Introduction

Life is a cycle as Keats’ poem beautifully illustrates.¹ We progress through the seasons of life as we do with our professional lives, intertwining with our more private lives and our personal development. Shakespeare wrote about the seven ages of man [1] in As You Like It in the famous speech of Jacques when he compares the world to a stage and roles that we occupy as we pass through life. The psychoanalyst Eric Erikson developed his theory of the stages of psychosocial development [2] where we experience conflicts at each stage of development that need to be negotiated to feel a sense of mastery and develop a strong sense of self. Many of us would have come across Shakespeare and Erickson linked together in Brown and Pedder’s Introduction to Psychotherapy [3] where we also read about Freud and his psychosexual developmental stages, where Freud described how we can become fixated at a stage in our development that we can regress to in times of stress.

As we progress through our lives and careers, as doctors and psychiatrists, we have to negotiate transitions which invariably involve a letting go of old certainties and identities as we move on to the next stage; from medical student to doctor, from trainee to consultant and through to retirement. This entails feeling insecure and being able to tolerate uncertainty while we find our feet in the next phase of our career, and the right kind of nurturing facilitative support to enable a process of establishing ourselves in our developing professional roles. This needs time and space for reflection, to enable working through of loss, and renewal, if we are not to become stuck in a repetition of an earlier developmental struggle, burnt out or ossified in our professional lives.

The chapter starts with the nature of Freud’s beginning of his psychoanalytic discovery with his articulation of the unconscious nature of mental life. It then touches on relevant developments by psychoanalysts that came after him, and discusses how these can help us think about our own professional developmental life cycle, and how this relates to our potential to develop as psychotherapeutic psychiatrists.

Johnston defines psychotherapeutic psychiatry in his paper ‘Learning from the cradle to the grave’ [4], as being ‘a frame of mind’ where psychotherapy is seen ‘less an activity of others but more a therapeutic way of thinking about patients and a vital part of our psychiatric² professional identity’, where we are able to see the ‘person beyond the diagnosis and problem’. Johnston describes how this therapeutic frame of mind, which he terms ‘therapeutic attitude’, is both a reflective and reflexive intersubjective examination of the mind. The mind of the patient, which is ‘on examination’, affects the mind of the psychiatrist, which will also be in part a reflection of the psychiatrist’s ‘own life experience and personality’.

A reflective capacity and therapeutic attitude may be difficult to achieve and maintain because it means being and remaining open, and alive to our emotional responses; being disturbed by forgotten aspects of ourselves that emotional contact with our patients resonates with. This can feel antithetical to the carapace of a dispassionate professional, ‘scientific’ and technical approach to psychiatry [6].

The chapter takes readers on their passage alongside the psychiatrist in his/her developmental stages through the lifespan of a professional career to illustrate the developmental challenges that are faced by all of us who seek to be compassionate self-aware clinicians. This is a task not to be underestimated given that however much we might like to see ourselves as working independently we are inevitably interdependent on the settings within which we work, and the socio-political cultural environment within which we and our patients live.

Beginnings

We are all drawn to medicine for our own reasons and some of these are more unconscious than conscious. It may be that these hidden reasons, alongside our rational explanations, underlie our motivation that brought us to study medicine and then on to specialise in psychiatry. If the practice of medicine is about the alleviation of suffering combined with a wish to heal and make better; we can link this on a personal level with our own experiences and those that are or have been close to us, who have been subject to illness, loss, separation, death and trauma of one kind or another, that are woven into the tapestry of our lives. It is these experiences that have emotionally and psychologically deeply affected us that may have initiated us on our medical journeys. They function like a kernel, a motive agent, hidden or less hidden, that lives on as a chrysalis in the psyche, motivating our curiosity, and appetite for knowledge and understanding, described by Melanie Klein (1928) [7] as the epistemophilic instinct in her observation of young children.³ It is this instinct, in the German ‘Trieb’, that underlies the maturational development of a nascent psychotherapeutic psychiatrist. This is alongside identifications with significant others, parents or other aspirational role models who have been or are doctors.

Concepts: Transference, Projection and Identification

Freud’s research into hysteria, a condition encompassing the psyche and the soma, at the end of the nineteenth century building on the work of Charcot and Janet, and the mental mechanisms which repressed unacceptable mental contents from conscious articulation, led to his discovery of dynamic mental processes. He continued to elaborate these in his evolving models of the mind. From his initial affect-trauma model through to the topographical and structural models, continuing to develop his theories throughout his life.

