LIFE MOTIFS AND SERIOUS SOMATIC DISEASE

Psychic reality of a somatic desease is a patient’s own construction. When an illness takes place during the whole life, the question which is undoubtedly posed is what is the inner world of such a person. Can a request for surviving this day, too, be imposed on a patient who lives every day with a threat of death and limited capabilities. She has learnt to struggle and withstand, denying that it is possible to live without fatigue and suffering. In the most difficult moments on the road to nowhere, this rich inner world has offered phantasmagoric comfort in all colours. Her world is not split or burdened by envy, but by bright colours of attractive mental development here and now. Million deaths have made this young woman unique and distinctive. The serious flaw on the aorta and pulmonary hypertension, haemoptysis and preagonal condition have, only for a moment, made her slower to her current destination. The atmosphere that MN has created is in the true sense the Winnicott’s saga of the world of transient phenomena which contain the hidden road to a real world through play and reality. Life does not just happen, it is learnt and wanted. There was a religious symbolism in our encounter as well, that she has been carrying her cross for 33 years. Acta Medica Medianae 2016;55(1):59-63.


Introduction
A person's inner world is a special evaluative system including everything we experience.Visually, this is the sum total of all our experiences.While searching for the basic emotion of severe physical illness I met Professor Apostolović who supported my endeavors to talk to people who are seriously ill.She believed that the talk helped and encouraged me think about life and death.As a result, I met many people who inspired me to believe in the beauty of life but also to realize the utter loneliness and the undivided depths of which every one of us carries on inside.While discussing the issue of psychosomatic problems with Svetlana Apostolovic, PhD, a part-time professor of internal medicine and a specialist in cardiology she suggested to me that she paid great attention to psychological resources as well as the presence of dreams in patients who were seriously ill.As a psychologist I am a defender and a guardian of the complete identity, I might as well expect the same from others.What am I saying?: Lets for a second call Serbia the country next to Bulgaria and let's try to identify some important things in terms of description.Even though the psychic reality of a body disease is a patient's own construction, we can help him if we depersonalize him/her so that he/she demoralizes, humbles and even thinks of suicidal ideas and thoughts.We notice that the patient views the doctor as God, that he/she views a psychologist as a person who will represent his or her inner world.But not a single patient refused to talk to me.They even told me that they changed their view on psychology.I find an observation of one patient very much; he said that it was like visiting a priest, but better.When the disease is present throughout the patient's entire life time, the inner world of such a person is a mystery.Can you have a futuristic discussion or an extremely cynical social politics with a person that lives each day with a death threat and the threat of limited abilities?These people often experience the neglect of the society and even various insults, where, perhaps, the only way out is to find balance in being.My task is not easy.The story about it is always the search for measure (2).

The patient and I
We met at the Center for the protection of mental health in the community Medijana where I was doing my internship within my PhD.We greeted each other warmly, thanks to her.She came there with her mother and she was very spontaneous.Her mom sat on a bench and said that she would wait for as long as it takes for N.M. to tell her story.Her mom struck me as a very sweet and supportive; she also had a quality of determination which I had not seen for a long time.
N.M. could not even climb the dozen steps due to the weakness of her heart muscle and she immediately informed me of this.
-I cannot climb the stairs, it tires me.
-That's alright, I replied.We will talk in that room down here.
Right away she spontaneously engaged me in a conversation which was more of a medical confession and I needed to manage all those numerous medical expressions and diagnosis.Once we were seated and a friendly atmosphere was established, I managed to perceive her as a psychological being which was indeed very attractive.I did not tell her this, but I causally remarked that she was energetic and that she struck me as a person who could manage many situations on her own.She told me that nearly everyone remarked the same thing about her.M.N. had had a different upbringing since her birth, and she developed herself carefully and dedicatedly.She learned to be a fighter and to endure, denying that one can live without fatigue and suffering.That thriving inner world offered phantasmagoric consolation with its colors during the moments of severest hardships when it seemed all was lost.Her world is not split / fragmented nor burdened with envy, but rather filled with bright colors of an attractive mental development here and now.A thousand deaths have made this young man a unique and special person she is.The sever heart disease (a defect with her aorta) as well as pulmonary hypertension, hemoptysis and the general condition close to agony have slowed her down just a little bit on her way to the destination she reached today.
During our first meetings I was to realize that by HERE she meant everything outside the hospital and THERE the time she had spent in hospitals.I never even for a second noticed in here the signs of hospitalism, and even more astounding was the fact that she was not unaware of her mortality.Cardiologist have had serious conversations with her as well and they offered her some recent palliative sedation / methods in her treatment, but the limitedness of her life and the time that is running out somehow hovered somewhere in the same space.At first, I was frustrated by the setting I offered her as she could not climb the stairs, but she comforted me by saying: "I don't mind talking.I can do that anywhere." We mostly started our conversations spontaneously and without any preparation.We talked at a slow pace both about her ailment and about her life.She began her confession which was medically very concise as she had done it a thousand times already.I felt that I should not interrupt her and that she would eventually tell the story of who she was and the things that happened between life and death.The meaning which M.N. had created is in the true sense of the word Winnicott's saga about the world of transitional phenomena which hold the path to the real world through play and reality.

