|Year : 2017 | Volume
| Issue : 1 | Page : 40-44
An account of psychiatric casework in three clinical encounters using a psychoanalytic lens
Department of Psychotherapy, Leeds and York Partnerships NHS Foundation Trust, Leeds, LS2 9PJ, UK
|Date of Web Publication||19-Jun-2017|
Department of Psychotherapy, Leeds and York Partnerships NHS Foundation Trust, 40 Clarendon Road, Leeds, LS2 9PJ
Source of Support: None, Conflict of Interest: None
Transference and countertransference are key diagnostic concepts in psychoanalysis which are unacknowledged in categorical diagnostic systems in psychiatry. This may also highlight the fundamental differences in understanding clinical presentation in the context of the individual. In psychoanalysis, the clinician's response to each patient is carefully thought about. Three vignettes are used to illustrate how clinicians use their countertransference to ask key questions which address the sense of the uncanny that the patients' stories evoke. This is then linked, using the theoretical notion of projective identification, to unconscious communication between doctor and patient. I conclude by describing an ICD-10 category of patients who present a disturbance in articulating emotions, tending to evoke and manifest powerful bodily experiences. The examination of countertransference is suggested as adding depth to a diagnostic process that risks losing the value of data from individual patients.
Keywords: Countertransference, ICD-10, psychoanalysis, transference, uncanny
|How to cite this article:|
Menon A. An account of psychiatric casework in three clinical encounters using a psychoanalytic lens. Ann Indian Psychiatry 2017;1:40-4
|How to cite this URL:|
Menon A. An account of psychiatric casework in three clinical encounters using a psychoanalytic lens. Ann Indian Psychiatry [serial online] 2017 [cited 2019 Jan 22];1:40-4. Available from: http://www.anip.co.in/text.asp?2017/1/1/40/208340
| Introduction|| |
I first considered writing this article following a lively discussion with some colleagues about the differences between a psychoanalytic and psychiatric practice. Most seem obvious: the frame and setting, relevance of prescribing, remit of the clinician, primacy of establishing diagnosis in psychiatry versus understanding process in psychoanalysis, and so on. In my work with psychoanalytic patients, I offer open-ended work, with a commitment between the analyst and patient to a curiosity about their inner worlds. In psychiatry, one is perhaps limited by having to identify therapeutic goals. Patients are understood and formulated in very different ways by the two disciplines. One of the crucial differences, the close attention paid to transference/countertransference, highlights an aspect of routine psychiatric work which, being more subject to external considerations, becomes difficult to calibrate.
| Transference and Countertransference in Context|| |
Hughes and Kerr  state in a mainstream psychiatric journal that any therapeutic setting where a person is seen frequently (and sometimes even infrequently) and his or her emotional needs attended to promotes transference, defined by Laplanche and Pontalis  as the “process of actualization of unconscious wishes” (in the analysand). In psychoanalysis, where transference is the core of the therapeutic endeavor, great attention is paid to create the atmosphere for its emergence and growth. Transference in psychiatry, however, being often regarded as an “incidental” development, is viewed differently.
Countertransference in psychoanalysis refers to the entirety of the analyst's unconscious responses to the patient, especially to their transference. Unfortunately, the myriad inner responses that psychiatrists have toward patients are often dismissed as inconvenient or “subjective,” in favor of more objective and “evidence-based” methods of diagnosing psychiatric conditions.
| Clinical Vignettes|| |
I have chosen these patients for two reasons.
First, they are all patients I saw in my clinic where I practice as a psychiatrist, not as a psychoanalyst. Superficially, there is nothing unusual in the requests made by the family doctors who referred them to me. They all query, in different ways, why these patients don't seem to be responding to medication, whether there could be another approach that helps. But such was the presentation that, rather than debate-exciting pharmacological options, I found myself examining a strange sense of the “uncanny” I felt in the patients' presence.
Secondly, all the three patients had reached a point where they were unable to relate meaningfully to others; yet they all seemed to have evoked powerful responses in assessors, who seemed to refer them on to seek understanding and help.
Writing a case series could be done either by making a deliberate link between the cases or not. Here they are linked, and I think that the link is my countertransference, a sense of disquiet which spurred me on to reach for psychoanalytic theory and a writing exercise to offer meaning.
Ms. B, aged 50 years, presented with a depressive relapse, and this time, it was proving difficult to treat. She was an efficient-looking, pleasant single woman who introduced herself as a senior paramedic on easy terms with her worried family doctor. At home, she was the responsible daughter who looked after others, different from her more easy-going older siblings. Her father was a silent, absent man, and Ms. B was close to her youthful mother. While she established a good career, her relationships were with rather callous men who eventually lost interest in her. Overeating seemed a long-standing, hidden problem. She told me that she had never quite understood why she was so good at her job yet so inept with personal relationships.
