it wasyears before she could bring herself to go to Somerset House to see if they held a deathcertificate. When in the end she did go it was the Insurance man, not Ted, who insisted andsupported her.

It was now too that I heard for the first time that she had run away from home to marryCharlie when they were both only 18, which her aunt considered too young. Was thisevidence of her assertion of her own identity as a woman coming to life again now? Ithought so for she spoke of visiting a friend whose neighbour gave her a model of Pinocchioto take home. At one level the plan was to copy the model in toy-making in which she wasvery skilled. At another level I thought her preoccupation with Pinocchio symbolised more,for she spoke of Pinocchio who had been on a string becoming alive. This was in thepenultimate session and as she left my hall she took my dog's lead with her umbrella -evidence perhaps of her anxiety as to whether she could manage the freedom of being aliveand so to speak `off the lead'. She had wanted in this penultimate session to pay me what sheowed. I declined saying I never took payment in advance. I thought in seeking to pay the billshe might be seeking to avoid the pain of the final session by not coming.

She came to the last session and spoke at length but more calmly, leaving quite longsilences which she now seemed able to bear. Her stories touched on what was needed intimes of dire need and the value of friends. She went on to speak of the sister of a friend,aged 67, who was very ill, saying `You never know who'll go next do you?'. I wondered ifshe was thinking herself into her own death while she still had me there. When it was time togo she said `You know I feel I've known you a long time - ships that pass in the night - whenone door closes another opens'.

Discussion

Mary was first bereaved as a child of three when her father died suddenly. It wasinteresting that she remembered the tea-cup game; a game in which adult and child denyreality although both are aware of what they are doing. It is tempting to conjecture that notfor nothing was he the partner of Charlie Chaplin and that his use of jokes and humour wasextensive. Be that as it may it is clear why jokes with their yield of pleasure at the expenseof feeling would be particularly acceptable to Mary in her emotional predicaments after hisdeath. Further, `the internal father' protecting the ego from the reality of adversity inhumour, bringing grandeur, and the triumph of narcissism might well have engenderedwarm memories as well as being such an acceptable defence.

Mary recalled that both husbands used diminutive terms of endearment. I have referredto her experience of the loss of Ted in terms of the blow to her narcissistic status. It appearsthat her marriage to him was at an unconscious level indeed purposive, and that heresponded to some of the needs of early developmental stages from which she had not beenable in the first instance to enjoy and later leave behind. Although the marriage wasundoubtedly a happy one, evidence suggests that there was `a fit' whereby he colluded withher narcissistic status rather than facilitating growth. This would account for the collusivesilence in the months when his death was imminent, although his final remarks suggest thathe

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was as uneasy about it as she was. The general practitioner for whom she had the highestregard had told her the truth; it seems possible that her husband also knew and it seemsprobable that they might have both responded to the psychotherapeutic approach describedby Goldie (1982) if this had been offered, and have spoken at this last stage to each other.Help to do so would have certainly been needed for the evidence suggests that jokes andhumour were their means of keeping sadness off their communication agenda.

It seems clear, in view of the extent to which Ted had responded to her infantilenarcissistic needs without facilitating growth and colluded with the defensive structure thatshe had erected, why the shock of his death, against which this defensive structure could nolonger hold, resulted in disequilibrium. Yet she proved able to work in the transference toexperience feelings she had hitherto had to deny mainly about past and present separations,and in so doing she began to discover latent strengths in herself which enabled her toseparate from the therapeutic partnership in a way that augured well for a more maturequality of life of her own.

Conclusion

The social worker who had referred Mary never saw the presenting symptoms again. Inthe twelfth month after treatment had ended I wrote to Mary saying that, if she would care tocome and see me to talk about how things were going, she should telephone for anappointment. If she did not want to come I told her simply to ignore the letter.

Mary made an appointment and as she came into my consulting room she said `I'mgetting on very well although I sometimes have sad times, but as I thought it was very niceof you to write I came'. She looked younger and was more casually dressed in dark greenslacks, matching cardigan and attractive modern boots. I had the welcome feeling of beingredundant and attributed this to the fact that the transference neurosis had not been allowedto run its normal course.

She spoke of enjoyable outings with friends and said `I thought I'd never be able to go tothat hospital again', but said that she had visited a friend there who had fallen and brokensome bones. She spoke of meeting the Sister there who had looked after Ted without anysign of inappropriate emotion. She made me laugh by quoting an amusing remark of a youngfriend's child but there was no evidence of any `sick jokes'.

It appeared that Mary, despite her years, had been able to use the therapeutic experiencein a way that facilitated growth and change, so that she was able to enjoy, in later life, anemotional freedom she had not hitherto known.

ACKNOWLEDGEMENTS

My thanks are due to Dr. S. Visram, Member of the British Psycho-Analytical Society, withwhom I consulted regularly while the work described in this paper was in progress.

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