Psychodynamically informed clinical work

In a world of diverse mental health treatments and treatment settings, psychoanalysis and psychodynamic psychotherapy have lost their former prominence.  Only a small fraction of patients have the time, money, and interest to engage in long-term, open-ended mental exploration — even if doing so would get to the root of their problems and lead to lasting improvement.  More commonly, emotional distress is dealt with in emergency departments, in crisis clinics, on the medical and surgical floors of hospitals, in short-stay psychiatric inpatient units, and in non-clinical settings such as schools and prisons.  These settings permit only limited assessment and clinical intervention.  Partly as a result, nearly all have embraced medication and cognitive behavioral techniques.  These treatments are seen as “evidence based” because they empirically decrease, as designed, the discrete signs and symptoms that make up psychiatric diagnostic criteria.  They are, in other words, very good for treating most psychiatric diagnoses.

Treating the person so diagnosed is another matter, though.  No two depressions, psychoses, or traumatic reactions are the same.  An individualized perspective recognizes the person behind the symptoms — and even the person behind the persona.  Knowing patients in depth may uncover why one gratefully accepts care while another resists; why one is consolable while another is not; why one prefers inpatient care while another opts for yoga and herbs.  Two patients may meet criteria for “major depressive disorder, recurrent, moderate,” yet look and act very differently from one another.  Attention to these differences is the strength of psychodynamic treatment, and exactly what is lost as we turn away from it.

Fortunately, psychodynamic understanding is not limited to dynamic psychotherapy per se.  Psychodynamics are everywhere if we look for them.  The way people handle stress, their typical defenses or coping strategies, distinguish one personality from another.   By acting on plausible hypotheses about another person’s conscious and unconscious motivations, we align our efforts to his or her emotional reality, feel more empathy, and help that person meet his or her true needs.

Psychodynamically informed clinical thinking starts with staying awake and paying attention.   It takes no formal training to appreciate that, faced with the same threat, one person laughs it off, another counter-punches, while still another retreats and concedes.  Observing and acting on these personality differences can improve one’s skills as a trial lawyer, a salesperson, or an elementary school teacher.   If attorneys, salespeople, and teachers can enhance their work in this way, surely mental health professionals, and clinicians in general, can as well.  How does the patient relate to the clinician and to treatment recommendations?  How much motivation is there to get well?  How fearful is the patient?  Is it fulfilling to work with this person, or is he or she antagonistic, self-sabotaging, or working at cross-purposes?

The next step is curiosity: why is the patient this way?   From childhood we hear and apply informal explanations for what motivates others.  Psychodynamic theory refines this natural inclination.  It offers principles based in the dynamic unconscious to explain and predict human behavior, and to recognize emotions the patient may not have articulated or even been conscious of.  A prescription can feel generous and caring to one patient, and a brush-off to another; knowing something about the personalities of these patients can guide effective treatment.  The agitated patient in the emergency room may be an assault risk, or just frightened.  Knowing the difference can mean calling Security versus having a calming conversation.  In any setting the clinician can still prescribe the same medications, order the same lab tests, or conduct (or refer the patient for) the same CBT, just with a deeper sense of what the patient seeks, and what is most apt to help.

The final, optional step is to share psychodynamic wonder with patients, i.e., to encourage their own curiosity about themselves.  This is where clinicians differ from attorneys and salespeople: besides providing a service, we also strive to help patients feel and stay well.  Dynamic insight may help a patient better understand herself or himself (“know thyself”), tie together apparently disparate symptoms, and lay out a path to emotional healing.  It doesn’t take a mental health professional with psychodynamic expertise to imbue this curiosity and self-reflection — although it may help.  Minimally, it takes a psychodynamically informed clinician who is willing and able, even when providing other types of assessment and treatment, to see the patient as an individual with unique emotional reactions, a characteristic way of dealing with stress, and a subtle depth of personality that is meaningful and important.  While this perspective would enhance any clinical practice, its absence in any area of clinical psychiatry or psychology is a particularly glaring omission.

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