quickly"to get it over with"without taking the patient's readiness into consideration. Denial, at least partial denial, is used by almost all patients, not only during the first stages of illness or following confrontation, but also later on from time to time. Who was it who said, "We cannot look at the sun all the time, we cannot face death all the time"? These patients can consider the possibility of their own death for a while but then have to put this consideration away in order to pursue life I emphasize this strongly since I regard it a healthy way of dealing with the uncomfortable and painful situation with which some of these patients have to live for a long time. Denial functions as a buffer after unexpected shocking news, allows the patient to collect himself and, with time, mobilize other, less radical defenses. This does not mean, however, that the same patient later on will not be willing or even happy and relieved if he can sit and talk with someone about h impending death. Such a dialogue will and must take place at the convenience of the patient when he(not the listener! )is ready to face it. The dialogue also has to be terminated when the patient can no longer face the facts and resumes his previous denial. It is irrelevant when this dialogue takes place. We are often accused of talking with very sick patients about death when the doctor feels- very rightfully so-that they are not dying. I favor talking about death and dying with patients long before it actually happens if the patient indicates that he wants to. a healthier, stronger individual can deal with it better and is less frightened by oncoming death when it is still"miles away"than when it"is right in front of the door, "as one of our patients put it so appropriately. It is also easier for the family to discuss such matters in times of relative health and well-being and arrange financial security for the children and others while the head of the household is still functioning. To postpone such talks is often not in the service of the patient but serves our own defensiveness Denial is usually a temporary defense and will soon be replaced (P36) placed by partial acceptance. Maintained denial does not al ways bring increased distress if it holds out until the end, which I still consider a rarity. Among our two hundred terminally ill patients, I have encountered only three who attempted to deny its approach to the very last. two of these women talked about dying briefly but only referred to it as"an inevitable nuisance which hopefully comes during sleep"and said"I hope it comes without pain. After these statements they resumed their previous denial of their illness The third patient, also a middle-aged spinster, apparently had used denial during most of her life She had a visible, large ulcerative type of cancer of the breast but refused treatment until briefly before she died. She had great faith in Christian Science and held onto this belief to the last day. In spite of her denial, one part of her must have faced the reality of her illness since she did finall accept hospitalization and at least some of the treatments offered to her. When I visited her prior to planned surgery, she referred to the operation as "cutting part of the wound out so it can heal better. " She also made it clear that she wished only to know details regarding her hospitalization which have nothing to do with my wound "Repeated visits made it obvious that she feared any communications from staff members, who might possibly break down her denial, i.e., talk about her advanced cancer. As she grew weaker, her makeup became more grotesque. Originally rather discretely applied red lipstick and rouge, the makeup became brighter and redder until she resembled a clown. Her clothing became equally brighter and more colorful as her end approached
quickly "to get it over with" without taking the patient's readiness into consideration. Denial, at least partial denial, is used by almost all patients, not only during the first stages of illness or following confrontation, but also later on from time to time. Who was it who said, "We cannot look at the sun all the time, we cannot face death all the time"? These patients can consider the possibility of their own death for a while but then have to put this consideration away in order to pursue life. I emphasize this strongly since I regard it a healthy way of dealing with the uncomfortable and painful situation with which some of these patients have to live for a long time. Denial functions as a buffer after unexpected shocking news, allows the patient to collect himself and, with time, mobilize other, less radical defenses. This does not mean, however, that the same patient later on will not be willing or even happy and relieved if he can sit and talk with someone about his impending death. Such a dialogue will and must take place at the convenience of the patient when he (not the listener!) is ready to face it. The dialogue also has to be terminated when the patient can no longer face the facts and resumes his previous denial. It is irrelevant when this dialogue takes place. We are often accused of talking with very sick patients about death when the doctor feelsvery rightfully so-that they are not dying. I favor talking about death and dying with patients long before it actually happens if the patient indicates that he wants to. A healthier, stronger individual can deal with it better and is less frightened by oncoming death when it is still "miles away" than when it "is right in front of the door," as one of our patients put it so appropriately. It is also easier for the family to discuss such matters in times of relative health and well-being and arrange 'or financial security for the children and others while the head of the household is still functioning. To postpone such talks is often not in the service of the patient but serves our own defensiveness. Denial is usually