Psychoanalysis in Medicine

Applying Psychoanalytic Thought to Contemporary Medical Care

Paul Ian Steinberg

• Publisher: Routledge
• Year: 2020
• ISBN:
  9780429627422
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This book shows how contemporary psychoanalytic thinking can be applied in the everyday practice of medicine to enhance the practice of family medicine and all clinical specialties.

Dr. Steinberg analyzes his writings over the past 35 years—on psychiatry and family medicine, liaison psychiatry, and mentoring—based on developments in psychoanalytic thinking. Divided into sections based on different venues of medical practice, including family medicine clinics, inpatient medical and surgical units, and psychiatric inpatient units and outpatient programs, chapters illustrate how various concepts in psychoanalysis can enhance physicians' understanding and management of their patients. A concluding section contains applications of psychoanalytic thought in non-clinical areas pertinent to medicine, including preventing suicide among physicians, residents, and medical students, sexual abuse of patients by physicians, and oral examination anxiety in physicians.

Readers will learn to apply psychoanalytic concepts with a rational approach that enhances their understanding and management of their patients and practice of medicine generally.

Introduction Part 1

How could a strange treatment invented by an obscure neuropathologist-turned-clinician (only because he could not secure a research career, being Jewish) treating the “hysterical” symptoms of middle-class Viennese women at the end of the nineteenth century, have any relevance for the practice of medicine and surgery in the third decade of the twenty-first century? According to Balint (1964), at least a quarter and possibly much more of the work of family physicians is taken up with psychological issues. At a time when the practice of medicine is becoming increasingly influenced by technology, including clinical examinations by video, increasing reliance on laboratory tests at the expense of clinical data, reliance on information available on the internet rather than personally acquired knowledge, and algorithms for diagnosis and management, I propose that carefully listening to patients still has a lot to offer, especially when informed by psychoanalytic thinking.

The main theme of this book is that psychoanalytic thinking can be applied in clinically useful ways to the provision of medical/surgical care. This applies to the work of family physicians and all specialist clinicians, who inevitably need to deal with psychological aspects of their patients’ conditions and management of the latter. Psychoanalytic thinking also can contribute to better understanding and practical approaches to some non-clinical areas related to healthcare. A secondary theme is that one has a capacity to keep on learning as one ages, something I have experienced between the time when the original papers on which this book is based were being written and in subsequent years, during and since my psychoanalytic training.

I can illustrate the secondary theme, that learning can be lifelong, in a couple of ways related to the primary theme of the book. I undertook psychoanalytic training relatively late in my career. When I was in psychiatric training, most psychoanalytic institutes did not accept candidates over the age of 40. Now the average psychoanalytic candidate begins training in his 40s or 50s. Similarly, when I was in psychiatric training, individuals older than 40 were generally thought to be too old to benefit from psychoanalysis. Now there is no age limit beyond which people are thought to be unable to benefit from psychoanalysis. It is not uncommon for senior citizens to undertake analysis (Segal, 1958), or even to be candidates in psychoanalytic training. Of course, not only individuals but disciplines can continue to grow and learn; this is something I have emphasized throughout this book regarding the growth of psychoanalytic theory and technique over more than 120 years.

Developments in psychoanalysis have been documented in books oriented towards mental health professionals (Symington, 1986), and in both popular (Mitchell & Black, 1995), and scholarly (Ellman, 2010) texts, which I suspect have not attracted much attention from physician readers, despite their high quality. I wish in this introduction to assume as little as possible about the reader’s familiarity with psychoanalysis, and to provide an orientation for what follows. This essentially will be continued in the second introductory chapter, in which I provide some basic psychoanalytic theory.

For the sake of gender equality, I will employ both masculine and feminine personal pronouns to denote individuals such as physicians and patients, remaining consistent within any given paragraph.

What is Psychoanalysis?

Psychoanalysis is an intensive psychological “talk” therapy that explores the patient’s unconscious, in particular, her unconscious motivations for how she feels, thinks, and behaves. The unconscious does not consist just of what is unbearably terrifying and painful, and is therefore repressed outside of conscious awareness. It also contains what is joyful, creative, interesting, exciting, and fantastic, which an individual may have learned early in life was too threatening to, or just neglected by, someone important to them to tolerate experiencing and developing these qualities. This can result in an individual living her life in a sterile, unsatisfying manner, not realizing her potential in relationships, work, and recreational pursuits; that is, in work, love, and play. The unconscious also includes the mechanisms of defense we employ to remain unaware of what makes us anxious, especially regarding painful truths about ourselves. There are many parts of each of us that we can profitably explore and develop. When unconscious obstacles to growth are understood, felt, experienced, and lived, this can permit renewed growth, or growth that an individual never previously has experienced.

