Psychodynamic Issues

General Principles

Psychodynamic terms have numerous definitions, and are used in different ways in different contexts. However, some of the basic psychodynamic terms and principles that are useful in understanding the ways that people relate to one another emotionally include:

• 1.

  Transference—the feelings the patient has for the psychiatrist. Some of these arise in response to the psychiatrist as he or she truly is in reality, whereas some of these are reactions to characters in the patient’s past (parents, teachers, bosses, etc.) being displaced on to the psychiatrist.

• 2.

  Countertransference—the feelings aroused in the psychiatrist in reaction to the patient (or the family of the patient, other medical professionals, etc.). Some of these responses may originate from the patient, such as in a psychiatrist’s reaction to a patient who has a history of malingering presenting to the emergency room and demanding to be seen immediately. In other cases, countertransference may come from the life of the physician, such as when a patient who has recently lost a family member reminds the on-call psychiatrist of a recent loss in his or her own life.

• 3.

  Conscious mind—the part of the “mind” that is experienced as the ongoing thought process during waking hours of the day.

• 4.

  Unconscious mind—the part of the “mind” that is not always accessible as conscious thoughts (although there are glimpses of it visible in dreams) but that also influences behavior and decisions people make.

• 5.

  Defense mechanisms—patterns of behavior that help people deal with the day-to-day conflict between what they really want for themselves and the demands of real life (e.g., financial obligations, the needs of other people).

All people use defense mechanisms to cope with the stressors of everyday life, and generally do so at an unconscious level (i.e., the person is usually not aware of the behavior). The kinds of defense mechanisms used (often considered on a scale from “immature” to “mature”), or the rigidity with which they are used, make them adaptive or maladaptive. For instance, many people adaptively use the mature defense of humor as a way to deal with what might otherwise be an overwhelming situation (e.g., a cancer patient who has lost her hair because of chemotherapy joking about how she will not have to spend money on the hairdresser for a while). However, sometimes less adaptive defenses come to the fore, especially in psychiatrically ill patients, or even generally well-functioning patients who are under medical stress. Understanding some of these more immature defenses through the case examples in this chapter may help the on-call psychiatrist deal with patients and other people on call. The defense mechanisms illustrated will include:

• 1.

  Denial—refusing to acknowledge the reality of a situation without being consciously aware of this refusal.

• 2.

  Projection—attributing one’s own ideas or emotions to another person.

• 3.

  Projective identification—one person has unconsciously “telescoped” his or her feelings “into” a second person, and the second person has unconsciously taken these feelings as his or her own.

• 4.

  Splitting—seeing people as being either all good or all bad; this involves the process of idealizing and/or devaluing another person.

• 5.

  Somatization—focusing on the body to avoid focusing on emotions.

• 6.

  Help-rejecting complaining—asking for help with a problem and then rejecting the help that is offered.

Recognizing defenses used by a patient on call serves essentially two purposes for the psychiatrist:

• 1.

  If the psychiatrist is able to recognize what is happening, he or she can then exercise a choice to not react counter-therapeutically. For instance, if the psychiatrist finds himself or herself on the bad side of a split (i.e., devalued), he or she can try to understand why the patient is reacting in this way. Being able to think this through will provide valuable information about the patient and help the psychiatrist develop the short-term alliance that is essential in dealing with patients on call.

• 2.

  The goal of the psychiatrist on call is not necessarily to help patients change, but to help them through their current emergency safely. Therefore recognizing defenses and attempting to encourage the patient to use his or her most adaptive ones in the present is often helpful. Alternatively, if no adaptive defenses seem to be available to the patient in the moment, the psychiatrist can sometimes use awareness of the patient’s maladaptive defenses to educate other staff on how to best deal with the patient acutely.

Clinical Examples

These clinical examples will further elucidate some of the principles listed and demonstrate the ways they will be useful on call.