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The Royal College of Psychiatrists Improving the lives of people with mental illness

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

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