Psychoanalysis is defined by both extrinsic and intrinsic criteria. Extrinsic criteria refer to the setting or frame of psychoanalysis. This includes the patient lying on a couch, the analyst sitting out of sight, and sessions being frequent, approximately four times a week, with duration of the analysis measured in years. Intrinsic criteria include the general technical approach being that the patient is invited to say whatever comes to her mind (the technique of free association), with the analyst’s emphasis on understanding and articulating something about what the patient is communicating about which she is not consciously aware. This might include, depending on the analyst’s orientation, sexual and aggressive impulses that are consciously unacceptable to the patient; mutually contradictory and disturbing unconscious images of oneself and others; terrifying experiences of the self fragmenting, falling into space, or not existing; and experiences of the analyst–patient relationship that neither partner in the analytic dyad may be prepared for. The corresponding technique in the analyst is his freely floating attention to whatever the patient says in any given session, without having preconceptions about what would be important to talk about. The analyst also needs to be open to his own thoughts, feelings, impulses, and reverie, including visual images, such as myths, songs, literature, or other aspects of culture that may occur to him, apparently “out of the blue,” may represent unconscious communications from his patient. Other intrinsic factors include a technical focus on interpretations of the transference, that is, the experience the patient has of the analyst; and the analyst remaining neutral, essentially not having an agenda for the patient.

In general, the purpose of psychoanalysis is to explore the patient’s mind, understanding and experiencing the patient’s unconscious conflicts and unmet emotional needs that impede psychological growth and development. It is accepted that an individual’s early relationships have a strong ongoing influence on the structure and content of her mind, including her characteristic ways of thinking and feeling, leaving her with specific psychological strengths and weaknesses that affect her capacity to adapt to the changes, losses, and challenges, both mundane and extraordinary, that all people experience. This involves discovering areas of both vulnerability and resilience in the patient. There is a specific focus on the analyst–patient relationship, not only because of how fruitful it is to explore that relationship in order to understand the patient’s other relationships, but also because of the transformational potential of talking about an intimate relationship in a way that the patient hasn’t experienced in other close relationships. Alternatively, the analytic relationship may be the first opportunity the patient has to establish a truly intimate relationship, which itself can be discussed. It is inherent in psychoanalytic work that being open to what one is thinking, and allowing oneself to experience and reflect on one’s feelings before immediately acting on them, are highly valued. This involves containing one’s feelings and bearing them, as opposed to evacuating them, for example, through physical violence, impulsive sexual activity, substance abuse, or other addictive behaviors, or trying to forget them. This favors the opportunity of getting acquainted with formerly unacceptable or unarticulated aspects of oneself, with the aim of integrating these split-off aspects of the self into the rest of one’s personality.

Psychoanalysis is not only a method of psychological treatment, but also a theory, or, more accurately, a group of theories, to explain psychopathology, based on the positing of the existence of unconscious factors that influence one’s thinking, feelings, and behavior, which can result in psychiatric symptoms. It relates psychopathology to the individual’s emotional development. Psychoanalysis is also a general psychology, offering theories regarding normal human psychological development. Finally, psychoanalysis comprises a set of theories that can be applied in non-clinical disciplines such as literature (fiction, drama, and poetry), cinema, sculpture, painting, music, and academic disciplines such as sociology, anthropology, and biography.

Psychoanalysis and psychoanalytic psychotherapy, its briefer derivative, offer some benefits that time-limited, manualized, symptom-oriented treatments such as cognitive behavior therapy (CBT), which have gained much popularity and prominence in recent decades, do not. This includes an approach aimed at understanding the patient’s unconscious motivations, with the richness and depth of insight that this entails, offering the opportunity for patients to undergo transformations such that they are able to cope with their unconscious conflicts and unmet emotional needs in a more constructive manner, needing to rely less on painful and unproductive symptoms and self-destructive behaviors. A symptom-oriented approach, on the other hand, does not deal with the person enduring the symptoms in exploring the meaning of his symptoms, but rather attempts to relieve him of them. When a symptom-oriented treatment is followed by symptomatic improvement, the patient remains vulnerable to having the symptoms return when he again is exposed to environmental situations that have the potential to reactivate the conflicts and the experience of unmet needs that initially led to the symptoms. Of course, symptom-oriented approaches, being quicker and cheaper, are very attractive to providers of healthcare, both government and private. They are, as well, attractive to patients who wish for quick solutions that do not involve psychological work or pain. This is not to devalue these forms of treatment. They can provide some patients with symptomatic relief, and help some patients who cannot be helped by psychoanalytic treatment. Conversely, psychoanalytic treatment can help some patients who cannot be helped meaningfully with briefer treatments.

