Psychoanalysis and Non-Adherence to Medical Advice: An Ethical Dilemma in Covid-19 Pandemic

*Paolo Azzone*

#### **Abstract**

Mitigation measures required by Covid-19 pandemic have posed severe restrictions on individual freedom and have been met with persistent opposition in minority circles. As non-adherence to preventive measures is believed to increase health risks for the society at large, dissent from official policies has been a source of concern. Within this framework several eminent psychoanalysts have suggested psychoanalysis should be enrolled as a component of health related public opinion campaigns. The chapter will discuss the historical relation between mental health institutions and social control strategies and will formulate a psychoanalytic model of the social dialectic associated with the Coronavirus pandemic. The model will allow the author to offer grounded ethical perspectives on the issue.

**Keywords:** Psychoanalysis, Adherence to medical advice, Ethic, COVID-19 Psychological Sequelae, COVID-19 mitigation measures

#### **1. Introduction**

Psychoanalytic and psychiatric practices have often got me in touch with people displaying a disproportionate fear of infectious diseases. They wastes their life among washing and cleaning rituals, but can get back no sense of safeness. The patient's partner or relatives – at length even the patient himself – get to realize his anxiety about infectious risk is clearly unrealistic and that he is wasting all of his existential energy. So, in the end a professional help is sought, and a psychiatric diagnosis is formulated, which generally includes phobic neurosis or hypochondriasis.

Anxiety about inter-human contact has a long story and no doubt antedates our modern understanding of the etiology of infectious diseases. In primitive or archaic societies contact with certain members of the community was associated with the violation of severe religious prohibitions. The anthropological literature speaks of *taboos* [1, 2]. In the caste system, which till now has a substantial impact on Indian social structure, the even indirect contact with members of inferior castes is bound to elicit a dangerous pollution.

In Europe the culturally accepted representation of pollution had gone through several stages over time. Medieval Christianity focused on improperly polluted sexual

#### *Anxiety, Uncertainty, and Resilience During the Pandemic Period - Anthropological...*

contacts. The water of Greek-Roman ritual purifications gave so way to the sacrament of Penance, which included magical components and often featured a compulsive quality.

In modern societies the danger associated with inter-human contact has often been equated with an infectious threat. So the feared contagion diffused by supposed plague spreaders has repeatedly replaced sexuality as a paradigm of pollution. In his masterpiece, *I Promessi Sposi*, Alessandro Manzoni [3] taught the readers how the populace is permanently willing to unleash against guiltless minorities whenever health and physical life are supposedly endangered.

Nowadays, humanity is confronted again after decades with an infectious disease characterized by significant morbidity and mortality rates, particularly so in older people. And fear grows more and more. Epidemiologists, the government, the media, and the public opinion are racing in the pledge for more and more restrictive measures which put severe limits to individual freedom.

Hostility among citizens is increasing by the day. Older retired women use to blame the rare pedestrians when they fail to properly wear their face masks; fierce checkout girls spell detailed hygienic regulation to fearful consumers; zealous citizens report to the police their neighbour for any supposed violation of lock-down measures; young people with substantial internet skills expose innocent runners or reckless children to mediatic shame.

No doubt: the SARS COVID-19 Coronavirus had yielded a deep and dramatic cultural change. The epidemic mitigation measures have called for an interpersonal distancing which is unprecedented in western history. Social and economic problems which have been tripping European governments over the last decades have been suddenly put aside, while public wealth has been wasted without reserve in the unfortunately useless attempt to stop the spread of the disease.

In a recent book [4], the well-known philosopher Gorgio Agamben formulated the coronavirus epidemic within the framework of German theory of the state as a *state of exception* [5], an emergency against which the constitutional guarantees appear as absolutely irrelevant, needless concern for trifler jurists. Freedom, social justice, religious experience and the whole lore of values on which our society is based – values which could be established only through long and bloody struggles – have suddenly lost all of their importance.

Fear has gained a core position in current socially shared representation of human reality. The politicians, the media and the public opinion have unanimously agreed that all the social structure and the economic organization should be rapidly reformulated according to illness prevention needs.