a temporary defense and will soon be replaced (P36) placed by partial acceptance. Maintained denial does not always bring increased distress if it holds out until the end, which I still consider a rarity. Among our two hundred terminally ill patients, I have encountered only three who attempted to deny its approach to the very last. Two of these women talked about dying briefly but only referred to it as "an inevitable nuisance which hopefully comes during sleep" and said "I hope it comes without pain." After these statements they resumed their previous denial of their illness. The third patient, also a middle-aged spinster, apparently had used denial during most of her life. She had a visible, large ulcerative type of cancer of the breast but refused treatment until briefly before she died. She had great faith in Christian Science and held onto this belief to the last day. In spite of her denial, one part of her must have faced the reality of her illness since she did finally accept hospitalization and at least some of the treatments offered to her. When I visited her prior to planned surgery, she referred to the operation as "cutting part of the wound out so it can heal better." She also made it clear that she wished only to know details regarding her hospitalization "which have nothing to do with my wound." Repeated visits made it obvious that she feared any communications from staff members, who might possibly break down her denial, i.e., talk about her advanced cancer. As she grew weaker, her makeup became more grotesque. Originally rather discretely applied red lipstick and rouge, the makeup became brighter and redder until she resembled a clown. Her clothing became equally brighter and more colorful as her end approached
During the last few days she avoided looking in a mirror, but continued to apply the masquerade in an attempt to cover up her increasing depression and her rapidly deteriorating looks. When asked if there was anything we could do for her, she replied, "Come tomorrow. She did not say, " Leave me alone, " or"Don't bother me, but left the possibility open that tomorrow might be the day that her defenses would not hold up any longer, thus making help mandatory. Her last statement was guess I cannot make it anymore. She died less than an hour later Most patients do not use denial so extensively. They may briefly talk about the reality of their situation, and suddenly indicate their inability to look at it realistically any longer. How do we know, then, when a patient does not wish to face it anymore? He may talk about relevant issues as far as his life is concerned, he may share some important fantasies about death itself or life after death(a denial in itself), only to change the topic after a few minutes, almost contradicting what he said earlier. Listening to him at this point may seem like listening to a patient with a minor ailment, nothing as serious as a life threatening condition. This is when we try to pick up the cues and acknowledge(to ourselves) that this is the moment at which the patient prefers to look at brighter, more cheery things. We then allow the patient to daydream about happier things, no matter how improbable they may be. (We have had several patients who daydreamed about seemingly impossible situations which-much to our surprise-became true What I am trying to emphasize is that the need for denial exists in every patient at times, at the very beginning of a serious illness more so than towards the end of life. Later on the need comes and goes, and the sensitive and perceptive listener will acknowledge this and allow the patient his defenses without making him aware of the contradictions. It is much later, usually, that the patient uses isolation more than denial le can then talk about his health and his illness, his mortality and his immortality as if they were twin brothers permitted to exist side by side, thus facing death and still maintaining hope In summary, then, the patient's first reaction may be a temporary state of shock from which he recuperates gradually. When his initial feeling of numbness begins to disappear and lie can collect himself again, man's usual response is"No, it cannot be me. "Since in our unconscious mind we are lI immortal, it is almost inconceivable for us to acknowledge that we too have to face death Depending very much on how a patient k told, how much time he has to gradually acknowledge the inevitable happening, and how he has been prepared throughout life to cope with stressful situations, he will gradually drop his denial and use less radical defense mechanisms We have also found that many of our patients have used denial when faced with hospital staff members who had to use (P38) this form of coping for their own reasons. Such patients can be quite elective in choosing different people among family members or staff with whom they discuss matters of their illness or impending death while pretending to get well with those who cannot tolerate the thought of their demise. It is possible that this is the reason for the discrepancy of opinions in regard of the patient's needs to know about a fatal illness The following brief case description of Mrs. K. is an example of a patient who used massive denial for an extended period of time and shows our management of her from the time of admission until her death several months later