Psychoanalysis and psychoanalytic psychotherapy also offer long-term therapeutic relationships in which the difficulties inherent in all relationships, including the patient’s characteristic relationship difficulties, can be explored in the intensive here-and-now setting of the analyst–patient relationship, with the opportunity to compare the difficulties the analytic dyad experience with difficulties in the patient’s previous and concurrent relationships. There also is considerable empirical evidence that longer psychotherapies have more lasting beneficial effects than shorter ones (Leichsenring et al., 2013). Psychoanalysis and psychoanalytic psychotherapy, with their focus on exploring the patient’s mind, also offer patients the support of being understood in a manner much more profound than is the case with short-term symptom-oriented therapies. A psychoanalyst’s very lengthy intensive training, including a personal psychoanalysis, lengthy experiences in supervision, and years of didactic teaching, provides her with the opportunity to internalize standards that have developed over 120+ years to best serve the goals of treatment and the patient’s needs. Personal psychoanalysis gives psychoanalysts a perspective of being a patient that they couldn’t otherwise have. No other therapeutic modality requires the therapist to undergo lengthy treatment in the therapy they are going to provide. This experience also gives the psychoanalyst familiarity with her areas of vulnerability, “blind spots,” and “raw and exposed nerves,” to help her manage her personal emotional reactions to her patients, that is, her countertransference. Other treatment modalities don’t make this consideration an essential part of treatment. Countertransference also provides psychoanalysts with much important information about their patients that would not otherwise be available to them, such as through their reverie (Steinberg, 2017b). Therapists in non-psychoanalytic short-term therapies are not trained in this, and have very limited time to consider it.

Some authors do not make a cut-and-dried distinction between psychoanalysis and psychoanalytic psychotherapy. For many analyst–patient dyads, psychoanalysis is a richer and more profound therapeutic experience than can be achieved from once- or twice-a-week psychotherapy. Nevertheless, much valuable psychotherapeutic work can be accomplished at this frequency of sessions, depending partly on the nature and severity of the patient’s difficulties, the openness of the patient to exploring her inner world, and the goodness of the therapist–patient fit. One concrete way of distinguishing psychoanalysis from psychoanalytic psychotherapy is by considering the frame mentioned above. A reliance on free association, a focus on interpretation of the transference, that is, the patient’s experience of the analyst, use of the couch, and a frequency of about four sessions a week is a classic way of distinguishing psychoanalysis from psychoanalytic psychotherapy.

Psychoanalysis sometimes is characterized, usually by individuals who are not very familiar with it, as an outdated or inappropriate treatment for contemporary patients. Nothing could be further from the truth. Psychoanalysis does make great demands on patients, not only of time and money, but also of psychological work, including bearing pain that many patients would rather avoid. However, psychoanalysis continuously has changed over the decades, developing from a drive/instinct-oriented theory, to a focus on the ego, to theories of the self, internal object relations (considerations of the patient’s internal world populated by unconscious images of self and others), and most recently of the analytic field. This continuous development and adaptation has enabled psychoanalysts to treat patients with an increasingly wide range of psychiatric conditions, including severe symptomatic conditions and personality disturbances that often cannot be treated effectively with other modalities.

Psychoanalysis is the original psychotherapy invented by Sigmund Freud before the turn of the twentieth century. Although one of the motivations for the reduced frequency of appointments in psychoanalytic (also called psychodynamic) psychotherapy is practical, in that it consumes less time and money, some patients who might regress too much with psychoanalysis can be treated more successfully, at least initially, with a reduced frequency of appointments. Far more people are treated with psychoanalytic psychotherapy than with psychoanalysis because of practical considerations, although psychoanalysis would be the treatment of choice in many cases. Similar techniques are used in psychoanalytic psychotherapy as in psychoanalysis, although usually in a less rigorous manner. However, there usually is considerable flexibility of technique within any given psychoanalysis, and much more variability of technique between psychoanalyses than was acknowledged in the past. Many patients with more severe symptomatic conditions and personality disturbance can be treated more effectively with psychoanalysis than with psychoanalytic psychotherapy. Some patients choose psychoanalysis because of their wish to go into as much depth as possible in their psychotherapeutic work.

Which of my Patients Can Benefit From Psychoanalysis or Psychoanalytic Psychotherapy?

An appendix at the end of this chapter provides diagnostic exclusion factors and relative positive and negative prognostic factors regarding the suitability of patients for psychoanalysis and psychoanalytic psychotherapy. In general, patients who wish to understand the basis of their symptoms and think in terms of their symptoms having some connection with their difficulties in life and relationships are more highly...