Her initial depression came on after her mother died of cancer, and although I had an impression of a recent bereavement, it turned out that her mother had died about 3 years ago. Her vivid description of a very short period between diagnosis and death chilled me. Ms. B chose to nurse her mother till the end and retained powerful visual and tactile impressions from this period, mainly to do with mother “looking dead” while she tried to keep her alive. After this first episode, she improved but a job restructure recently had left her feeling disempowered and less necessary to others. As she described her humiliation at being told what to do by a younger line manager, and the emerging depression which brought her to me, I wondered again about her feelings while she nursed her dying mother. I felt an intense urgency, a pull to address her loss, and return something to her.
| My Question|| |
Why did I feel that losing her mother was recent (contrary to facts), and was this relevant to her state of mind?
Mr. R, aged 52 years, began his story at the exact point in his life after he made a suicide attempt, 20 years ago. Following a period of depression, he took a massive overdose of antidepressants. He woke feeling sick and weak and managed to seek help a few days later. Mr. R began to feel that he had “died” by overdose and returned after a period of rigor mortis. His body “never felt the same afterward,” and he described valves “going” in his stomach, internal joints in his wrists/arms/shoulders morphing. He described the triggering damage as a sudden rent, a sort of piercing force that moved up from his stomach to his heart at the time of his attempt.
One specialist wondered whether he presented with somatic delusions. Mr. R's presentation did make me consider the same, except that he apologized repeatedly for “sounding mad.” I asked him how he'd like to be addressed, a question I'd thought was innocuous enough, he unexpectedly told me he never felt that he belonged when he grew up in the rough part of town with such a fanciful name that his mother saddled him with.
He was 50 and he had no idea how he got there, saying it was a “lost life.” He was on a quest for answers. My feelings at this point were a mix of pity, helplessness, and an odd, yet intense curiosity which made me re-book him into my clinic for a better “full” assessment, something I later discovered that most psychiatrists who saw him had done, one way or another.
Mr. R's view was that his parents' marriage broke down as his mother was socially superior to father. She had children from a previous marriage; this had also broken down as she perhaps felt morally superior to a husband who had been unfaithful to her. Mr. R seemed to have grown up feeling that he was just like his rough and illiterate father, ignored by a bitter mother, and ostracized by his half-siblings in a home where “nothing made sense” and he never could gauge others' motives. His two romantic relationships turned out unsatisfactory as he eventually felt inferior. The suicidal depression set in soon after he inherited some property when his mother died.
| My Question|| |
What made me (and all the other doctors who saw Mr. R) react with curiosity and an effort to search for answers?
When Ms. K, aged 21 years, walked into my room, I felt a sense of dread in her presence completely at odds with the picture she presented: she was a petite young woman who was dressed like a schoolgirl, and suddenly I thought of the fictional Alice in Wonderland. Her general practitioner (GP) had sent an unusually detailed letter. Ms. K was a university student. Her parents' marriage broke down when she was 4; her sister was 2. She described her mother as “odd” and “unreliable” and her father as “crazy.” Ms. K missed most classes, sitting in corridors, indifferent to coursework till she started finding it difficult to progress in any way. Once in my room she said simply, “I don't like strange places.” Sitting near the window, she kept glancing around, as if she had a secret to keep from me, all the while making me wonder what or who she was actually looking at. The room began to feel unreal to me, unfamiliar although the menace did not seem to actually come from her. I lost track of time. She told me she was now very worried about herself, “my brain isn't right, I'm broken because I was dropped as a child.” There was no preoccupation with body image or weight. She was alert and articulate although the content of her speech was odd. She had never told anyone the details of something traumatic which had happened to her during childhood, the incident was investigated when her behavior deteriorated at school and children's services were involved; the outcome was that the girl stopped visiting her father and nothing was ever discussed further at home. At home, at this time, she went “off” food, and never quite regained a capacity to eat. This is when she started to feel her body was not really her own. For a long time, she could not sleep; she worried she would die any time. She developed odd beliefs that her food may not be edible that it could not be “prepared properly.” When she left home, the feelings intensified: she could not sleep, or eat, and always felt like she was not “really here.” There was an overall sense of ordinary conversation being impossible with this girl, and I found myself in dark, as if following her lead rather than “taking a history” as a psychiatrist. She had clearly been functioning in an odd, but in a stable way for a very long time before things worsened. As the interview progressed, my dread gave way to a profound uncertainty which felt paralyzing to my own sense of professional identity.
| My Question|| |
- What was the quality of the dread and uncertainty I felt, and did it link to her state of mind?
| Discussion|| |
There are many ways that one could look at emotive material like this. These are patients who come to us with powerful affects: a deep sense of ambivalence, or guarded suspicion, or a disturbing state of feeling lost, and so on. In all cases, there is significant clinical value in allowing these states to percolate into one's own listening mind. As a jobbing psychiatrist, this may mean taking seriously the questions and feelings that arise in one's own mind in the assessment, to be able to see this as the response to the patient's projections.
