Abstract
The practice of psychiatry is an extraordinarily complex task. Mental disorder produces bizarre and illogical symptoms, our patients may behave self-destructively and engage in harmful relationships, activities which seem puzzling to the rational mind. Despite the distressing and disabling effects of mental illness the most carefully considered treatment plans may be met with resistance and refusal to engage. Working with disturbed states of mind allows privileged access to the deeper workings of the human psyche which may be fascinating and difficult to comprehend. The emotional impact of the work is often deeply involving and intense.
A psychodynamic approach to psychiatry provides an overarching coherent conceptual framework from which all other treatments can be prescribed.
The practice of psychiatry is an extraordinarily complex task. Mental disorder produces bizarre and illogical symptoms, our patients may behave self-destructively and engage in harmful relationships, activities which seem puzzling to the rational mind. Despite the distressing and disabling effects of mental illness the most carefully considered treatment plans may be met with resistance and refusal to engage. Working with disturbed states of mind allows privileged access to the deeper workings of the human psyche which may be fascinating and difficult to comprehend. The emotional impact of the work is often deeply involving and intense.
Meeting this multilayered task draws deeply on our skills and resources and requires a conceptual framework with the depth and range to accommodate this complexity. This chapter describes how a psychodynamic approach to psychiatry can helpfully contribute to this framework and enhance clinical understanding as the basis of treatment. Psychodynamic psychiatry rests upon psychoanalytic theory and key concepts underpinning this approach will be outlined. These ideas will be illustrated by case examples to show how the application of a psychodynamic approach deepens and enriches everyday psychiatric care.
Key Concepts in a Psychodynamic Approach to Psychiatry
So what does the term psychodynamic psychiatry mean? In general terms a psychodynamic perspective enables the importance of relationships, psychological development, life experiences and constitutional factors to be integrated and considered together in understanding the development and presentation of mental disorder. The key underlying principles can be summarised as follows:
1. A focus upon the unique personal biography of the individual presenting to mental health services
2. Symptoms are viewed as having meaning, however curious they may seem
3. Psychological mechanisms in disturbed states of mind are seen as continuous with, and more extreme versions of, normal functioning
4. Psychiatric breakdown is recognised as occurring along pre-existing fault lines in the psyche in keeping with developmental vulnerability
5. The ability to mourn is recognised as key to psychological development and difficulties with the mourning process predispose to the development of symptoms and breakdown, which is often triggered by loss events
6. Unconscious mental processes are powerfully expressed in mental disorder and attending to the transference, countertransference, projection and splitting significantly enhances clinical understanding
7. Countertransference enactments can define the way in which patients are managed
8. Emotional and psychological aspects of containment are key to psychiatric care
9. Resistance to change perpetuates mental illness as symptoms may be performing an important function
10. Psychodynamic and biological factors interact and influence the expression and form of psychiatric symptoms
A Biopsychosocial Approach to Psychiatry
It is much more important to know what sort of patient has the disease than what sort of disease the patient has
Although writing as a physician, William Osler recognised the importance of attending to the person with the illness rather than the physician limiting his interest to the pathology of the disease process.
This resonates with what we hold dear in psychiatry, the branch of medicine most overtly directed at the person as a whole and their life experience. A fundamental idea in contemporary psychiatry is that an integrated biopsychosocial approach is the most helpful way to understand mental disturbance.
In addressing the psychological aspects of psychiatric presentation, a psychodynamic model provides a model of the mind which takes a primary interest in the personal biography of the patient presenting to services. In addition, the recognition of unconscious processes and exploration of how they operate can shed light upon the meaning conveyed in psychiatric symptoms. Our patients become more understandable if their preoccupations and beliefs are seen as more extreme or bizarre means to both express and manage disturbing internal responses to the painful realities of life common to us all, such as loss, deprivation, limitation and trauma.
Ms P’s father had left the family when she was 13 years old and moved to another country. Upon hearing at the age of 19 that he had remarried and had another daughter Ms P presented to psychiatric services expressing delusional beliefs that she was marrying Prince Harry and that Paul McCartney would be the vicar.