Just as in primitive or early modern societies, contagion, contact and fear occupy the centre stage. Hypochondriac anxieties have begun to spill out of the corner where modern thought and the advancements of medicine had confined them. The phobic parts of personality have taken control of contemporary culture.

So, in XXI century advanced societies, hypochondriasis becomes the official, or rather the single accepted thought, and severe opponents of critical thinking call for a strict censorship of any dissent.

The dissidents have been the victim of a savage mediatic campaign which associates them explicitly to neo-Nazi's intellectuals. Just as the latter strive to negate the width of Hitler instigated butchery of Jews during World War II, the opponents of the health related state of exception would be negationsists, *i.e*. obviously insane or even demented people [6].

Against such a background several eminent psychoanalyst have taken sides. They have openly blamed dissidents. They have suggested psychoanalysis gives up its traditional option for neutrality and enlists beside traditional institutional powers in the repression of dissent.

#### *Psychoanalysis and Non-Adherence to Medical Advice: An Ethical Dilemma in Covid-19… DOI: http://dx.doi.org/10.5772/intechopen.97744*

Over the last years a greater integration of psychoanalysis within the healthcare system has been authoritatively advocated [7]. Now Austin Ratner [8], an advisor to the American Psychoanalytic Association advocacy, public information, messaging, and branding task force, stated that psychoanalysis should contribute to fostering the citizens' widest consensus to contagion preventing measures.

In Italy, many mediatically prominent psychoanalysts are sharply critical of the opponents of the government. Massimo Recalcati ("I paradossi della tirannia sanitaria" *La Stampa*, October 13th, 2020) writes that lockdown critics fall prey of an "underestimation of the clinical and epidemical severity of the virus". The opponents of institutional power would be only immoral "libertines", unable to tolerate the wise limits which political institutions have to pose to an unrestrained freedom.

In an interview to the TV network *La7* Umberto Galimberti does not hesitate to name the dissidents mad and delirious. "With lunatics you can't easily discuss. Can you persuade those who deny reality that reality is different? It is very difficult". Meanwhile, from the pages of *Il Sole - 24 Ore* Vittorio Lingiardi and Guido Giovanardi summon all psychoanalytic colleagues to join forces against any dissent to the management of the pandemic emergency.

Lingiardi and Giovanardi have no doubts: any opposition to infection prevention measures "increases the number of cases and deaths due to coronavirus infections" and is dependent on a primitive mental functioning, where denial is a basic defense mechanism. Psychoanalysis should therefore leave her century old withdrawal from the political arena and become "a force for social change" merging within public health institutions with the aim to reeducate and free from their own neuroses the scanty army of the dissidents.

Sarantis Thanopolus, current President of the Italian Psychoanalytic Society, in an article for the *Huffington Post, Italian edition*, chose a more balanced position. He believes psychoanalysts should stick to a mainly clinical attitude and be available to treat both patients denying the severity of the epidemic risk and the phobic excesses which the pandemic emergency might induce in predisposed subjects.

#### **2. Mental health and social control**

How could this deep change be brought about? How could psychoanalysis turn into a compliant device for the management of public opinion? In order to answer this question we will now cast a look at the history of the relations between professionals and praxes of mental health, on one side, and control of socially improper behaviors, on the other.

Our review will begin with the late Middle Ages. In the year 1321, authorities close to the King of France began to spread (obviously forged) evidence that a dangerous international plot was underway ([9], p 5–28). The plot would have been supported by Islamic powers along the Mediterranean coasts and maybe by international Jewish elites.

The plot was aiming to overthrow legitimate Christian sovereigns and establish a new rule. The inquirers had no doubt about the main agents in the conspiracy: people living at the margins and all the more dangerous as suffering from an infectious disease. The Pope couldn't but yield to the overwhelming evidence and authorized the civil servants to take appropriate action.

The lepers' slaughter began in June, 1321, in several cities. The outraged populace took active part in the repression of the rascals, enthusiastically welcomed the authorities' recommendations and, should these prove late, initiated the rampage without waiting for "a judge or a bailiff".

As could be expected, such a wide slaughter could not be completed. The surviving lepers were therefore permanently confined within *ad hoc* institutions. Focault [10] taught us that in the Baroque age lunatics will become the heirs of these very places devoted to seclusion and control.

