Practical Psychodynamics in the Diagnostic Interview

It might be said of psychoanalysis that if you give it your little finger it will soon have your whole hand.

–Sigmund Freud

Keeping an ear open for psychodynamic material can help you in a number of ways as you conduct your diagnostic interviews. First, you can increase the accuracy of your diagnosis, because symptoms are often the product of life circumstances and dysfunctional ways of responding to them. Psychodynamics provides the preeminent language for describing defense mechanisms, and it also helps you understand how to use countertransference toward patients productively. Second, understanding psychodynamic principles will help you manage the interview itself, especially if your patient has negative transference toward you. Finally, understanding defense mechanisms will help you to diagnose personality disorders, which are covered in more detail in Chapter 31.

REALITY DISTORTION

Reality distortion is often the first clue that significant psychodynamic factors may be at work in your patient’s psychology. Psychosis is the extreme of reality distortion, but many non-psychotic patients distort reality as well. Examples include the depressed woman who unfairly castigates herself for being the cause of all misfortune in her family, the
narcissist who tells you that all his past therapists have been substandard and therefore unhelpful, and the alcoholic who says her husband is being ridiculous in criticizing her drinking habits.

Often, reality distortions will jump out at you over the course of the interview. Occasionally, you’ll need to dig for them. In Chapter 27, I suggest some screening questions to elicit the presence of the delusions. In these patients, however, we’re not talking about frank delusions; we’re talking about milder distortions. The way to elicit distortions is to be curious about how your patients interpret the motivations of others or how they make sense of events overall.

CLINICAL VIGNETTE

The patient is a 25-year-old woman with a history of panic disorder with agoraphobia and comorbid alcohol abuse. She recently terminated visits to her last psychiatrist because he refused to prescribe benzodiazepines for her anxiety disorder.

Patient: Dr. × said, “Absolutely not. I won’t give you any Xanax.”

Interviewer: What do you think was on his mind when he said that? (You are probing for her world view.)

Patient: To tell you the truth, I have no idea. Maybe that’s his rule.

Interviewer: What sort of rule do you mean?

Patient: Maybe he never prescribes those kinds of drugs for people like me.

Interviewer: People like you?

Patient: People with anxiety, people who really need them.

Interviewer: Why wouldn’t he prescribe meds to people who need them?

Patient: Who knows. He’s probably burned out. Most shrinks are.

The patient presents a jaded view of psychiatrists, possibly reflecting a more general view of the world as uncaring. Alternatively, her statements may reflect the defense mechanism of projection, in which the patient disavows her own anger at being deprived of an addictive drug and projects it onto her psychiatrist, who then appears sadistic to her because he doesn’t prescribe medications to people who need them. Whatever the nature of her distortions, you can be certain that you will not be exempt from them, and you can begin to prepare your own strategy to prevent future struggles. This
might include making statements that demonstrate an understanding of her world view:

As I listen to you, it sounds like you’ve gotten the short end of the stick over and over again in life. I wouldn’t be surprised if you’re assuming that it’s going to be the same way here, too.

Once you detect a reality distortion, determine whether defense mechanisms or transference is at work.

NEGATIVE TRANSFERENCE

Whenever two people meet there are really six people present. There is each man as he sees himself, each man as the other person sees him, and each man as he really is.

–William James

In transference, your patient unconsciously reenacts a past relationship and transfers it to a present relationship; this doesn’t necessarily pose a problem in the initial interview. Your patient may have a positive transference toward you, in which you remind him of someone he admired, like his mother, causing him to automatically ascribe to you all kinds of wonderful qualities. Sit back and enjoy it.

Negative transference, however, can be problematic, especially when it involves anger. Your patient may have been poorly treated by people throughout his life, and he expects you to be no different. Look for negative transference when there is a sense of tension. Perhaps your patient is making angry comments or asking provocative questions. Perhaps he is giving monosyllabic answers to your questions.

In psychoanalytic psychotherapy, negative transference is actually elicited, because its interpretation is the backbone of treatment. In the diagnostic interview, however, negative transference is usually counterproductive, and the best way to deal with it is to recognize it and make an empathic comment that neutralizes it. Although there’s no easy way of learning how to make these comments—other than practice, practice, and more practice—the following list contains some common statements (in italics) made by patients during diagnostic interviews. Most of these statements reflect negative transference or a defense mechanism of some sort. All of these statements tend to throw novice interviewers for a loop.

Possible hidden meanings are listed after each patient statement; the emphasis is on possible. Sometimes, such statements have no hidden meaning and are a statement of fact. For example, you may look bored during an interview and, in fact, feel bored. If the patient is making an accurate observation, don’t try to interpret the comment. That is dishonest and unfair to your patient. In addition, the hidden meanings I’ve listed are illustrative only. They don’t imply that all patients making such a statement actually mean what I suggest. You should interpret each statement individually, based on your knowledge of the particular patient.

In general, the possible responses are ways of moving beyond the negative statement, so that the work of the diagnostic interview can proceed. Note that this is a very different approach from what you would do if you were engaged in psychodynamic therapy.

You’re not a very helpful doctor.

Possible hidden meaning: No one has ever cared for me, and you’re no exception.

Possible response (while nodding empathically): “You know, that’s not the first time I’ve heard that, and when I’m not being helpful to a patient I always ask, ‘How can I be more helpful? Because I really do want to help.’” (This communicates that you really do care and implies that the therapeutic alliance won’t be damaged by your patient’s comment, but may actually be strengthened by it.)

Possible hidden meaning: I’m a very special patient, and you should treat me unusually well.

Possible response: “I bet it feels disappointing to have a doctor who doesn’t come up to snuff. Is it possible, though, that you’re judging prematurely?” (Empathize with the patient’s injured sense of specialness, while giving him an out to repair the relationship.)

You look bored.

Possible hidden meaning: Of course you are bored, I’m such a boring person.

Possible response: “I’m actually not at all bored, but do you think that the things you’re saying are boring?”

Possible hidden meaning: I expect you to respond lovingly and immediately to everything I say; if you are silent, I have to assume that you’re feeling something negative toward me.

Possible response: “In my profession, silence rarely means boredom. It usually means concentration and interest.”

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