During the last few days she avoided looking in a mirror, but continued to apply the masquerade in an attempt to cover up her increasing depression and her rapidly deteriorating looks. When asked if there was anything we could do for her, she replied, "Come tomorrow." She did not say, "Leave me alone," or "Don't bother me," but left the possibility open that tomorrow might be the day that her defenses would not hold up any longer, thus making help mandatory. Her last statement was, "I guess I cannot make it anymore." She died less than an hour later. Most patients do not use denial so extensively. They may briefly talk about the reality of their situation, and suddenly indicate their inability to look at it realistically any longer. How do we know, then, when a patient does not wish to face it anymore? He may talk about relevant issues as far as his life is concerned, he may share some important fantasies about death itself or life after death (a denial in itself), only to change the topic after a few minutes, almost contradicting what he said earlier. Listening to him at this point may seem like listening to a patient with a minor ailment, nothing as serious as a life threatening condition. This is when we try to pick up the cues and acknowledge (to ourselves) that this is the moment at which the patient prefers to look at brighter, more cheery things. We then allow the patient to daydream about happier things, no matter how improbable they may be. (We have had several patients who daydreamed about seemingly impossible situations which-much to our surprise-became true.) What I am trying to emphasize is that the need for denial exists in every patient at times, at the very beginning of a serious illness more so than towards the end of life. Later on the need comes and goes, and the sensitive and perceptive listener will acknowledge this and allow the patient his defenses without making him aware of the contradictions. It is much later, usually, that the patient uses isolation more than denial. He can then talk about his health and his illness, his mortality and his immortality as if they were twin brothers permitted to exist side by side, thus facing death and still maintaining hope. In summary, then, the patient's first reaction may be a temporary state of shock from which he recuperates gradually. When his initial feeling of numbness begins to disappear and lie can collect himself again, man's usual response is "No, it cannot be me." Since in our unconscious mind we are all immortal, it is almost inconceivable for us to acknowledge that we too have to face death. Depending very much on how a patient k told, how much time he has to gradually acknowledge the inevitable happening, and how he has been prepared throughout life to cope with stressful situations, he will gradually drop his denial and use less radical defense mechanisms. We have also found that many of our patients have used denial when faced with hospital staff members who had to use (P38) this form of coping for their own reasons. Such patients can be quite elective in choosing different people among family members or staff with whom they discuss matters of their illness or impending death while pretending to get well with those who cannot tolerate the thought of their demise. It is possible that this is the reason for the discrepancy of opinions in regard of the patient's needs to know about a fatal illness. The following brief case description of Mrs. K. is an example of a patient who used massive denial for an extended period of time and shows our management of her from the time of admission until her death several months later
Mrs. K. was a twenty-eight-year-old white Catholic woman, mother of two preschool children. She was hospitalized with a terminal liver disease. A very careful diet and daily laborator measurement were mandatory to keep her alive We were told that two days before her admission to the hospital, she visited the medical clinic and was told that there was no hope for a recovery. The family reported that the patient"fell apart"until a neighbor reassured her that there was al ways some hope, encouraging her to attend a tabernacle where many people had been healed The patient then asked her priest for support but was told not to go to a faith healer On Saturday, the day after the clinic visit, the patient went to this faith healer and"immediately felt wonderful. She was found in a trance on Sunday by her mother-in-law, while the husband was out at work and the small children were left alone without being fed or otherwise attended to. The husband and mother-in-law brought her to the hospital and left before the physician was able to talk to them The patient asked for the hospital chaplain"to tell him of the good news. " When he entered her room she welcomed him in an exalted mood "Oh father it was wonderful. i have been healed. I am going to show the doctors that God will heal me. I am all well now. She expressed her sorrow that "even my own church did not understand how God works, "referring to the priest's advice not to visit the tabernacle The patient was a problem for the physicians since she denied her illness almost completely and became quite unreliable in regard to her food intake. She occasionally stuffed herself to a degree that she became comatose; at times she followed the orders obediently. For this reason a psychiatric consultation was requested (P39) When we saw the patient she was inappropriately cheerful, laughed and giggled, and reassured that she was completely well. She went around the ward visiting patients and staff, attempting to collect money for a gift for one of the staff physicians in whom she had immense faith, which seemed to indicate at least a partial awareness of her present condition. She was a difficult management problem as she was unreliable about her diet and medications and"did not behave like a patient. Her belief in her well-being was unshakable and she insisted on hearing it confirmed a discussion with the husband revealed a rather simple, unemotional man who seriously believed that his wife was better off living a short time at home with the children rather than having her suffering prolonged by long hospitalizations, endless costs, and all the ups and downs of her chronic illness. He had little empathy with her and separated his feelings quite effectively from the context of his thoughts. He matter-of-factly related the impossibility of having a stable home environment, with him working nights and the children living out during the week. Listening to him and placing ourselves into his position, we were able to appreciate that he could deal with his present life situation only in this detached manner. We were unable to relate some of her needs to him, in the hope that his empathy might diminish her needs for such denial, thus rendering her