Official psychiatric narratives celebrates Philippe Pinel as the man who gave back freedom to lunatics, in 1795. Actually Pinel released lunatics from workhouses where their behavior had been controlled and their vices punished, but their psychiatric condition had never been treated. However, in the state hospital which succeeded to workhouses as a place for the specialized treatment of mental disorders, behavioral control rapidly reemerged as a basic institutional goal. In Italy, it took to Franco Basaglia decades of political fight to obtain a law who banned psychiatric hospitals, in 1978.

Psychiatrists in clinical practice know all too well that to the general public madness has always amounted to a frightful ghost, a gloomy, lurking danger which needs to be put under control at all costs. I will not discuss here the upsetting condition of contemporary psychiatric care in Italy or elsewhere, but none will deny that the control of improper behavior still stays a core concern of psychiatric services.

Today, against the background of epidemic emergencies, from psychiatric and psychoanalytic institutions something more is required than the sole enforcement of social norms. Nowadays, mental health professionals are called to substantially contribute to the establishment of an unrestricted compliance with institutionally proposed beliefs and ethical values.

This more ambitious social goal is however no complete novelty either. The reader may consider the role psychiatric services played in Soviet Russia as a device for the repression of political dissent [11]. In Soviet society the control of dissent relied on two concurrent and cooperating paradigms: the criminal justice and the mental health services. The Art. 70 in Soviet Criminal Code of 1958 included the crime of "Disorders and anti-Soviet propaganda". In addition, the "Dissemination of fabrications known to be false, which defame the Soviet political and social system" was the focus of the Art. 190–1, introduced in 1967.

The harsh juridical procedures were integrated by mental health interventions. A large number of dissidents were classified as suffering with mental disorders and relegated into psychiatric institutions. On a descriptive perspective, heterodox political ideas were interpreted in terms of delusion of reform, while the diagnostic category of latent schizophrenia was the most relied upon in order to justify compulsory admissions.

In the most perfect society the world over, opposition to government was obviously evidence of madness. As Khrushchev wrote on the *Pravda* of May 24th, 1959:

*Can there be diseases, nervous disorders among certain people in a Communist society? Evidently yes. If that is so, then there will also be offences, which are characteristic of people with abnormal minds. Of those who might start calling for opposition to Communism on this basis, we can say that clearly their mental state is not normal.*

The parallel between Khrushchev's thoughts and Galimberti's unsympathetic devaluation of lock-down opponents is obvious and dismaying. In Soviet Russia political violence and repression were everyday means to enforce consensus. We do hope they will not soon infiltrate the democratic West, too.

#### **3. Negation and negationism**

Propaganda, no less than advertisement, thrives on a skillful distortion of language. Psychoanalytic theory and practice, on the other hand, requires extreme

#### *Psychoanalysis and Non-Adherence to Medical Advice: An Ethical Dilemma in Covid-19… DOI: http://dx.doi.org/10.5772/intechopen.97744*

accuracy in word selection and use. Before we develop further our review of the role of psychoanalysis with reference to health related negationism vs. conformism, we need discuss briefly some words which are relevant to the issue.

Denial may refer to both internal and external reality. This may create substantial confusion. So, in order to be more accurate, we'd better rely on the original German terms. The *Verneigung* [12] is a defense mechanism. It withdraws from knowledge a content of the Unconscious through a direct negation. Here is an example from Freud's: "Sie fragen, wer diese Person im traum sein kann. Die Mutter ist es nicht" ("You ask me who such person in the dream might be. It's not mother", ([12], p 11)). The *Verneinung* do not remove a piece of information from reality (*e.g*., about virus lethality), it focuses on unconscious contents. It can in no way be associated with health prevention measures dissent.

The concept of *Verleugnung* was introduced by Freud in 1923 (*Die Realitätverlust bei Neurose und Psychose*, ([13], p 365)) and was further discussed in 1927 (*Fetischismus*, ([14], p 311 ff.)). *Verleugnung* tackles unpleasant realities and perceptions by directly disavowing them. In *Fetischismus* Freud mentioned two patients refusing to acknowledge their father's death.

