Citation

Auxéméry Y. Ann. Med. Psychol. (Paris) 2015; 173(1): 20-24.

Copyright

(Copyright © 2015, Societe Medico-Psychologique, Publisher Elsevier Publishing)

DOI

10.1016/j.amp.2011.10.016

PMID

unavailable

Abstract

INTRODUCTION: The world of medicine, hospitals, is in close contact with and is interested in death; many practitioners deny it and attempt to avert it themselves. Much research deals with the reaction of patients in the face of their own death or that of a family member or a friend. The problem of normal and pathological bereavement has been the subject of numerous publications. Within this editorial superabundance, one subject is missing: the psychotherapist, often the instigator of these studies. The death of the therapist, sudden or expected, is a difficult issue for their patients as well as their colleagues and certainly for the therapist themselves. This death, always sudden, will surely lead the patient to question the meaning of life, the reality of death, the possibility of obtaining lasting support. This question of denial of the death of the aging and ill psychiatrist is undoubtedly ingrained in the history of the father of psychoanalysis who, suffering from a particularly painful post-smoking neoplasia, continued to smoke and see his patients until the day he died. Let us suppose that the psychiatrist had an unconscious mind; within it he may therefore be persuaded of the absence of possibility of his own death and live in the present of immortality. It is thus how Freud lived, like everybody he thought. Thus, structural elements of the analytical treatment increase this feeling of immortality. Clinical findings: A therapeutic relationship established over several years and for which the practitioner was the archivist and the guardian of the most intimate secrets, to prepare a better future, cannot be interrupted suddenly without suffering. The mourning of the therapist can be complicated that is to say unusual with a marked and persistent suffering,; or pathological triggering a physical or mental pathology by definition absent before the death but traditionally retained afterwards as latent and evidence of a prior vulnerability, vulnerability for which the subject had undertaken the therapy. The risk of anaclitic depression or even melancholic breakdown is to be feared. A psychotic decompensation can occur in the face of bereavement and when the secondary treatments are stopped lead to a medical escheatment. Acting out suicide or self-harm can bring into question the relationship between the therapist and the patient through the spectrum of pain and death. Of course the reaction of the subject can be strictly foreseeable due to the inter-subjective relationship uniting the protagonists. How can the patient therefore move on to another therapist and will this procedure necessarily be therapeutic? Guidelines: A non psychotraumatic announcement must be made to the patients to pre-empt a fortuitous discovery via another patient or the press, which requires good reactivity on the part of the medical team. The patients must be seen individually quite quickly to announce the death in person. It is a good idea for the patient to be seen by a doctor they already know, for example having met them when their referring therapist was absent. This announcement will enable an evaluation of the latent psychopathological picture and the psychic defences, which may or not be operative. The follow-up will depend on each clinical situation after looking very carefully at the anamnesis, detailing the psychiatric examination and evaluating the patient's reaction to the announcement of the tragedy. In any case, a second appointment will be proposed and the subject will be invited to join a therapy group. A cardinal question is to know if the patients can go to their therapist's funeral. We share this idea as it limits the capacity of denial and remains an operative social ritual which channels emotions. This event should be managed by the medical team and will retain a therapeutic value. Also, the possibility of group therapy bringing together patients and medical staff will enable them to share their fears and dispel any misunderstandings. An equivalent to a debriefing can be organised in the days following the announcement of the death. Subsequently, a place where they can come and talk freely can be set up in order ensure a group follow-up. The medical staff are thus regularly solicited to explicit the exact cause of the tragedy and the circumstances. The response provided is difficult as it concerns finding the right positioning between the necessary private life of the therapist, as the medical confidentiality has not been lifted by the death of the subject, and their public function, which justifies providing information. Refusing this is undoubtedly deleterious for the patients who will let an imagination favourable to unresolved bereavements run wild. The continuation of individual psychotherapy will necessarily integrate this recent confrontation with the possibility of death. The traumatogenic event of bereavement could be itself reinstated in the subject's trajectory via a therapeutic perspective, which will enable them to mourn and to continue the treatment already begun. Whereas the sudden death of a therapist is often lived in silence, the acceptation of the inevitability and the emptiness will on the contrary establish itself in the response of the subject. © 2012.

Language: fr

Keywords

human; Post-traumatic stress disorder; bereavement; Psychotherapy; Psychopathology; death; mental disease; psychoanalysis; psychiatrist; patient care; psychotrauma; melancholia; publication; sudden death; Guidelines; medical staff; confidentiality; health practitioner; accidental death; denial; group therapy; psychotherapist; Article; Psychic trauma; Dying psychotherapist; Post-traumatic grief; Traumatogene grief