Trauma, Transience, and Resilience in Chronic Illness: A Perspective on the Physician–Patient Relationship

This essay derives from a three-part discussion of asymmetry and mutuality in the patient–physician relationship. In this section, I emphasize the patient's reaction to the diagnosis of chronic/terminal illness and the developmental task he or she faces in mastering these life events. I am heavily indebted to Bob Stolorow's discussion of trauma in his book, Trauma and Human Existence (2007):

Devastating diagnoses of lethal disease often arrive like “bolts out of the blue,” evoking a “shocked and awed” response in the recipient whose regulatory capacities abruptly fall into disarray. Accustomed to medical exams that reveal minor fixable problems, the patient is confronted with an unanticipated highly ambiguous and ominous situation. As he enters this traumatic state a sense of unreality, estrangement, fragmentation and derealization ensues. One person likened it to stepping into a Dali painting, another as feeling at a

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remove from others, as though the world is behind a mirrored wall. It is an experience of disintegration, which Kohut [1977] described as “ … a deep unnamable dread entailing an estrangement from the body and mind in space and a breakup of the sense of continuity in time … graspable only through analogies and metaphors [p. 105].

The physician, bearer of bad news, observes this transformation of his patient from, “Hi Doc, how are you?,” to a deadened, disoriented, vacant ghost of a man with his own mixture of dread, denial, distance, hopefulness, and practicality. Bravely, reluctantly, and ambivalently, he wades into the maelstrom of disregulated affects with a “plan”—and this is the first selfobject function necessary for the patient's early reintegration and for the physician's sense of efficacy. Nameless dread is supplanted by verbalizable content. The treatment schedule provides basic orientation in time and space. Purposefulness is temporarily