*Verleugnung* is a primitive defense mechanism and is typically associated with schizophrenia or severe paraphilias. It operates on factual, universally shared realities, not on political or philosophical beliefs. It cannot help understand neither the socially spread dissent to illness prevention measures nor the poor trust in political institutions.

We may mention here *Schizophrenic Negativism*. It is a symptom of schizophrenia. It implies the refuse to perform what is required by the visiting physician. It is a symptom of a dysfunction of will, not of thought or cognition.

Let us finally come to the historical *Negationism* or *Shoah Denial*, a concept to which several supporters of educational psychoanalysis have associated any opposition to the epidemic mitigation measures. *Shoah Negationism* or *Denial* is an ideology purported by Neo-Nazi intellectuals. It denies the extent of the butchery of the Hebrew people which was implemented by Nazi institutions during World War II.

From a psychoanalytic point of view, Shoah Denial amounts to a sadistic interpersonal strategy. It aims to elicit the maximum possible emotional pain in the political enemies, through the downplaying and pollution of their most intimate and traumatic collective memories. It should not be misunderstood as a defense mechanism.

How can we then realistically describe social movements opposing pandemia mitigating measures? Which words could be the most appropriate? The core issue with preventive measure oppositions is no doubt the *dissent* with reference to the prevailing representations of and solution to the epidemic phenomenon, as are proposed by media and by scientific and political institutions. *Dissent* is the attitude of those who disagree with the prevailing ideology in a specific community.

Over the course of history, the citizens have ranged again and again along opposite poles: Catholic and Lutherans, fascists and antifascists, patriots and reactionary clericals, supporters of Stalinist Communism and democratic activists, and, nowadays, supporters of political freedom and advocates of sanitary ideology. Such ideology and identity polarization can be understood from a psychoanalytic point of view as a function of the defense mechanisms of splitting and projection into the adversary of one's own anxieties.

As for the opponents to the government policies and to prevailing social organization, a masochistic identification may play a significant role. This is particularly obvious whenever opposition implies facing overwhelming threats, like was the case for Christian undergoing martyrdom, for various national heroes wasting

their life for the good of their community, to Solzhenitsyn in the Gulag or Cato the Younger choosing freedom over life.

In the next section we will try to formulate a more articulated model which could help us better understand the splitting which has recently appeared within contemporary society and the harshness displayed by the two opposing sides.

#### **4. Biological viruses and emotional viruses**

What happened to contemporary man? How could a whole society get ill with fear? Can psychoanalysis contribute to the understanding of the changes which the Coronavirus pandemic has yielded in our society and of the amazing consensus which the ideology of social distancing has won the world over?

Wilfred Bion clinical and theoretical work during and after World War II cast an original light on regressive phenomena in groups [15]. Whenever a group experiences distress and helplessness, it regresses to primitive functioning patterns where emotional exchange and the search for the truth are replaced by Super-ego imperatives and prejudice.

Bion termed such patterns *basic assumptions*. Under such perspective the flooding of the social space by an irresistible feeling of fear can be associated in Bion's system with the basic assumption of *fight or flight*, where the unconscious fantasies shared within the group are annihilated by the experience of an overwhelming threat.

At the core of contemporary society an enigmatic and ominous threat is lurking, then. What frightens contemporary man? Why do as much or even more dangerous social threats – you may think of terrorism, nuclear war, climate change or cancer – exert a much milder impact on our emotional social life than an infectious disease? Which gloomy resonance can a respiratory virus elicit in Western cultural space?

In order to answer such questions we must firstly remember that modernity relies on a specific epistemological option: our society and our culture have explicitly opted for a strict and rigid materialistic reductionism. This has brought about an inevitable devaluation of emotional experiences and an underestimation of their role in the society and in the individuals' lives. Under this perspective, the pain associated with experiences of separation has been the object of a particularly fierce denial.

The life cycle brings about an inevitable amount of emotional pain (*cfr*. [16]). Growth implies more or less traumatic separations. Aging undermines adult's social and family roles. Even in the hyper-medicalized society of antibiotics, vaccines and organ transplants, illness and death stay embedded in the human condition and are followed by an inevitable trail of suffering in the family and the community.