In this case the content of Ms P’s delusions seems highly meaningful when her personal biography is taken into account. A wedding and the presence of a man with another family are central to the material. In addition, an understanding of primary process thinking helps to understand her symptoms as being driven by the wish fulfilment seeking and reality denying forces of the unconscious. The painful experience of being left and replaced by her father is transformed into the delusion that she is to become a highly envied wife and daughter herself, a princess in the eyes of the world, able to secure the undivided attention of a father figure who has left his family to attend to her at her wedding.
Her symptoms could therefore be seen as an attempt to both express and to compensate for the losses and hurt she has experienced and to find a solution which circumnavigates a painful reality. The external reality has been replaced in her mind by a preferable situation of her own creation. Such an approach considers the underlying issues behind her breakdown, enriches the case formulation and fosters treatment which conveys understanding and curiosity about the contents of her mind, her key relationships and her life experience. It also allows staff to recognise her vulnerability to feelings of rejection and replacement and to sensitively consider these issues in her relationships with staff in her ongoing care.
Psychodynamic Psychiatry and Biology
In the last 2 decades, it has become obvious that child abuse, urbanization, migration, and adverse life events contribute to the etiology of schizophrenia. …. Just as the lungs process air, so the brain processes external stimuli; consequently its healthy function can be harmed by noxious factors in the social environment.
A range of factors contributes to the development and expression of mental disorder. The relative influence of biological, psychological and social factors will vary on a case by case basis and between different conditions. There may be powerful genetic influences or drug-induced factors in the development of schizophrenia for example, but the psychotic process is still occurring in the context of the person’s history, relationships, attachment pattern and emotional internal world with all its unique sensitivities. These factors combine to influence the vulnerability factors, the nature of the symptoms, the relationships formed with the treating team and the course the condition takes.
Research findings in a range of fields, from neuroscience to attachment theory, have shown the brain to be a responsive, plastic and dynamic structure that adapts, develops and functions in the context of relationships. Constitutional factors combine with experiences of nurture and emotional attunement and are shaped further by trauma and other external experiences contributing in a dynamic manner to the development of the brain and personality [4–7].
Research has also shown how conscious thought is a limited resource and that much of mental life occurs outside conscious awareness [8]. The limited capacity of conscious memory means that much of our experience is stored in the unconscious on the basis of past similar experience and meaning, and we respond to situations in the present based upon recognition of patterns familiar to us. The psychoanalytic concept of the transference addresses a similar phenomenon with relationships describing how we respond to the present on the basis of internalised past patterns of relating [9].
Mental life can be thus viewed as a complex dynamic system in which biological substrates of the brain, conscious and unconscious aspects of the mind and external experiences are in constant conversation with each other. A unique individual internal world therefore develops which is in constant dialogue with the genome, the neurocircuitry of the brain and external reality. In mental disorder and psychiatric breakdown, the causal factors, the meaning of the situation for the individual concerned and the form the symptoms take depend upon the interaction and balance between these aspects of the system on a unique and highly personal basis.
A psychodynamic approach to psychiatry takes a holistic approach in addressing the biological factors, psychological processes and relational issues in mental disorder. This provides a comprehensive framework, emphasising emotions, relationships and meaning, from which all aspects of treatment, including the use of medication and need for medical investigation, can be considered.
The Unconscious
The understanding of mental disorder is deepened by exploring the unconscious layers of the mind, and the mechanisms, structures and processes by which early history, repressed memory and emotional biography are stored and expressed; the underlying tissues and physiology of the psyche as it were.
