Repetition of the Mother-Infant Dyad and the Process of Dying in the Psychotherapy of an Hiv-Positive Man

Despite recent progress in the treatment and prognosis of HIV infection, the issue of preparation for death frequently remains a crucial one in the psychotherapy of HIV-infected individuals, particularly when the illness reaches a terminal phase. Although psychodynamic authors have discussed at great length the problem of grief and mourning, there is a relative paucity of theorization on the intrapsychic process of dying. Freud stated that the notion of death cannot exist in the unconscious. In the unconscious, the pleasure principle prevails and our own disappearance cannot be conceived. In “Inhibition, Symptom and Anxiety,” Freud (1926) maintains that fear of death is essentially an analog of castration anxiety. In “Beyond the Pleasure Principle,” Freud (1920) formulated the existence of a controversial death instinct related to repetition compulsion, masochism, and aggressivity, issues that relate directly to life phenomena but not necessarily to the process of dying.

Nevertheless, even if it were only in reference to a conscious knowledge, death is an unavoidable element of life. Its impending occurrence can provoke profound modification of the human psyche, which needs to be symbolized. In the case of HIV infection, some sociocultural and psychodynamic elements create a complex psychological background to the unravelling of the dying process. Powerful unconscious association between sexuality and death, internalized or externalized homophobia, perception of oneself as contaminated, guilt, fears of abandonment and rejection, and confrontation of death at a young age, among others, have all been described as important elements in the adjustment to HIV (Blechner, 1993; Cadwell, 1994; Nichols, 1986; Schaffner, 1994) and will influence the intrapsychic integration in the dying process. In some cases, issues of self-destructiveness or unconscious punishment may further compound the process (Kaufman, 1993).

Many authors, like Leclaire (1975), believe that “there is noth