Mrs. K. was a twenty-eight-year-old white Catholic woman, mother of two preschool children. She was hospitalized with a terminal liver disease. A very careful diet and daily laboratory measurement were mandatory to keep her alive. We were told that two days before her admission to the hospital, she visited the medical clinic and was told that there was no hope for a recovery. The family reported that the patient "fell apart" until a neighbor reassured her that there was always some hope, encouraging her to attend a tabernacle where many people had been healed. The patient then asked her priest for support but was told not to go to a faith healer. On Saturday, the day after the clinic visit, the patient went to this faith healer and "immediately felt wonderful." She was found in a trance on Sunday by her mother-in-law, while the husband was out at work and the small children were left alone without being fed or otherwise attended to. The husband and mother-in-law brought her to the hospital and left before the physician was able to talk to them. The patient asked for the hospital chaplain "to tell him of the good news." When he entered her room she welcomed him in an exalted mood: "Oh, Father, it was wonderful. I have. been healed. I am going to show the doctors that God will heal me. I am all well now." She expressed her sorrow that "even my own church did not understand how God works," referring to the priest's advice not to visit the tabernacle. The patient was a problem for the physicians since she denied her illness almost completely and became quite unreliable in regard to her food intake. She occasionally stuffed herself to a degree that she became comatose; at times she followed the orders obediently. For this reason a psychiatric consultation was requested. (P39) When we saw the patient she was inappropriately cheerful, laughed and giggled, and reassured us that she was completely well. She went around the ward visiting patients and staff, attempting to collect money for a gift for one of the staff physicians in whom she had immense faith, which seemed to indicate at least a partial awareness of her present condition. She was a difficult management problem as she was unreliable about her diet and medications and "did not behave like a patient." Her belief in her well-being was unshakable and she insisted on hearing it confirmed. A discussion with the husband revealed a rather simple, unemotional man who seriously believed that his wife was better off living a short time at home with the children rather than having her suffering prolonged by long hospitalizations, endless costs, and all the ups and downs of her chronic illness. He had little empathy with her and separated his feelings quite effectively from the context of his thoughts. He matter-of-factly related the impossibility of having a stable home environment, with him working nights and the children living out during the week. Listening to him and placing ourselves into his position, we were able to appreciate that he could deal with his present life situation only in this detached manner. We were unable to relate some of her needs to him, in the hope that his empathy might diminish her needs for such denial, thus rendering her
more amenable to effective treatment. He left the interview as if he had completed a compulsory task, obviously unable to change his attitude Mrs. K. was visited by us at regular intervals. She appreciated our chats, which dealt with daily happenings and inquiries about her needs She became gradually weaker and-for a couple of weeks- just dozed and held our hand, and did not speak much. After this she became increasingly confused was disoriented. and had delusions of a beautiful bedroom filled with fragrant flowers brought to her by her husband. When she became more clear, we tried to help her with arts and crafts to make he time go by a bit faster. She had spent much of her past weeks alone in a room, with the double doors closed, and few staff people dropped in since there was so little they felt they could do. The staff rationalized their own avoidance by such remarks as, She is too confused to know"and"I would not know what to say to her, she has such crazy ideas. "As she felt this isolation and increasing loneliness, she was often observed to take the telephone off the hook, "just to hear a voice (P40) When she was put on a protein-free diet she became very hungry and lost much weight. She would sit on her bed, holding the little bags of sugar between her fingers and say, " This sugar is finally going to kill me. I sat with her, and when she held my hand she said, "You have such warm hand I hope you are going to be with me when i get colder and colder "She smiled knowingly. She knew and i knew that at this moment she had dropped her denial. She was able to think and talk about her own death and she asked for just a little comfort of companionship and a final stage without too much hunger We did not exchange more than the abovementioned words; we just sat silently for a while, and when I left she asked if I would be sure to return and bring that wonderful OT(occupational therapist) girl with me, who helped her make some leatherwork for her family "so they have something to remember me by Hospital personnel, whether they are physicians, nurses, social workers, or chaplains, don't know what they miss when they avoid such patients. If one is interested in human behavior, in the daptations and defenses that human beings have to use in order to cope with such stresses, this is the place to learn about it. If they sit and