Rebecca Twersky-Kengmana, MD
Psychiatrist in private practice, New York, NY
Dr. Twersky-Kengmana has disclosed that she has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
Psychoanalytic training may not be right for you, but here are some analytic concepts that can be useful to anyone practicing psychiatry.
~ The unconscious: Patients are often unaware of patterns of behavior and their underlying conflicts. Unacceptable feelings like aggression and sadness may be banned from conscious thought, and therefore inaccessible to direct confrontation. I find clues to these feelings in slips of the tongue, chronic lateness to sessions, dreams, and fantasies. If a patient brings in some artwork, I treat it like a dream, asking about its various elements and encouraging her to free associate in response to them, as well as exploring the reasons she brought it to our session.
~ Compromise formations: This term refers to maladaptive behaviors that may be a patient’s best attempt to solve an unconscious conflict with limited tools. If a patient is not taking medication as prescribed, I try not to dismiss this as “bad” behavior or noncompliance, but to explore its meaning. For example, the patient may wish to get well while simultaneously remaining attached to the sick role (see case on page 5).
~ Meaning and symbolism: The patient may think of medication as a gift, or poison, or a piece of the psychiatrist that he can carry around. I always assume it means something more than just pills. And if a patient talks about a movie, or public transportation, or even the weather, I listen for clues to what he’s trying to tell me about himself. One patient complained about the subway, and how he never knew whether to choose the express or local, and that he always picks the wrong one. I responded with an interpretation about his belief that he is “unworthy,” and it is his fate that only bad things can happen to him.
~ Multiple determination: Contrary feelings towards a single object (ie person), like love and hate, frequently coexist. It’s helpful to remind patients of this, because it encourages them to accept themselves and those with whom they are close. For example, when a patient protests that she enjoys her mother’s company and is therefore not resentful of her mother’s demands, I often say something like, “Why not both?”
~ Transference: Patients have strong feelings about their psychiatrists, even if those feelings are really about someone else. I’ve noticed that my vacations can evoke a painful sense of abandonment, and my occasional mistakes can evoke fury. It’s uncomfortable to have these emotions directed at me, but it helps the patient if we try to understand them together.