Key points about the unconscious:
1. Most mental activity occurs at an unconscious level. As clinicians this means even our most considered and rational thought processes are guided and informed also by pressures from the unconscious substructures of the mind. How we perceive situations in the external world, how we make decisions, how we feel and act largely beats to the rhythm of an unconscious score which we have limited conscious access to
2. All behaviour, symptoms and actions have meaning at an unconscious level, no matter how paradoxical and nonsensical they may seem
3. Unconscious processes operate differently to rational conscious thought and are more in keeping with primary process activity, characterised by replacement of external by psychical reality, wish fulfilment, tolerance of contradiction, timelessness, avoidance of pain and magical thinking (see Chapter 1)
4. Our defensive organisations strive to maintain an equilibrium between pressures emanating from the unconscious and the external world
5. When defences become overwhelmed symptoms can reveal the workings of the unconscious. A similar process happens in sleep when we dream
6. Unconscious processes may be floridly revealed in states of mental disturbance
In psychiatry, the most significant issues and key developmental events shaping the personality are available in the patient’s history, routinely gathered in mental health services. The key interpersonal issues are also manifest in the relationships formed and behaviours expressed towards staff. Mental health staff are therefore extremely well placed to make a comprehensive formulation about their patient’s difficulties; there is a richness of information available to them from the spoken histories from patients and families, and their own observations from within the team.
Symptoms and behaviours presenting to mental health services are brimming with information about unconscious processes. These may seem bizarre and incomprehensible as the psychological processes of unconscious operate differently to rational thoughts, but, like dreams, they have meaning. The manner in which a patient may relate to and emotionally impact upon staff contains vivid and immediate material which is also key to formulation and understanding. In disturbed states of mind the restraining function of the defensive organisation is challenged and unconscious emotional forces can ricochet around inpatient units and community team, powerfully affecting management.
Ms S was admitted with a relapse of a psychotic illness under Section 3 of the Mental Health Act. Prior to the admission her young children were taken into care. She constantly accused staff of neglect and not meeting her needs; they felt persecuted and inadequate, leading to frustration, irritation and a tendency to avoid contact with her on the ward. When able to consider their feelings towards her as containing important information about her own feelings of guilt and failure at not having been able to adequately care for her children, feelings of sympathy, interest and concern re-emerged in the team.
Ms S’s case illustrates how meaningful emotional states in an inpatient setting can be projected into staff, unconsciously steering management and requiring recognition and understanding.
Psychodynamic Psychiatry, Early Development and Paranoia
Psychoanalytic theory views the psychological mechanisms of pathological states as more extreme versions of normal function. This means that the potential seeds of mental breakdown reside in all of us and the degree to which these become manifest depends on a range of factors. In states of heightened anxiety and psychological distress more primitive forms of mental function come to the fore. Thus, developmental issues and transitions not satisfactorily negotiated or resolved earlier in life can reveal themselves in the form that the psychological disturbance takes. An understanding of psychological development can help to recognise when early wounds and difficulties are exposed as part of the patient’s presentation to mental health services.
Psychoanalytic theory emphasises the importance of early development in shaping adult personality. In early life the nature of the attachment relationships, the experiences of emotional attunement and containment of primitive and intense emotional states are internalised to form psychological structures in the mind. These internal templates, or ‘objects’ in psychoanalytic terms, inform how we later relate to the world and shape our response to challenges in external reality. The ability to manage primitive psychological urges, anxiety and appetites depends both upon constitutional factors and on the regulatory capacity of the external nurturing environment. The capacity to recognise feelings as distinct from reality (e.g. I am frightened rather than the world is dangerous) requires the capacity to symbolise to become established, along with the ability to think without the mind becoming overwhelmed and fragmented; and this is crucial in psychological development. The development of a secure sense of one’s own identity requires an ability to psychologically separate from the dependency of infancy, a challenge revisited in adolescence; thus patterns of dependency, difficulties with separation and hostility towards authority figures may indicate challenges with this complex process. Oedipal issues of longing for exclusive relationships, intolerance of exclusion and disappointment, the impact of traumatic life experiences and boundary violations and loss are key to determining the resource and vulnerability within the internal world. Issues related to these challenges may be forcefully expressed in how patients in disordered states of mind interact with mental health teams.
Some of these processes can be well illustrated if we look at the common symptom of paranoia.
