Academic journal article International Journal of Psychoanalysis

The Experience of Transplantation as Reflected in Dream Life: A Case Study Illustrating the Mental Processing of a Lung Transplant *

Academic journal article International Journal of Psychoanalysis

The Experience of Transplantation as Reflected in Dream Life: A Case Study Illustrating the Mental Processing of a Lung Transplant *

Article excerpt

Psychodynamic aspects of lung transplantation

A lung transplant is a successful method of treatment for a patient with a terminal lung condition, average survival time being 5.6 years, while survival rates after three months, one, five, and ten years are 88%, 64%, 53%, and 31% respectively (Yusen et al. 2013). Quality of life is significantly enhanced after a transplant (Goetzmann et al. 2008; Špirudová and Nol 2014; Seiler et al. 2015, 2016b). Physical symptoms, side-effects of medication, restrictions in daily life, and the fear of rejection are the most frequent concerns reported by lung transplant patients (Seiler et al. 2016b). Three outcome clusters (optimum, good, and bad) were identified in the first six months after a lung transplant (Seiler et al. 2016a). Patients with bad outcomes were older, more severely ill before the transplant, and required longer intensive care after the transplant.1

Comparatively little research has been undertaken on the psychodynamic processing of a transplant. The principal authors who considered the psychodynamics of organ transplantation in the early days of transplant medicine are Muslin (1971, 1972) and Lefebvre and Crombez (1972; Lefebvre, Crombez, and Lebeuf 1973). Muslin described a gradual internalization of the transplanted organ. Lefebvre et al. addressed the recipient-donor relationship: in the initial phase, the recipient identifies with the donor, who is unknown to him, while the transplanted organ is still an alien entity. According to these authors, this identification with the donor is based on an incorporation: the patient's self-image merges with his unconscious phantasies about the donor. The unconscious identification with the donor by way of incorporation facilitates assimilation of the transplanted organ via introjection: by identifying with the donor, the recipient can cathect the former's organ with narcissistic libido and integrate it into his bodily self. Schilder (1935,172) called this modification of the body image "appersonization." Following this early research, Neukom et al. (2012) presented a psychoanalytic model of the unconscious processing of a transplant based on qualitative examination of narratives concerning the figure of the donor and the transplanted lung. Here again, three stages of an intrapsychically represented constellation of the recipient, the transplant, and the phantasized figure of the donor are described. At the foreign-body stage, the transplanted lung is represented as an object not belonging to the self. In agreement with Lefebvre and Crombez (1972; Lefebvre, Crombez, and Lebeuf 1973), these authors observe an incorporation of the donor-that is, a fusion of the representations of the self and the donor. Next comes a transitional stage, in which the destinies of the donor representation and that of the organ intersect: both donor and organs are transitional objects (see Goetzmann 2004). At the stage of complete internalization, the lung is perceived as something that belongs to the self, the donor being represented as distinct from the self. Overall, the transplant can be regarded as an experience of relationship co-determined by the individual objectrelations history and the capacity to generate and use phantasies (see Lewin et al. 2013). Failure of this process impacts the organ recipient's mental condition as well as his behaviour: both incomplete integration of the lung and identificatory entanglement in phantasy with the donor figure are significantly correlated with distress and non-adherence behaviour (Goetzmann et al. 2007, 2008).

This contribution presents the analysis of a dream recalled by a patient immediately after a lung transplant-that is, on waking from anaesthesia. The results of this analysis are considered in relation to the waking narratives of the interviews conducted two weeks, three months, and six months after the transplant. We contend that the dream affords an insight into the unconscious processing of the transplant. …

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