However, Freud, as perhaps many of us do, initially struggled with his discovery of the transference seeing this as a resistance to free association and an obstacle to therapy. This is movingly described in the case of Anna O with his colleague Joseph Breuer.⁴ He later recognised transference as a ubiquitous phenomenon; and a tool to be used in the service of the psychotherapy, ‘the transference, which, whether affectionate or hostile, seemed in every case to constitute the greatest threat to the treatment, becomes its best tool’ [8]. The transference is a position we immediately unconsciously occupy as a medical student, doctor and psychiatrist. We become a subject in our patients’ unconscious representations, taking on a significance that is beyond how we consciously perceive ourselves. As such our representation is coloured and shaped by our patients’ projections and we become ‘facsimiles’ [9], characters, of our patients’ internal worlds represented in the here and now of the encounter.

These projections that we are subject to, ubiquitous in other parts of our lives, not only shape us but actually take up residence within us. Our receptivity to the impact of these projections depends on our own experiences, sensitivities and vulnerabilities. A projection is in search of a receptor, much as we might think of a drug that will have a greater affinity for certain receptors than others, which Wilfred Bion in his study of groups described as ‘valency’⁵ [10]. On locating the receptor, the receptor responds to accommodate the projection. It is this accommodation that then evokes a response in us; our identification with the projection. Our receptivity is at its most open as infants, or comparably when we come into medicine as students or when we start as new trainees in psychiatry, before we have built up our defensive structures which may be both personal and systemic.⁶

When we enter medicine and psychiatry we are sensitive and thin-skinned,⁷ newly exposed to the full range, highs and lows, of human experience from birth, the impact of illness and disability, to facing terminal illness and death. The latter may be sudden and unexpected, and we have to deal with the effect of sharing the news with families and loved ones.

‘Bodily Beginnings’ at the End of Life

Uniquely in medical training before this we are exposed to the cadaver in the study of anatomy through dissection in groups as a shared experience. We are brought face to face with death and the frailty of human existence at this sensitive stage in our professional development that has a rite of passage symbolic quality [11]. However, the context is often one where the past life of the person who inhabited the cadaver is split off and medicalised under the scientific umbrella of anatomy. Nevertheless in this exposure to mortality medical students will often be forced to reconnect with the embodied personhood of their cadaver through an aspect of their physical form, perhaps a small detail that allows for an imaginative leap into the person’s life and death.

Thus it is through this experience of dissection that as medical students we are confronted with the deep connection with our being and mortality, the psyche and the soma; and for generations of doctors this is their first exposure to a dead person that is out of the ordinary that needs to be digested and made sense of. The danger is that instead of being digested this experience can remain split off, deflected with black humour or distanced by inventive unflattering ‘cadaver naming’ [13], and stoicism can become ‘the litmus test for professionalism’ [14]. Medical schools are increasingly recognising the importance of humanising the experience of dissection [15], where the cadaver is seen as the first patient, or ‘Silent Mentor’ [16], and their identity revealed with contact with the donors’ families either before the start of dissection, or at the end with a memorial service where their contribution is recognised with families and loved ones invited. These contacts with lives of the donors and ceremonies help students to cultivate a sense of empathy and express their feelings.

These early experiences in a medical career received and taken in by the receptive medical student are ones that serve as a prototype for subsequent experiences in clinical encounters. We are affected and have to digest and make sense of encounters with our patients and it is this internal experience that percolates, in psychoanalytic language our countertransference, for which we need to have time and space to be able to acknowledge and recognise. Countertransference can be thought about as the totality of our experience that our work evokes in ourselves, it can be subtle, like a spontaneous thought or association or a bodily feeling, such as a ‘gut reaction’, which can then be used to help us in our contact with our patients and to deepen our understanding.

Starting with our early experiences in the dissecting room, we can begin to understand the shock and revulsion evoked present in many encounters when looking after patients; the smell of gangrene and bodily excreta; or the sight of a severe self-inflicted wound; are understandably things that we may seek to avoid because of their emotional and sensory impact. These gross manifestations of contact with others can be represented at more subtle levels.

For example a young male medical student who has struggled with his experience of brittle asthma during his childhood, and whose mother also had a chronic medical condition, found himself caring for an elderly man with breathing difficulties on one of the older people’s medical wards. He was often asked to go and take bloods from the gentleman and the older man clearly appreciated the time despite the intrusion, and would chat about his life to the young student. The student then learned during the ward round that his patient had been diagnosed with terminal lung cancer. He struggled to go and see him although he wanted to, and it was not until his attendance in his Balint group could he talk about how his grandfather had died of dementia and he had felt guilty for not going to see him when he was in his nursing home. He also spoke of his own experience of asthma in childhood and could then start to recognise that his avoidance of his elderly patient on his placement had very personal resonances for him. He was able to return to see his patient on the ward, who was pleased to see him and they were able to continue a conversation about a mutual love of art.