listen, and repeat their visits if the patient does not feel like talking on the first or second encounter, the patient will soon develop a feeling of confidence that here is a person who cares, who is available, who sticks around When they are ready to talk, they will open up and share their loneliness, sometimes with words sometimes with little gestures or nonverbal communications. In the case of Mrs. K. we never attempted to break her denial, we never contradicted her when she assured us of her well-being. We just reinforced that she had to take her medication and stick to her diet if she wanted to return home to her children. There were days when she stuffed herself with forbidden foods, only to suffer twice as much the next days. This was intolerable and we told her so. This was part of reality that we could not deny with her. So, in a way, implicitly, we told her that she was critically sick. Explicitly, we did not do it because it was obvious that she was unable to tolerate the truth at that stage of her illness. It was much later, after having gone through stages of semi-comatose stupor and extreme
more amenable to effective treatment. He left the interview as if he had completed a compulsory task, obviously unable to change his attitude. Mrs. K. was visited by us at regular intervals. She appreciated our chats, which dealt with daily happenings and inquiries about her needs. She became gradually weaker and-for a couple of weeksjust dozed and held our hand, and did not speak much. After this she became increasingly confused, was disoriented, and had delusions of a beautiful bedroom filled with fragrant flowers brought to her by her husband. When she became more clear, we tried to help her with arts and crafts to make the time go by a bit faster. She had spent much of her past weeks alone in a room, with the double doors closed, and few staff people dropped in since there was so little they felt they could do. The staff rationalized their own avoidance by such remarks as, "She is too confused to know" and "I would not know what to say to her, she has such crazy ideas." As she felt this isolation and increasing loneliness, she was often observed to take the telephone off the hook, "just to hear a voice. (P40) When she was put on a protein-free diet she became very hungry and lost much weight. She would sit on her bed, holding the little bags of sugar between her fingers and say, "This sugar is finally going to kill me." I sat with her, and when she held my hand she said, "You have such warm hands. I hope you are going to be with me when I get colder and colder." She smiled knowingly. She knew and I knew that at this moment she had dropped her denial. She was able to think and talk about her own death and she asked for just a little comfort of companionship and a final stage without too much hunger. We did not exchange more than the abovementioned words; we just sat silently for a while, and when I left she asked if I would be sure to return and bring that wonderful OT (occupational therapist) girl with me, who helped her make some leatherwork for her family "so they have something to remember me by." Hospital personnel, whether they are physicians, nurses, social workers, or chaplains, don't know what they miss when they avoid such patients. If one is interested in human behavior, in the adaptations and defenses that human beings have to use in order to cope with such stresses, this is the place to learn about it. If they sit and listen, and repeat their visits if the patient does not feel like talking on the first or second encounter, the patient will soon develop a feeling of confidence that here is a person who cares, who is available, who sticks around. When they are ready to talk, they will open up and share their loneliness, sometimes with words, sometimes with little gestures or nonverbal communications. In the case of Mrs. K. we never attempted to break her denial, we never contradicted her when she assured us of her well-being. We just reinforced that she had to take her medication and stick to her diet if she wanted to return home to her children. There were days when she stuffed herself with forbidden foods, only to suffer twice as much the next days. This was intolerable and we told her so. This was part of reality that we could not deny with her. So, in a way, implicitly, we told her that she was critically sick. Explicitly, we did not do it because it was obvious that she was unable to tolerate the truth at that stage of her illness. It was much later, after having gone through stages of semi-comatose stupor and extreme
withdrawal, and stages of confusion with delusions of her husbands tender loving care expressed in the flowers, that she developed the strength to look at the reality of her situation and was able to ask for more palatable food and final companionship, which she sensed was not forthcoming from her Looking back at this long and meaningful relationship, I am sure that it was possible only because she sensed that we respected her wish to deny her illness as long as possible. We never became judgmental no matter how much of a management problem she presented ( Granted, that was much easier for us as we were a kind of visiting staff and not responsible for the balance of her diet or around her all day long from one frustrating experience to another. We continued our visits even during the times when she was totally irrational and could neither recall our face nor the professional role we played. In the long run it is the persistent nurturing role of the therapist who has dealt with his or her own death complex sufficiently that helps the patient overcome the anxiety and fear of his impending death. Mrs. K asked for two people during her final days in the hospital; one was the therapist with whom she exchanged few if any words at the time, occasionally just holding hands and expressing less and less concern about food, pain, or