Psychological findings
Methods and techniques: Interview (clinical) Interview (directed by the client) Our meetings looked like a shot and dynamic psychotherapy as there were interventions on both sides coming from the deep parts of the psyche.There have been 13 meetings and the patient then went to further treatment so I hope that the therapy is not over and that it will once continue since the patient promised to get in touch again when she returns from Austria.
Number of meetings: 13 (we halted the therapy as the patient went abroad for further medical treatment).

Clinical interview
Client M.N. was born in 1981 with an inborn heart disease.She grew up in a complete family.She has a sister, and she pointed out that their mother treated them the same even despite her heart condition.I did not comment on this, but I presumed that she meant that her mother was not overprotective of her due to her condition.It is psychologically interesting for me to study this occurrence by observing the relationship between parents and children, that is, the two of them and of course, I perceived that the patient had not noticed neither any deprivation at home nor any consequences of deprivation due to her illness.
From early childhood, she had problems with games which demanded movement and speed, and she could not do any sports during her life.She did not complain about this, but she also did not develop any manual skills.She mainly engaged herself in activities which she was comfortable with, she was sociable and also socially well-informed.She simply accepted the situation as such.She underwent many surgeries.Due to the weakness of her heart, the doctors implemented an artificial aortic valve.She often experienced irregular heartbeats.Right from her birth she was diagnosed with aortic stenosis.I did not ask too many questions about her diagnosis, but I noticed that when she did talk about it she would go over that routinely and that she had the need to talk about different things.As if that had been the key to communication and that she expected different things from me.She offered me the following information herself and I laughed, but I carefully wrote them down nonetheless.
"I am an optimist, cheerful and full of hope.""I have graduated from high-school as an extramural student but I never enrolled in a college." Then she told me that she was divorced and that she had a daughter.She described her ex-husband as an amenable person and her daughter as a person who gives her life meaning.She told me that she considered her daughter's upbringing to be her life's mission.She also told me that her child understood her illness and that she had a good sense of humor and that she was a cheerful girl.She was born completely healthy but she mentioned that her daughter was wearing glasses.
During her pregnancy which was approved by the doctors, M. N. received injections to her stomach to preserve the pregnancy.She gave birth via a caesarean section.
While we were talking, I noticed numerous hematomas, which she explained to be standard consequences of her treatment.She was prescribed a special diet based on fruit and soft food.She was taking fluids in minor quantities.
And then came the toughest part.I had to decide whether to abide by the book and conduct an interview directed toward the client or to talk to her like a therapist, and to dive into her world if she lets me.

Interview directed by the client
T: Please, describe yourself and your view on life.
I felt somewhat silly asking this question, as if I were a person working at the Bureau of Employment Services, which I told her.She laughed heartily at this and said: M.N: I consider myself to be an optimistic, cheerful person despite my illness.
T: I nodded my head in approval of this attitude.
M.N: It is really important to know how to deal with hardships.
I somehow felt that I had to express my appreciation for her deep suffering and her fighter spirit.I wanted to tell her that I cannot help her heart and aorta get better, but that I admire the fact that her fragile body was able to endure that for so many years.I felt deeply disturbed because I was not sure whether I would manage to say all that, but I calmed down because she somehow understood me.
T: You are a terrific fighter, I told her.M.N: I came from the hospital because I like talking to psychologists.
T: … I fell silent.M.N: Cardiologist often asked me whether other people noticed my being different.I haven't noticed that, because nobody ever told me this.I was a sociable person, and back in my day, people skipped P.E. and went out for a cup of coffee.
T: Yes, we too skipped P.E. and went for coffee.Fortunately, the teacher understood this.
M.N: Our teacher had understanding as well.M.N: Nowadays, I hear there is such a thing as risky sports, and I am fighting for my life, which makes me angry.But every generation brings something new.But that is stupid and wasteful.I am very interested what do you call that in psychology?
T: Yes, I too have heard that some young people put their lives at risk, for example, bungeejumping or mountaineering or speed driving or parkour.I think that is called a high-risk romance.
M.N: I will remember that.At one of our sessions I was meaning to ask M.N. about her goals as a parent when she started talking about it herself, which was a very good proof that we understood and intertwined one another non-verbally as well.
M.N: I want to raise my daughter to be a good person.I want her to be independent and that she does not fear anything.
T: As I understood, you do not have any problems bringing up your daughter nor with her father.I understand that you and your ex-husband have a decent relationship and that he helps you.
M.N.Apart from him being amenable and being an ex, he is there for me.
M.N: I won't be able to come here often.It so happens that there is a program in Austria for all my defects.I would like to go there for myself, so that I do not have to end up in cardiology all the time because of my heart weakness, you understand.
T: I am glad that you will go there.I hope that we will meet again when you return.
I almost blurted out whether Professor Apostolvić knew anything about the program in Austria, but I remembered on time that M.N. was in control of her life and that she definitely knew what was in her best interest.I had an irrational urge to tell her: YOU have achieved everything in life (4)!I was sad and fulfilled after those thirteen interviews because I met someone who knows to how to live that way, who managed to spend her time truly and operatively despite staring at the sun.
Here and now, without forever and tomorrow… (5) Upon our parting, I saw her with an apple in her hand; a bit of apple and then a gulp of water.She exudes time and she conveys an immense desire for life.She was walking in front of me slowly, nibbling an apple, slim as she was with a stomach that was less swollen which meant that the ascites was smaller.I did not want to bother her.I had an impression that during the short therapy she became aware how important it was to be alone with oneself (2).She told me that herself.I explained to her then that being inside oneself is a very beautiful moment of freedom from everyone else.She then told me that she was waiting for what will happen in Austria and I realized that I should not be waiting for her.She has chosen her path.And she did not dare get lost on the way (6).She said she would call after she gets back from Austria, and I will wait for her call.