This is something that is hard to do in daily psychiatric practice, where so much depends on having enormous quantities of factual data at one's fingertips. In any case, the temptation to reach for a classificatory system, to allow the mind to scan various pharmacological options while the patient is still talking these are all useful to a degree, but risk slotting the patient into unimaginative categories that pretend to understand, but only ever, in reality, package the problem, anonymize, and strip the narrative of its individual character. In fact, it is tempting to be able to feel powerful and all knowing, even in delivering that heart sink edict, the “poor prognosis!”
Hence, for the purposes of this paper, I will try and address in this way the peculiar, yet familiar, clinical “theater” that the vignettes contain, and which evoked uncomfortable feelings in me. Drawing on Freud's original notion, Bergler  writes that a sense of the uncanny is experienced when we realize that we stand to another person or power in the relation of object and not, as we fondly imagined, of subject. This feeling of being lived by (italics mine) the unconscious evokes the feeling of the uncanny.
In the first case, my overriding emotion was of having recently lost something important. This was followed by a need, felt to be urgent, to set something right very quickly.
In the second case, my feeling was mainly of curiosity, a sort of powerful curiosity about phenomenology where fact finding seemed very important, cutoff from the levels of anguish the patient presented with.
In the third case, I felt something that I have felt only rarely – a deep, visceral sense of dread and uncertainty about something quite fundamental.
I considered the complex process first described by Klein,, projective identification. Ogden  writes, “In a schematic way, one can think of projective identification as a process involving the following sequence: first, there is the phantasy of projecting (here projection is used a specific defense as part of projective identification) a part of oneself into another person and of that part taking over the person from within; then there is pressure exerted through the interpersonal interaction such that the “recipient” of the projection experiences pressure to think, feel, and behave in a manner congruent with the projection; finally, the projected feelings, after being “psychologically processed” by the recipient, are re-internalized by the projector.”
Following Ogden, this is how I tried to make sense of what I experienced. First, projective identification had been used as an unconscious mechanism by all the patients as a defense (thus getting rid of an unwanted part of their minds, and at the same time, in phantasy, keeping it alive in another), as communication (thus putting pressure on another person to feel what they felt), as a type of object relating (thus making it possible to have a particular type of need-fulfilling relationship), and as a way to psychological change (by getting another to process the feelings and return it to them in a more digestible manner).
In a clinical encounter, the patient comes to a doctor who tries to make sense of the jumble of emotions that the patients bring. One way of understanding this type of material is that it is undigested. These patients have been unable to process and integrate an emotional experience for themselves. A task of a doctor then is not to just try and disentangle the historical strands, but also to allow themselves to be used in a particular way by the patient, and then examine their own feelings, however uncomfortable, in an open and authentic manner. This is only possible if one is truly available, listening for nuances in the story.
Projective identification is not to be generalized as pathological; there is a benign version which is the basis of interpersonal communication. However, when a patient projects in a way that feels inherently uncomfortable to the clinician, it is perhaps more a case of expelling unwanted parts of the self. It then takes experience and self-awareness to resist reprojecting it back, or dissociating from the material. “Uncomfortable” material may be that which evokes among other unpleasant affects, a sense of the uncanny.
Kantrowitz  points out that Freud was aware that we often feel we know something for which we have no conscious supportive data. Freud described, but did not try to explain, unconscious communication between patient and analyst. His method to address this was the systematic application of self-analysis. Using the principles of analysis to study phenomena that are seemingly unknowable or unexplainable, he postulated that using the principles of analysis to study phenomena that are seemingly unknowable or unexplainable, would eventually transform them into something that could be understood by the scientific mind. For him, it was a process and tension between “a succession of bold fantasy and merciless criticism exercised by reality.” Contemporary analysts who examine countertransference have written on “uncanny” experiences in this context, notably about “unanticipated and nonunderstood” countertransference reactions which could be approached in three ways: by scientific investigation of the facts, retrospective reasoning using one's knowledge of psychological functioning, and finally, examining an area of “preconscious resonance.” It is this last one that I am interested in, where the analyst begins the investigation at the point of his/her own affective response. Thus, a seemingly inexplicable response in the analyst gains meaning in being able to link to the patient's communication. As mentioned before, this process is difficult to transpose on to ordinary interactions in psychiatric practice. However, I think that the “self-analytic method” may help the clinician to respond in a way which makes possible a deepening of a routine psychiatric assessment.
