A fundamental premise of psychodynamic psychiatry is that mental activity going on outside our awareness can be profoundly influential. Freud saw signs of the unconscious in two major types of clinical evidence: parapraxes and dreams. Parapraxes, commonly referred to as slips of the tongue or ‘Freudian slips’, involve substituting one word for another. For example, a patient who intends to say ‘Protestant’, may unwittingly say ‘prostitute’. Parapraxes may also involve actions, such as forgetting, or executing one action when intending to do another.

Freud regarded dreams as the ‘Royal Road’ to the understanding of the unconscious. Another primary way that the unconscious manifests itself in the clinical setting is the patient’s behaviour toward the clinician. Certain characteristic patterns of relatedness to others set in childhood become internalized and are manifested automatically and unconsciously as part of the patient’s character. Hence certain patients may consistently act deferentially toward the clinician, while others will behave in a highly rebellious way. This type of procedural memory is closely linked to Squire’s⁽²⁾ notion of implicit memory, which occurs outside the realm of verbal narrative memory.

While declarative or autobiographical memory involves remembered events and narratives of one’s life, procedural memory
stores the ‘how’ of executing sequences of actions, such as motor skills. Once guitar-playing or bicycle-riding has been mastered, no conscious recall is necessary when one sits down with a guitar or jumps on a bicycle. The schema referred to as unconscious internal object relations are to some extent procedural memories repeated again and again in a variety of interpersonal situations. They are non-conscious, but not dynamically unconscious, in the sense of being defensively banished from conscious awareness.

The notion that much of mental life is unconscious is one that is often challenged by psychoanalytical critics, but it is also one that is extensively validated by literature from experimental psychology.⁽³⁾ Repression of memory has even been demonstrated in fMRI research.⁽⁴⁾ The active effort to ‘forget’ unwanted past experiences involves a novel form of reciprocal interaction between the prefrontal cortex and the hippocampus. When subjects control unwanted memories, there is increased dorsolateral prefrontal activation associated with reduced hippocampal activation. The magnitude of forgetting is predicted by prefrontal, cortical, and right hippocampal activations.

The notion of psychic determinism is intimately linked with the construct of the unconscious. Freud felt that behaviour and mental life were related to multiple and complex causation.⁽⁵⁾ The term overdetermination implies that a variety of intrapsychic and unconscious factors come together to produce specific symptoms or behaviours. The notion of multiple causation implies that there can be alternate sets of sufficient conditions, some involving primarily unconscious conflicting forces, others stemming from biological and environmental influences that ultimately produce similar symptoms or behaviours.

Regardless of which psychoanalytical theory seems to fit best with a particular patient, the dynamic psychiatrist always thinks in terms of developmental models. Patterns of relatedness established in childhood are repeated in adult relationships. Modern dynamic psychiatrists avoid the early psychoanalytical reductionism that attempted to link an adult psychopathological syndrome to a specific developmental arrest or fixation in childhood. Today, full account is taken of genetic contributions to personality and to psychiatric disorders. Environmental influences and genetic factors interact with one another reciprocally to shape the human being in health and illness. Still, the wisdom of the psychodynamic approach is that within each of us is a child yearning to complete some unfinished business from earlier in life.

In much of descriptive psychiatry the major focus is on taxonomy —specifically: How do groups of patients fit together under one classification? In psychodynamic psychiatry, by contrast, there is great interest in how a particular patient is unique—in other words, different from others. The subjective experience of the individual has been forged through an idiosyncratic narrative that is different from all other life stories and involves a specific interaction between genetic predisposition, intrapsychic factors, and environmental influence.

Intrinsic to the developmental model of mental organization is that adults are constantly repeating childhood patterns in the present. Transference is the best-known example of this phenomenon. The patient unconsciously experiences the doctor as a significant figure from the past and reacts to the doctor based on a set of unconscious attributions based on those past experiences. Transference has undergone considerable revision in more recent writings, so that today much more emphasis is placed on the clinician’s contributions to the patient’s transference. In other words, if a clinician is silent and remote, the patient may experience that clinician as disengaged and cold. While an internal template of past experiences with authority figures may correlate with that perception, we would also recognize that the clinician’s real behaviour contributes to that precise transference paradigm. In that regard, a more contemporary view of transference would be that every treatment relationship is a mixture of new features based on real characteristics of the clinician and old experiences from the patient’s past. Psychodynamic clinicians also recognize a bidimensional quality to transference: while one dimension involves repetition of the past, another dimension is seeking an experience with a new object to facilitate further emotional growth.

Central to the psychodynamic viewpoint is that the clinician and the patient bring their own separate subjectivities to an encounter, and mutually influence one another. Countertransference, in this respect, is the counterpart of transference. In other words, as Freud originally used the term, it referred to the analyst’s attribution of certain qualities to the patient based on the analyst’s past experiences with similar figures. This perspective, often referred to as the narrow view of countertransference, regarded the phenomenon as an obstacle to be removed because it interfered with the analyst’s objectivity.

Subsequent contributors to the literature on countertransference^{(6, 7)} noted that countertransference with severely disturbed patients often involves an objective component. The patient behaves in such a provocative manner that virtually anyone would respond with a certain set of emotional reactions to that patient. This way of looking at countertransference is often regarded as the broad or totalistic view. Inherent in this perspective is that the clinician’s reaction has much less to do with his or her own individual past than with the specific characteristics of the patient and that patient’s capacity to induce strong reactions in others.

As the definition has continued to evolve, countertransference is now generally regarded as involving both the narrow and the broad characteristics. In other words, most theoretical perspectives view countertransference as entailing a jointly created reaction in the clinician that stems, in part, from contributions of the clinician’s past and, in part, from feelings induced by the patient’s behaviour.⁽⁸⁾ In some cases the emphasis may be more on the contributions of the clinician than the patient, while in other cases the reverse may be true. This model also regards countertransference as something of a unique construction that varies depending on the two subjectivities involved (see Box 3.3.1). In this contemporary perspective, countertransference is both a source of valuable information about the patient’s internal world and something of an interference with the treatment.

In 1912 Freud⁽⁹⁾ wrote, ‘The resistance accompanies the treatment step by step. Every single association, every act of the person under treatment must reckon with the resistance and represents a compromise between the forces that are striving towards recovery and the opposing ones’. The patient’s resistance defends the patient’s illness from the clinician’s attempt to treat it and change it. Resistance may be conscious, preconscious, or unconscious. It may take many forms, including not taking medication as prescribed, forgetting appointments with the psychiatrist, changing the subject in the middle of an appointment to something trivial, and discounting every insight the psychiatrist offers. The patient’s characteristic defence mechanisms are often transformed into resistances in the treatment situation. The dynamic psychiatrist knows that all progress will be accompanied by some degree of resistance, and the exploration of resistance is a major part of therapeutic work. Resistance is intimately related to transference because the patient often rebels against the doctor resulting from unconscious transference configurations that lead the patient to oppose the doctor’s help.