Against such experiences, contemporary culture has tried to put up an impassable wall, through the activation of massive defensive mechanisms. It has isolated and sterilized death within the hospital container. Has hidden corpses in far-flung crematoria.

We all know the impact such cultural structures have had on the elaboration of the response to Coronavirus epidemic. Besides, the distancing between generations, but also within the sexual couple, which is so obvious in contemporary society, dates back to some decades before virologists have agitated the threat of intrafamilial contagion.

The ever increasing and now undisputed success of the paradigm of the nuclear family and the concurrent spread of permanent celibacy give evidence of a widely shared fear and uneasiness with close interpersonal relationships and amount to an exasperated response to the issue of interpersonal and couple conflicts.

*Psychoanalysis and Non-Adherence to Medical Advice: An Ethical Dilemma in Covid-19… DOI: http://dx.doi.org/10.5772/intechopen.97744*

No human interaction, though, can be immune from a meaningful exchange of emotions: happy, but more often sad ones. Any contact within the couple or the family conveys not only viruses but also an unavoidable burden of anxiety, pain, conflicts and fears. This is the very contagion which frightens contemporary men: the emotions which arise in interpersonal interactions.

No safety measure, though, no surgical or FPP3 mask can spare us this emotional contagion. From the toil of interpersonal relationships can only the most extreme autism free us. Or death.

We will now report a psychoanalytic case, which may offer some further insight in the phenomenon of pandemic related anxiety and the use of social distancing as a way to regulate emotional distance in relationship.

#### **5. Nedda and social distance**

COVID pandemic stroke during the third year in Nedda's second analytic experience with me. Nedda – then about 50 years old - had been referred to me for a depressive state some years earlier. Her first treatment segment had been focused on her interpersonal patterns. The analytic work had revealed a severely dependent oral structure with inability to handle separation from mother and sisters within a large family.

Since the first consultation, Nedda's imposing appearance had given further evidence of a severe dysfunction in her oral libidinal organization. Her severe obesity seemed to have stripped her body from the most obvious female shape markers. Her dressing style, her attitude and her behavior all concurred in reassuring the interviewer that she represented no sexual challenge or opportunity. In fact, she was compliant with every social norm or widespread ethical ideal, and made every effort to let the interviewer feel at ease and in control. She never questioned treatment rules and conventions.

In the first treatment segment the interpersonal sources of depressive symptoms had been a major concern and interpretative interventions had been limited to the more superficial components of transference. Nearly two years elapsed before Nedda sought again my help.

In the second treatment segment, the question of weight control took the foreground in sessions for a while. Due to her obesity, she experienced severe abdominal problems, which required surgical treatment. For a few weeks, she attended self-help meetings for eating disorders. However, at the time of the onset of COVID-19 epidemic in Italy, the issue of weight control had already slipped back in the background or, rather, it had even been forgotten.

Nedda was now completely focused on her unique marital relationship. Consistently with her developmental pattern, the relation was very close, nearly suffocating, and the spouses' social interactions outside the couple were limited to immediate relatives. A single medication supported intercourse, on the wedding night, had been extremely dissatisfying, and was followed by no other attempt over 15 years. Nedda and her husband used to spend all of their free time in their apartment, but their relationship was strained, with chronic hostility and coldness, and occasional rage outbursts.

Nedda seemed absolutely unaware of her contribution to the permanent sexual inhibition in the couple. Her husband's poor availability to undergo treatment for a possibly somatically based impotence was to her the undisputable evidence of his guilty indifference. While never considering the option of becoming a mother through artificial insemination, she laid on him all the blame for her having missed the experience of motherhood.

She consumed sessions after sessions in complaining of her husband's insensitivity. If her house was usually in a mess and the furniture had never been completed this was due only to her husband's insufficient motivation and general fear of responsibility. Consistently, Nedda believed her consistent devaluation and coldness had no impact on the chronic depression he had been suffering for years. This highly ambivalent but obviously symbiotic lifestyle was bound to get even more strained due to the impact of COVID 19, as we will soon see.