discomfort. The other person was the occupational therapist who helped her forget the reality for a while and allowed her to function as a creative, productive woman, making objects which she would leave for her family- maybe as little signs of immortality I use this example to show that we do not always state explicitly that the patient is actually terminally ill. We attempt to elicit the patients' needs first, try to become aware of their strength and weaknesses, and look for overt or hidden communications to determine how much a patient wants to face reality at a given moment. This patient, in many ways exceptional, made it quite clear from the very beginning that denial was essential in order for her to remain sane. Though many staff people regarded her as clearly psychotic, testing showed her (P42) sense of reality was intact in spite of the manifestations to the contrary. We learned from it that she was not able to accept her family's need to see her dead "the sooner the better "she was unable to acknowledge her own end when she had just started to enjoy her small children, and she desperately grasped at the reinforcement by the faith healer who assured her of excellent health Another part of her was, however, quite aware of her illness. She did not fight to leave the hospital in fact, she made herself quite comfortable there. She surrounded herself with many familiar items as if she was to stay for a long time.( She never left the hospital. She also accepted our limit- setting. She ate what she was asked to eat, with a few exceptions when she went overboard. She later acknowledged that she was unable to exist with so many restrictions and that the suffering was worse than death itself. One may regard the episodes of excessive overeating of forbidden foods as a form of suicide attempt, in that they would have brought about a rapid demise if the staff had not interfered so vigorously In a way, then, this patient showed a fluctuation between an almost total denial of her illness and a repeated attempt to bring about her death. Rejected by her family, often overlooked or ignored by the hospital personnel, she became a pitiful figure, a disheveled-looking young woman who sat desperately lonely on the edge of her bed, clutching the telephone to hear a sound She found
withdrawal, and stages of confusion with delusions of her husband's tender loving care expressed in the flowers, that she developed the strength to look at the reality of her situation and was able to ask for more palatable food and final companionship, which she sensed was not forthcoming from her family. Looking back at this long and meaningful relationship, I am sure that it was possible only because she sensed that we respected her wish to deny her illness as long as possible. We never became judgmental no matter how much of a management problem she presented. (Granted, that was much easier for us as we were a kind of visiting staff and not responsible for the balance of her diet or around her all day long from one frustrating experience to another.) We continued our visits even during the times when she was totally irrational and could neither recall our face nor the professional role we played. In the long run it is the persistent nurturing role of the therapist who has dealt with his or her own death complex sufficiently that helps the patient overcome the anxiety and fear of his impending death. Mrs. K. asked for two people during her final days in the hospital; one was the therapist with whom she exchanged few if any words at the time, occasionally just holding hands and expressing less and less concern about food, pain, or discomfort. The other person was the occupational therapist who helped her forget the reality for a while and allowed her to function as a creative, productive woman, making objects which she would leave for her familymaybe as little signs of immortality. I use this example to show that we do not always state explicitly that the patient is actually terminally ill. We attempt to elicit the patients' needs first, try to become aware of their strengths and weaknesses, and look for overt or hidden communications to determine how much a patient wants to face reality at a given moment. This patient, in many ways exceptional, made it quite clear from the very beginning that denial was essential in order for her to remain sane. Though many staff people regarded her as clearly psychotic, testing showed her (P42) sense of reality was intact in spite of the manifestations to the contrary. We learned from it that she was not able to accept her family's need to see her dead "the sooner the better," she was unable to acknowledge her own end when she had just started to enjoy her small children, and she desperately grasped at the reinforcement by the faith healer who assured her of excellent health. Another part of her was, however, quite aware of her illness. She did not fight to leave the hospital; in fact, she made herself quite comfortable there. She surrounded herself with many familiar items as if she was to stay for a long time. (She never left the hospital.) She also accepted our limitsetting. She ate what she was asked to eat, with a few exceptions when she went overboard. She later acknowledged that she was unable to exist with so many restrictions and that the suffering was worse than death itself. One may regard the episodes of excessive overeating of forbidden foods as a form of suicide attempt, in that they would have brought about a rapid demise if the staff had not interfered so vigorously. In a way, then, this patient showed a fluctuation between an almost total denial of her illness and a repeated attempt to bring about her death. Rejected by her family, often overlooked or ignored by the hospital personnel, she became a pitiful figure, a disheveled-looking young woman who sat desperately lonely on the edge of her bed, clutching the telephone to hear a sound. She found