In common with his initial concerns about transference Freud had first thought that this experience of countertransference was something to be ‘conquered’, a problem for the analyst – just as in the example of the medical student, ‘the patient represents for the analyst an object of the past onto whom past feelings and wishes are projected’ [17], and that can lead to problems. This would now be viewed as a communication from the patient that occurs in an intersubjective space. As such it needs to be digested by the receptive doctor/student, made available for thought, and then used as a helpful fragment of information that can enrich our understanding of what might be taking place in the here and now of the relationship.

These developmental steps in psychoanalytic theory evolved with the work of Melanie Klein and her development of the concept of projective identification. For Klein this was a phantasy where parts of the self are projected into the mother, or other, and evoke the feelings of the phantasies that are being projected. Klein viewed this as a defence, that is these were aspects of the self, self-objects and associated affects, which for whatever reason could not be contained by the projector. These could be either good or bad, depending on the underlying phantasy for the projection, and what might be internally threatening and therefore need to be projected.

For example, a patient who felt very ambivalent about her relationship with her father who was both abandoning and longed for and had suddenly died prematurely in her adolescence. In her session shortly after a break in the psychotherapy her therapist found she was feeling very uncomfortable and felt there was something missing in her contact with the patient, although the patient was outwardly pleased to be back in her psychotherapy. It was only later in the session when the patient was able to express her ambivalence to her therapist whom she suspected of selfish motives could she be open about her phantasy that she had killed her father with her long-standing hatred.

In its original sense projective identification tends to be viewed as pathological and not normative, that is part of life. It was Bion who extended Klein’s concept of projective identification and highlighted the communicative aspects of projective identification viewing it as a primitive non-verbal communication that babies used as a way of communicating with their mother. Bion liked to think in terms of mathematical formula and wrote about how primitive beta elements projected by the baby were by the mother’s process of reverie, which he termed alpha function, turned into ‘alpha elements’ that were available for thought. The baby can then re-introject his projections modified by understanding and also introject the experience of the mother as a container capable of dealing with his anxiety.

Early Medical Years

Therefore, we might consider how can this process be provided for doctors in training? We might think of creating a space where this process of maternal alpha function, to use Bion’s terminology, can enable these experiences to be digested and made sense of. In order to do this safe spaces need to be created to be able to talk about these feelings. Exposure to psychological disturbance early in the psychiatric career, such as depression, self-harm, suicide, substance misuse, emotional turmoil and psychosis, evokes powerful emotional responses, anxieties and identifications at both conscious and unconscious levels. Fear of contagion by madness may underly the stigmatisation of psychiatric patients and those that work with them [18].

The wish to heal which motivates many of us to train in medicine also applies to psychological wounds. We are drawn to psychiatry for complex personal and psychological developmental reasons, and a wish to understand, care and make better.

Identification Separation and Mourning

In psychiatry therefore the difficulties faced by our patients may have an unconscious familiarity that resonates with us on a personal level. Being able to identify with our patients is helpful in establishing empathy; we can place ourselves in the shoes of another – ‘Einfühlung’ coined by Edward Titchner [20] and translated into the English word empathy comes from the Greek Em – into and Pathos – feeling.

This can be used to the therapeutic benefit of patients but there is a risk. If we are too closely identified then it can become difficult to distinguish ourselves from our patients who are then no longer viewed as separate from ourselves. It can then become hard to make difficult decisions that are in their best interests, or we can go to extreme lengths to help them which can be exhausting and emotionally draining to the detriment of the doctor’s well-being. Differentiation between self and other is needed as a prerequisite to maintain our capacity for thinking.

Developing as a psychotherapeutic psychiatrist requires us to acknowledge our identifications which bring us into contact with our patients and then being able to differentiate ourselves from them, and acknowledge our own vulnerabilities, needs, wishes, desires and feelings. This can be through self-reflection, use of supervision, Balint groups, or in our own psychotherapy and psychoanalysis.

This is a complex task. Klein articulated in her conceptual development of the depressive position a constellation of anxiety and defences that the infant experiences from about six months of age, when he perceives the loved object as a whole separate object. The infant’s anxiety focusses on concern for the welfare of the object which leads to a remorseful guilt for hateful feelings to the object, and painful feelings of sadness. The recognition of the object as separate leads to pining for what has been lost and the wish to repair and the process of reparation provides a means to overcome the despair for the damage done.⁸

The ego feels impelled–by its identification with the good object–to make restitution for all the sadistic attacks that it has launched on that object.

Klein, 1935 [22]

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