Sessions with Nedda used to develop along one of two possible patterns. In the first pattern, which we might term *warm*, Nedda flooded the office with her emotions and words. Outrage and blame were the prevailing affects.

The object of blame might vary: the boss, a colleague, a sister or a sister in law. Usually, the husband seemed to carry most of the guilt. When a session unfolded according to this *warm* pattern I had limited room available for my interventions.

Generally, the misdeeds of the guilty character were described in detail and took most of the session. I had only the option to listen in silence or ask for some additional information. Whenever I could finally have a chance to offer an interpretative intervention, Nedda would immediately got overcome by emotionality and tears.

In the subsequent session or sessions, Nedda would typically appear quiet and satisfied. She would waste the session in trivial chatter, which offered no meaningful material for my interventions. I will term this second associative pattern a *cold* pattern. During *cold* sessions I often felt uninvolved and needed a substantial effort to keep adequate attention.

At the time COVID-19 epidemic reached our country, I was dissatisfied with Nedda's treatment. I could envisage no clear goal or therapeutic pathway. I began to believe Nedda was unable to sustain any interpretative work. She apparently came to the sessions to the only aim of checking my continuing availability and keeping at bay any interpretative effort by me.

COVID pandemic unavoidably had a substantial impact on the therapeutic relation. As a physician spending some hours a week in an inpatient psychiatric facility, located within a general hospital, I expectedly got ill with Coronavirus syndrome early, even days before the epidemic had been officially recognized in Italy by local health authorities. I could personally inform Nedda of my condition, which kept me from meeting her in session for some time. Nedda had no difficulty in getting back to analytic work as soon as I had recovered.

While back in my office, I felt clearly relived by my somewhat easy recovery. Although I needed no hospital treatment, the experience of a potentially lethal condition is bound to bring about a closer awareness of the reality of death. In the first session after the interruption, I often realized my interventions included a measure of basically improper optimism about the epidemic, which gave evidence of the activation of manic defenses.

Nedda's behavior in session showed a clear compliance with what she guessed were my unconscious expectations. Neither then nor later she showed any hesitation in attending sessions with me, and the treatment was suspended only over a short time period, when a general ban on outpatient health services was enforced by authorities for epidemiological reasons.

However, in her life outside the analytic situation, Nedda stuck to the opposite attitude with reference to contagion prevention. As time went by and the morbidity and lethality associated with the COVID 19 disease came to be more and more apparent, Nedda's social isolation got absolute.

She worked only on a remote working basis. She left her house only to purchase food. She meticulously disinfected each shopping bag. She ceased meeting any relatives of her, including her old mother.

*Psychoanalysis and Non-Adherence to Medical Advice: An Ethical Dilemma in Covid-19… DOI: http://dx.doi.org/10.5772/intechopen.97744*

At the time the illness was ravaging in Italy, her life choices were far from exceptional within the general population. However, as the months elapsed, most citizens kept to the restrictions suggested by official health institutions and avoided any further preventive procedures.

Nedda, on the other hand, continued to lead an extremely secluded life. At length she got back to office every now and then, but met her mother and sisters only in a couple of instances (two funerals) over an entire year. She had no other human contact beside her husband. However, oddly enough, particularly as the media were emphasizing the epidemiological risk associated with healthcare professionals, Nedda never questioned meeting me regularly in sessions. Nedda used to enter the room with some hesitation, as if she feared the contact with me might be actually the cause of an infection, but once inside she seemed to lose any inhibition, and even occasionally dropped her face mask as a matter of course.

I will now report a sequence of sessions which yielded novel insights into Nedda's specific transference patterns and into the anxieties elicited in her by the COVID pandemic. Nedda began a session by reporting how the COVID pandemic had painfully affected her own life. She particularly missed very much a chance to meet again her mother physically. I pointed out to her that the COVID-19 epidemic had led her to a nearly complete withdrawal from social and even family life, but that she apparently didn't fear meeting with a physician in occasional clinical contact with COVID patients.

Nedda felt the need to justify herself. She had not forgot her mother. She got in touch with her daily on the phone. Beside, the choice for a definitive physical distancing from her had not been completely her own, and had actually been forced on her by her youngest sister. Nedda had always described the latter as aggressive and authoritarian. Against her will, no one in the family, and particularly Nedda, dared to act.