| Links to Case Material|| |
In Ms. B's case, I think I found myself trying to “re-find” a mother who was lost somewhere in the labyrinths of time. The patient's difficult reality was of having to nurse a dying mother. This was the internal object relationship she carried with her and which was activated at times of strain. Freud's theory of melancholia  describes the powerful hold that an ambivalently cathected love object exerts on the sufferer, whereby the object that is both loved and hated cannot be given up and therefore cannot be mourned. The patient's loss was of a dependent mother who, overcome by her own death sentence, was unable to mourn her impending death and therefore unable to find a way to help her daughter mourn her. I think this was the internal object relationship the patient brought to me. In the return of the depression when threatened by a potentially humiliating demotion, the patient was returning to this state of mind, powerfully identified with a particular maternal object, of not being able to accept loss, and projecting into the other a powerful need (as she had experienced at her mother's deathbed) to redress a balance.
With Mr. R, my clinical curiosity seemed out of touch with the frightening void that he described in his life, and the hopelessness at what seemed like my obviously limited options as his doctor at this stage. Freud's original notion of an “actual neurosis” as a contentless psychic state manifested by various somatic symptoms and a depressive mood has survived various efforts over the years to understand psychosomatic illnesses.,, Freud included neurasthenia, hypochondria, and anxiety neurosis in this category. Post-Freudian writers have extended this in interesting ways, in trying to describe the peculiar effects in such patients: operational thinking , alexithymia,, or in a return to Freudian ideas, “discharge in action.” In “psychosomatic” conditions, what emerges is that a bodily state replaces a capacity to think and makes emotional contact with others. Perhaps, my response to Mr. R was a pull to search him, a parallel process to his own wish to access more tangible investigations, rather than try and understand his own mind.
In Ms. K's case, there were many diagnostic dilemmas; the nature of her odd eating habits, the child-like demeanor, and her cutoff attitude. I returned then to my experience of an instant sense of dread, of being in a bizarre unfamiliar world, and then a feeling of being on the outside of something secret and tantalizing, like I was in some strange land where I did not know the language. What was the patient projecting into me, and was this something that was unacceptable and frightening to her? Sabbadini  writes about various phenomena listed as depersonalization, derealization, fantasies of not being one's parents' child, the sense of living in a dream, and so on, as a gap in the sense of time and one's own continuity, as the uncanny sense of not being oneself (italics mine).
Here is a difficulty, temporary or permanent, in acquiring or maintaining a sense of identity and in keeping the “self” contained within the boundaries of one's physical and psychological body.
The lack of a meaningful relationship with a reliable caregiver leads to these disturbances in the process of psychological development, reality testing, and object relationships. Sometimes, this disruption is traumatic and gives rise to lasting changes, as perhaps it did to Ms. K.
Although what I was able to offer felt limited, these patients changed the way I attended to my own emotional responses in what was proving to be a very busy psychiatric job. Being open to this aspect of my work helped to communicate more effectively with the GPs and other staff involved.
| Conclusion|| |
Examining countertransference qualifies rather than quantifies. This is the idea of trying to understand the individual rather than slot them into artificial categories.
It may need to be simply stated that this method could be thought of as quite divergent from the way one makes ICD-10 diagnoses. In attempting the latter, I came up with the following:
- Ms. B: F32.1 (depressive episode, moderate): I also considered a differential diagnosis of adjustment disorder (F43.2) as the patient seemed clearly unable to cope with a profound yet common bereavement, change in social role and career losses
- Mr. R: F45.0 (somatization disorder): due to chronic, fluctuating, multiple complaints, complicated by iatrogenic factors, his poor functioning and reduced quality of life supported this diagnosis
- Ms. K: (F48.1) depersonalization–derealization syndrome (the presence of odd thoughts/behaviors, identity disturbances, and compromised food intake that appeared stable over a period of time). Differential diagnosis of (1) an early-onset psychotic disorder, and (2) a developmental disorder, with an onset in childhood, of behaviors and emotions.
In a sense, all the three cases come under the ICD-10 neurotic, stress-related, and somatoform disorders, which hold in common a struggle with articulating emotion in the ordinary way. Conflicts find expression in bodily symptoms and events become held in time in a way that organizes the individual's functioning. Responses to life events are often out of the expected norm and fears of illness and infirmity, as well as a profound detachment from reality replace a normative concern for the self and its survival in time. These conditions are not considered as psychotic in themselves, rather, neurotic in that they present to the world evidence of how a difficulty in articulating an “unacceptable” experience gets converted into a tangible symptom that comes to “stand for” the difficulty. Exploring “uncanny” countertransference responses may yield valuable data that add depth to a diagnostic process. If this is used sensitively, it may introduce an idea that is new for a patient who finds themselves often misunderstood and patronized: evidence that something authentic could be actually communicated rather than disguised.
I gratefully acknowledge the R & D Department, Leeds and York Partnerships NHS Foundation Trust, for their support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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