Process Implications
Even though we met only thirteen times, the life of our therapeutic process was immense.The process was stopped due to further medical treatment and it got me to think about loss and death differently.Million deaths that we experience in a single day are mere shifts from one state into the other (1).
Mortality and immortality are eternal topics.
There are numerous questions that people ask themselves, starting with individualization and reaching one's identity and including reaching the happiness as a necessary goal in life.Freud wrote that a man denies his own mortality by creating his own funeral.Psychological process lasts from birth onwards.During life, one can experience many products of the emotion of pleasure with the achieved engagement of the mind or feelings through different experiences of growth and development (7).
By respecting of one's personal system of value one sets in motion the engagement of the emotional consumption of the thing we advocate.Minor deviations from the stands which construe us produce the sense of pleasure, which results in a state of happiness (Kant, quote: "Two thing fill my spirit with respect, a starry sky above me and moral laws within me") (8).
Where did discussion about M.N. come from?It started my own life capacities within me.The patient was ready to share with me her psychological world in which there was no despair or darkness.I had the feeling that that was her virtue and I was filled with great happiness that we met, if I may say so, in order to communicate.It was worthwhile.
It appears that she went through her identity and individualization easier than the others.I noticed that she loved herself in a special way and that her self-love was tender and unburdening.She did not produce pity because she knew how to love healthily.Probably the woman who was waiting for her outside knew how to fill her with good objects and hope.
Man is a being of mind, reason and feeling.Man possesses logos.Man is a being of culture.What can I hope for?Only the division of the mind creates a tomorrow (4).
She is definitely a social being as well.It does not matter to her how close she is to self-realization.Her meanings are her simple needs and a short-term life, only here and only today.The meaning blooms from the need.Her needs are reduced to the essential existence in which physical pain is a realistic factor against which one is to fight, and life is the product of the reduction of pain and the activity one undertakes to eliminate the symptoms.She knows that all this will end soon and that her time will be up.She considers these things to be so simple that they are not worth discussing.Her task is that she makes here and now her daily step and to win a battle with herself.She believes that there is time because by living the moment she does not waste it.

Conclusion
It is very difficult to quantify mental processes.Mostly, there exist subtle qualifiers in metapsychology (psychoanalysis) which are specified by unconscious processes and unconscious language.Our client M.N. is very well-focused on her current events.She has learned somehow that optimism and established life cycle give good feeling of prosperity.She knows that it would not be soon, that hourglass will leak out soon.She considers that those are so simple things and that it should not be talked about them.Her task is to achieve her daily life croquets and to cope with herself today.She thinks there is time, because by living now she does not waste it.To me as an expert, especially after reading the book by Irvine Yalom "Staring at the Sun", I was enabled to essentially believe that you can sooth the fear of death in somatic patient and that he/she can essentially value his/her life.Of all from the above, my client has not mentioned dying for once.My assumption is that she does not have time for lament of that sort.If that is even the escape from death then it is very good defense because she is greatly present in the lives of those she loves.Psychological instrumentation often does not have explicit answers for some highly subtle things related to fear of death.Anxiety is one of derivatives of fear of death.I would rather not talk about M.N. as someone who is a prodigy.She is a very heavy somatic patient.Great fascinating psyche stays in her frail body which has covered the disease and in that, I guess, is some secret of her survival.Her evolution of life has flowed simultaneously and there has not been any dilemma whether something can get better.That completely fascinated me.I certainly know that M.N. is gravely sick and she is completely ready, but she does not want to talk about that.I have not got the impression that it would hurt her.She has left an assurance that it was her personal thing and that she did not have time to talk about it.Her personality structure has some other kind of maturity.She looks on people in a different way.She sees them like someone who would spend some time with her today and she is looking forward for that pleasure.There exists continuous battle for psychoanalysts between urge to live and urge to die.There exists fear of death from which we defend all the time with various types of mechanisms of defense.M.N. indulged to life and my impression is that it was because she was truly loved by her parents and because she accepted her disease, not as a choice and destiny but as a way of existing.