A psychoanalytic view: on being reminded
When I was a medical student looking through psychiatric text
books and reading about various mental and personality disorders, I
had the somewhat disturbing realisation that some aspects of these
descriptions reminded me of myself.
Despite the difficulty that we might have recognising that some of
our patients’ difficulties remind us of aspects of ourselves, I
think that, at the heart of the human relationship that can become
therapeutic, is the use we make of ourselves emotionally to
understand our patients. This is the basis of empathy. The idea
behind the title 'On being reminded’ is that, in psychoanalytic
psychotherapy, the concept of transference can be understood as the
patient being reminded in their experience of the therapist of
someone from their past or some aspect of a relationship from their
past. The therapist too can be reminded in their experience of the
patient of someone from their past or of an aspect of a
relationship from their past and this is one part of what is known
in psychoanalytic psychotherapy as the countertransference.
Both patient and therapist are
mainly unaware of these reminders as they are unconscious, but it
is in the emotional impact of these mutual echos of the past in the
present that the work of trying to understand the patient takes
place in psychoanalytic psychotherapy. This is the theraputic work
of using the resonance of the past in the present relationship with
the therapist to process now what happened (or did not happen)
then.
Another way of thinking about the
idea of being reminded is that many people who come into
psychotherapy in NHS settings have endured severe emotional
deprivation and traumatic experiences in childhood, that is, they
have had an experience in growing up of not having been adequately
minded or held in mind in their development. For some patients,
privation may be a more appropriate word to describe their
experience than deprivation, to denote a primary lack of care
rather than care which has been inconsistent or which has first
been present and then became absent. What some, though not all, of
these patients seek is a relationship in which they can be held in
mind with the unconscious aim of being re-minded in a sense of
being held emotionally and psychologically in mind in a way that
they may never have encountered in their previous development.
This, in my view, is at the heart of what makes a therapeutic
relationship therapeutic. That is the process of a unique
relationship between the professional and the patient in which a
shared human experience, a shared emotional encounter, can take
place in which both parties are engaged in a process of emotional
and psychological work.
In psychoanalytic psychotherapy
this concept of working over one’s emotional difficulties from the
past is understood as working through. This working through
needs to take place in the patient in terms of working over and
working through their conflicts from the past with the therapist
but it also involves the therapist working over and through some of
their own conflicts that will be evoked in the emotional
relationship with the patient. This can be understood to be a
process of transference working through and counter-transference
working through for patient and therapist together.
In my twenty odd years in
psychiatry and psychotherapy, I have come to see that beyond the
specialist therapeutic setting, this process of an ordinary human
encounter in which the professional is prepared to be receptive to
the patients’ emotional communications, is at the heart of good
psychiatric practice generally.
As a Consultant Psychiatrist in
Psychotherapy one of my roles, alongside my therapeutic work, is to
consult with colleagues in psychiatry and other mental health
disciplines. I therefore encounter many situations where
people achieve what I am describing in terms of a genuinely
receptive emotional encounter with their patients, but also
struggle to maintain this level of emotional contact and enter an
impasse with some of their patients. I am interested in what
leads to people getting stuck emotionally and this links with the
whole concept of a disturbing process of being reminded. It is
when the patient presses the professional’s emotional and
psychological buttons that they get under that professional’s skin
and if that can’t be thought about and understood it can lead to
some very stuck situations clinically.
Dr James Johnston
Consultant psychiatrist in psychotherapy, Leeds