I told Nedda that the COVID-19 pandemic had dramatically changed her own life. She had lost the relationships which had meant so much, which had even meant all to her till some months earlier. I acknowledged her view that her sister's pressure had been a meaningful factor but formulated the hypothesis that she was less in need of contact with her relatives than before.

The patient acknowledged only that she felt some annoyance towards her sister. She had felt rejected in a couple of episodes. She did not appeared particularly moved or interested by my comments.

Some sessions elapsed and Nedda entered my office in a state of deep distress. After some unsubstantial interpersonal memories, she focused on her husband. She was fed up with him. She reported that he had been withdrawn and depressed for a couple of weeks. She was not willing to put up with him any longer, and in fact she had been more explicitly aggressive and devaluing towards him than ever.

Nedda went on reporting that during a quarrel her husband had even put his hands at her neck, and could only with difficulty control the drive to chock her. I, too, found some difficulty in controlling my countertransferential response to the patient's communication.

I felt the patient was in some way provoking me no less than her husband. She was apparently precipitating an explosive couple conflict which could prove dramatically dangerous. After years of analysis, she was still turning more to acting out than to associations in the analytic room as a communication device. I could exteriorly control my helplessness feelings and shared with the patient my concern for her health and even life. Nedda spent most of the last part of the session in tears but did not express any manifest comment on my intervention.

In the following session things were different. Nedda was outraged and flooded the room with savage blaming. The focus was no more the husband, though,

rather myself. In a way disregarding my manifest comment on the dangers she was exposed to, she relied on an intuitive insight into my countertransferential feelings. To her I was implicitly siding with her husband, a violent, murderous man. I wasn't defending her from him, even when her own life was at stake.

At the time, Nedda's transference was obviously dominated by an oedipal unconscious fantasy where a heroic knight was bound to rescue her from the hand of an impotent but murderous father. Nedda's fantasy may also have included a dawning awareness that her enormous body would never allow her to compete with mother's beauty and erotic power.

Nedda talked in a loud voice and vomited her blames on me one after the other. For several minutes I was unable to stop her complaint. I felt both hurt by her authoritarian projective blames and helpless. Finally, I commented that she was realizing psychoanalysis, particularly psychoanalysis with myself, was different from what she expected and maybe even from what she could actually need.

She was looking for someone to encourage, support and praise her, someone who could show agreement with all she made and said. I admitted a relation like that – which we can here characterize as regressive and narcissistic – could temporarily ease her emotional pain, but made clear that psychoanalysis was something different.

It amounted to an interaction with a professional who has his own identity, and just because of that can offer novel views and open new doors. This was the only way genuine interpersonal change might be brought about.

The intervention proved able to loose tension in the session. The patient told me she didn't need now to interrupt the treatment as she had decided before entering the office.

To me the session had been extremely informative and had offered the elements I was badly in need to properly formulate Nedda's transference. I was now in the position to answer some questions: Why had Neddda exceeded authorities' recommendations and turned to a phobic avoidance of most human interactions? Why did she meet her analyst with no apparent anxiety and even occasionally and deliberately pull off her face mask?

In fact, Nedda feared nothing more than an object, an interpersonal object. After weaning she had never accepted her mother could no more directly answer her oral emotional needs. And had turned to concrete, material nourishment in order to sustain the fantasy of an omnipotent mother which was indefinitely available to her oral wishes.

Her regressive oral inner world was at ease with self-object and only with selfobjects. A male sexualized object did not frighten her because of his valuable gifts or his ability to elicit libidinal forces within her body. Rather, she deeply feared the emotional exchange which any interaction with an external object is bound to yield. An object has his own wishes, fears and memories. An object hosts his own fantasies within his own inner world. An object can receive projections, can react empathically, but may also be withdrawn, hurt or enraged.

In the transference, she was often unable to resist her own oral greed. She felt forced to close distance to the analyst, to meet at last a human being, to find a listener to her pain. Such transference wish brought about *warm* sessions, where communication in the analytic situation was intense.

