The Relationship
Underlying psychodynamic ideas is a belief that the relationship we have with each other is very important. This is so obvious but many people working in hospitals pay scant regard to this. Much communication in a relationship goes on at a level below consciousness which we are either vaguely aware or completely unaware. Sometimes this becomes very important.
Example:-
A. Patient with backache comes in looking as if he is going to crumble. The body speaks far more eloquently than words. Until you say, “you look at breaking point” the patient may think he just has back ache.
Importance of the Patients Feelings
Another idea is that patients have strong reactions to us doctors and vice versa. Such reactions are determined by a myriad of perceptions and expectations.
Consider oh I expected to see somebody older.
How do you feel? Put down, incompetent feelings resurrected, feel like a small child, flattered that you still look youthful!. Considerate it from the patients views. Is there a wish to humiliate, to avoid being humiliated as he or she has something to say which is shameful. Is there a wish to be fathered or mothered to be in a dependant relationship. Is there an envy of youth? Is there a fear you might be too lively and upset this patients unnecessary cocktail of drugs that his usual doctor dishes out? Does the patient want a mutually collusive relationship where there is no movement just like he had with the old doctor?
A Psychodynamic contribution makes us wonder what is the central anxiety behind the statement oh I expected to see somebody older. This anxiety is likely to have antecedents in that it connects with early childhood relationships. For instance instead of being the father figure the patient wanted to rely on for advice and wisdom you are a potential rival sibling.
It is not necessary to know details of the patients childhood to be able to infer this sort of idea. The interesting question is who do I represent to this patient? This sounds a very long drawn out process but I think it happens intuitively and actually you do this sort of processing all the time but often without being aware of it. I think it is sometimes important to be aware of it because it affects the therapeutic alliance or the doctor patient relationship and might determine the outcome of the consultation.
Thinking Before Action
I think it is also helpful to think Psychodynamically because it stops you immediately reacting to situations such as the comment I expect to see somebody older. You become curious rather than defensive.
Importance of Your Own Feelings
Psychodynamic thinking also places emphasis on the importance of your feelings. If you feel unaccountably bored, sad, angry or sleepy with a patient, that often indicates something about the patients state of mind. It might also be something to do with your own pre-occupations, but why does patient X really interest me while patient Y bores the pants off me – is patient X really trying to seduce me and triumph over somebody in authority and is patient Y trying to control me just like he does with his wife?
Emphasis on Anxiety
Another psychodynamic idea is that anxiety is universal and that is present from birth. There should be two anxious people in a room in a consultation. Your anxiety is manageable much of the time because it is helped by a body of knowledge, some experience, hopefully a helpful trainer, an institutional role as the doctor, as a trainee GP in an esteemed practice. The patients anxiety is often unmanageable that is why they have come. It might be that anxiety that their chest infection is cancer. But it might be much more diffuse.
Containment
Illness makes us all regress to when we were much more dependant on our parents to help us with anxiety. One psychodynamic model of anxiety which is quite useful is based on an early infant-mother relationship. The hungry baby is not just physically hungry but is emotionally hungry. It is all really one at that stage. His flaying limbs and strangled increasingly distressed cried evoke the desperate need to do something even in the most hard-hearted of us. This communication is so intense that it really gets inside and the mother by being attuned to the babys extremely anxious state appears to be about to fall apart if he is not satisfied, is able to gradually calm the baby down through both the emotional and physical sustenance. The mother has literally been able to manage the anxieties for the baby by taking them inside. This is called containment. Gradually the baby is able to learn how to hold himself together a bit more, because the mother is able to pass on her capacity to contain this sort of anxiety back to the baby.
This model gives us a way of thinking about anxieties of patients. In the process of your work, patients bring a load of their anxieties to you, anxieties about how serious their problem is, their anxieties about whether they are failing as a mother etc. Much of your time, you are receiving their anxieties and absorbing them, detoxifying them and handing the anxieties back in a more manageable form. This is not an obvious conscious process. On the whole you probably agree that most patients do not want all anxiety and responsibility taken away from them. In a good consultation the patient feels understood and exits much less anxious. The patients trigger our own fears of dying and suffering which lie buried under the surface of us all, even the most crusty of GPs. These are universal primitive anxieties which are often defended against by denial and externalisation and projection onto our patients. These defence mechanisms help us not to feel overwhelmed but to a certain extent, the patient is asking us to tolerate these states and that is where you need support. Manic overwork and an inability to delegate, arrogance, alcoholism are some of the less useful but sadly common defence mechanisms used by doctors. Your anxieties can be dealt with by your own discussions with your colleagues, your trainer and the group here. My anxieties can be dealt with by Brad!
Why Now? Why This Patient? Why This Set of Symptoms?
Both psychodynamic and systemic ideas help us to think about the question why has the patient come to see me. Is it purely because I have vacancies? Why didnt the patient see Dr X the usual doctor? What or who has brought or sent the patient along at this particular time with this particular set of problems to see this particular doctor. This is such a helpful question and cuts through a lot of confusion. The patient in the room maybe the wrong one in the sense that it is really somebody else in the family that is suffering. A classic example is the child who is brought along by the parents and whose marriage is going wrong.
Reflective Practice.
Lastly, thinking psychodynamically is really a process of reflection. Can you reflect on how you fit into the practice. You are in a position to probably be more objective about the tensions in the practice than if you were a permanent member of the practice. Reflective thinking helps in separating, your feelings about patients and their feelings which sometimes become confused. How do you cope with dependant patients who want to make a long term relationship? There will also be a beginning, middle and end of this group as will also apply to the attachment to your practice.