ABSTRACT
It is possible to teach residents to listen psychodynamically within pressured clinical systems that are organized around brief management interventions without changing the structure of the training program to create "selected psychotherapy cases." Two case vignettes illustrate the amount of psychodynamic data that can be elicited from a time-limited clinical assessment. Focusing on the psychodynamics of social systems and the subtle ways in which patients and clinicians become involved with each other during assessment meetings can allow trainees to grasp unconscious functioning, projective identification, transference/countertransference, and interpretation. This perspective opens a way of thinking that illuminates the patient's struggles, reduces the need for management by helping the patient take charge of his or her treatment, and opens possibilities for both patient and trainee to improve their capacity to listen, both to themselves and to the human systems that surround them.
Subject(s)
Internship and Residency , Physician-Patient Relations , Psychiatry/education , Psychotherapy/education , HumansABSTRACT
Hospitalized patients with treatment resistant comorbid Axis I and II psychiatric disorders have in common a developmental history that includes a lack of fit between their needs and their human environment. Adaptation of their personalities to this environmental failure contributes to these patients' lack of trust in authority. Treatment resistance may represent a repetition of this early experience, with the current biological and symptom focus of the field representing yet another insufficient environment. The author describes the components of a psychodynamic treatment institution that focuses on overcoming this dilemma through studying the process of relationships, attending to meaning, and maximizing patient authority. These principles may be applicable in a range of treatment settings where clinical staff members work with so-called "treatment resistant" patients.
Subject(s)
Authoritarianism , Hospitals, Psychiatric/organization & administration , Interpersonal Relations , Mental Disorders/therapy , Patient Participation/methods , Psychoanalytic Therapy/methods , Adaptation, Psychological , Humans , Massachusetts , Mental Disorders/psychology , Parent-Child Relations , Patient Compliance , Patient Participation/psychology , Personality Disorders/psychology , Personality Disorders/therapy , Professional-Patient Relations , Social Environment , Transference, Psychology , Treatment Failure , TrustABSTRACT
When engaged with others in tension-filled dialogue, the temptation is for us to treat the other disrespectfully by unconsciously choosing an exclusive subgroup in our minds to belong to, and assigning the other to a devalued group. Unconsciously asserted exclusive membership allows us to deny the ways in which, by disconnecting the other, we are also alienating parts of ourselves. Using three stories, the author explores the notion of unconscious group membership and raises the possibility of discovering a shared membership in the midst of conflict. Internalized shared group membership can constitute a mediating "third" to a dyad in apparent opposition. The shared internal context both contains and defines the pair within a task and set of values that can be used to transcend apparent conflict.