In early life paranoid anxieties are understood by the paranoid-schizoid position as serving a useful purpose in separating and preserving good experiences by projecting unbearable states of anxiety and frustration into the outside world [11] (see Chapter 1). This psychological mechanism is universal and necessary in early life but in more extreme form underlies paranoid mental states. In mental disturbance or intense stress, normal projective processes can intensify into paranoid ideation in which the bad feelings projected outwards are experienced as persecutory threat. If the anxiety is sufficiently high, the suspicion of persecutory anxiety can develop into delusional conviction, where there is a visceral certainty of danger and of others intent to harm. So paranoid states presenting to psychiatric services are based on an extreme form of normal psychological processes, which can be traced developmentally. The return to more extreme and primitive forms of mental functioning ubiquitous to us all helps to explain why paranoia is such a common symptom in a range of mental health disorders. It also means that there is often an understandable kernel of truth at the heart of the paranoid belief – as Freud also wrote ‘There is not only method in madness …but also a fragment of historical truth’ [12].
Mr B had been severely neglected as a baby by his parents and as a result had been brought up in the care system. He worked as a hospital porter in the same hospital for many years. He had struggled to maintain close relationships and was socially isolated although he was on superficially friendly terms with other hospital staff. He presented to psychiatric services in a floridly agitated and paranoid state having started a hunger strike at home. He was severely malnourished at the point of admission and spoke of a conspiracy by his managers to abuse him sexually then leave him to die. This had been triggered by a reorganisation of services in which his job was threatened and he felt his managers had treated him as a problem to be got rid of.
It seems Mr B had repeated his childhood presentation to services in a seriously neglected state, a direct repetition of his past in the present. The threat of losing his job had triggered an eruption of intense emotion and the re-emergence of traumatic material and allowed the effect of disrupted attachments in his early life to become vividly apparent; perhaps then too he had felt he was a problem to be got rid of and a vulnerability to seeing himself in this way had always resided somewhere within him. The accompanying distrust which may have also lain quietly within him had become floridly manifest as a paranoid delusional state as he was threatened with the loss of his secure base at work; as Freud wrote he was not entirely mistaken but the extreme reaction and paranoia with which he met the events in the present was informed by long-standing and understandable developmental experiences.
Childhood Adversity, Pre-existing Fault Lines and Psychiatric Breakdown
If we throw a crystal to the floor it comes apart along its lines of cleavage … predetermined by the crystal’s structure …. Patients are split and broken structures of the same kind
The incidence of psychiatric breakdown, as well as physical illness increases in line with adverse childhood experience [14]. In addition to crude disturbances in early relating such as parental loss, abuse and neglect, the fine-grained repeated patterns of relating with their unique characteristics and limitations are also internalised. A model of the internal world populated by these experiences with their resources, blind spots and fragilities can be helpful in seeing the mind as having pre-existing fault lines that may determine the timing and nature of a psychiatric crisis. In stable states of mind the ego and defensive organisation is more or less able to contain these areas of psychological vulnerability and more destructive aspects of relating; but when the fault lines are stressed these unresolved issues come powerfully to the fore. Implicit to this is the idea that the breakdown or illness reveals in more florid form underlying problematic parts of the personality.
The idea of the mind having pre-existing faultiness is helpful in situations when diagnostic conflicts emerge in clinical management. If the mind has a series of potential cracks, a range of relational and psychological issues may become expressed in highlighted form during a crisis all of which may settle once agitation has settled and recovery is underway.
Once admitted to an inpatient unit Mr B was suspicious of staff on the ward, secretive and accusatory towards others that he came across, although opinion was divided about this and other staff members experienced him as being warm and likeable. Discussion of whether he had an underlying personality disorder and should be referred to specialist services for personality disorder ensued. However, as he settled on the ward and medication helped him to become less agitated and paranoid he became more friendly and open towards others; as his psychosis receded his usual reserved but sociable personality functioning was restored.
Related posts:
Chapter 4 – Psychodynamic Psychotherapy: The Consultation Process
Chapter 10 – Cognitive Analytic Therapy (CAT):
Chapter 11 – Group Analytic Psychotherapy and the Group Analytic Model: A Clinician’s Guide
Chapter 16 – Complex Post-traumatic Stress Disorder
Chapter 20 – Forensic Psychotherapy
Chapter 25 – Therapeutic Communities
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