Conscious/Unconscious
Unconscious processes must be considered to understand more fully the patient–physician relationship. The reality is that the majority of mental activity remains outside of conscious awareness. In the interview, unconscious processes may be suggested by tangential references to an issue, slips of the tongue or mannerisms of speech, what is not said or avoided, and other defense mechanisms. For example, phrases such as “to tell you the truth” or “to speak frankly” suggest that the speaker does not usually tell the truth or speak frankly. In the initial interview, it is best to note such mannerisms or slips but not to explore them. It may or may not be helpful to pursue them in subsequent sessions. In the interview, transference and countertransference are very significant expressions of unconscious processes.
Transference is the process of the patient unconsciously and inappropriately displacing onto individuals in his or her current life those patterns of behavior and emotional reactions that originated with significant figures from earlier in life, often childhood. In the clinical situation, the displacement is onto the psychiatrist, who is usually an authority figure or a parent surrogate. The psychiatrist must recognize that the transference may be driving the behaviors of the patient, and the interactions with the psychiatrist may be based on distortions that have their origins much earlier in life.
The patient may be angry, hostile, demanding, or obsequious not because of the reality of the relationship with the psychiatrist but because of former relationships and patterns of behaviors. Failure to recognize this process can lead to the psychiatrist inappropriately reacting to the patient’s behavior as if it were a personal attack on the psychiatrist.
Similarly, countertransference is the process where the physician unconsciously displaces onto the patient patterns of behaviors or emotional reactions as if he or she were a significant figure from earlier in the physician’s life. Psychiatrists should be alert to signs of countertransference issues (missed appointments by the psychiatrist, boredom, or sleepiness in a session). Supervision or consultations can be helpful as can personal therapy in helping the psychiatrist recognize and deal with these issues.
Although the patient comes for help, there may be forces that impede the movement to health. Resistances are the processes, conscious or unconscious, that interfere with the therapeutic objectives of treatment. The patient is generally unaware of the impact of these feelings, thinking, or behaviors, which take many different forms, including exaggerated emotional responses, intellectualization, generalization, missed appointments or acting out behaviors. Resistance may be fueled by repression, which is an unconscious process that keeps issues or feelings out of awareness. Because of repression, patients may not be aware of the conflicts that may be central to their illness. In insight-oriented psychotherapy, interpretations are interventions that undo the process of repression and allow the unconscious thoughts and feelings to come to awareness so that they can be handled. As a result of these interventions, the primary gain of the symptom, the unconscious purpose that it serves, may become apparent. In the initial session, interpretations are generally avoided. The psychiatrist should make a note of potential areas for exploration in subsequent sessions.
KAPLAN & SADOCK’S SYNOPSIS OF PSYCHIATRY
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