However, this very transference communication and exchange was bound to enhance her deep fears. Her need to be fully in control in any interpersonal relationship was severely threatened. She felt helpless, exposed, dependent on the transference object for her emotional well-being. To her, human interactions included then a virus, an emotional contagion. In the *cold* sessions which systematically followed the warm ones, she wore again an emotional mask and meaningful communication got restricted.

#### *Psychoanalysis and Non-Adherence to Medical Advice: An Ethical Dilemma in Covid-19… DOI: http://dx.doi.org/10.5772/intechopen.97744*

In Nedda's case, exaggerated illness prevention measures amounted to a strategy to control interpersonal interactions and keep at bay her unlimited interpersonal greed. The severe social and interpersonal withdrawal Nedda had gone through in the third analytic year was not based on health related concerns. It was Nedda's strategy to shelter herself from the threats implied by close interpersonal relationships and particularly by the transference relationship.

Nedda's case teaches us that the primitive part of personality may be continuously concerned with the emotion elicited by interpersonal relationships. The resulting persistent conflict between the unlimited longing for close interactions with significant others and the concomitant fear of being flooded with projections by the interpersonal objects has played a significant role all through human history. We have mentioned above how widely shared cultural representations and institutions offer evidence that inter-human contact is dangerous. Contemporary society enhanced concern with the threat of infectious diseases, a concern which dates back much earlier than coronavirus epidemic, is very likely to thrive on this very unconscious threat.

To a psychoanalytic eye, the general public representations of compliance vs. nonadherence to prevention measures are massively infiltrated by socially shared unconscious phantasies based on the dangers of interpersonal contact. As both clinically active and theoretically informed psychoanalysts, we are consistently called to understand the unconscious roots of these very phenomena.

#### **6. Psychoanalysis and freedom**

Sigmund Freud developed psychoanalysis as an antidote against the hypocrite moralism of Victorian Europe. Freud believed that the freedom with which he had been able to explore human sexuality was the most important source of the opposition psychoanalysis met in the to him contemporary culture.

Psychoanalysis still remains a theory and a practice which allow those who have been silenced to open their mouth at last, which lend to the repressed unconscious contents an unexpected freedom of speech. Psychoanalysis is a subversive discipline.

Psychoanalysis has always been unwelcomed in totalitarian regimes. In Soviet Russia it was banned altogether [17]. In Nazi Germany it underwent a process of *Gleichschaltung* (integration) within Nazi state institutions, and was submitted to the leadership of Mathias Göring, the cousin of the infamous Hermann Göring, Hitler's close co-worker [18].

Within the framework of the dramatic reality we are currently experiencing, psychoanalysts, no less than other citizens, can agree with various different preventive strategies and support various political forces. They must always remember, however, that the psychoanalytic endeavor implies a position of strict neutrality vis-a-vis political and social issues.

In *Tatbestandsdiagnostik und Psychoanalyse,* Freud [19] wrote that psychoanalysis is a *sui generis* science of the inner world, i.e., of the wishes and representations which haunts the patient's unconscious. Psychoanalysis can in no way contribute to the testing of factual reality. It can validate no political or ideological statement.

Freud believed psychoanalysis thrived on the search for truth ([20], p 94), but psychoanalytic truth is never an external, objective truth. It's always a subjective truth, better a dyadic truth, which is piecemeal constructed within any specific patient-analyst couple.

In order to effectively reach such subjective truth, the psychoanalyst is required to keep to a position of strict neutrality with reference to the object of his investigation. There's no doubt: a psychoanalyst will never be able to enroll his or her professional skill in the service of any ideology or social model, however valuable to the society at large it might be, without permanently infringing his or her professional ethic.

## **Author details**

Paolo Azzone Unit for the Outpatient Treatment of Forensic Psychiatric Patients, ASST-Rhodense Hospital, Milan, Italy

\*Address all correspondence to: paoloazzone@hotmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Psychoanalysis and Non-Adherence to Medical Advice: An Ethical Dilemma in Covid-19… DOI: http://dx.doi.org/10.5772/intechopen.97744*

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*Anxiety, Uncertainty, and Resilience During the Pandemic Period - Anthropological...*

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#### **Chapter 14**
