Psychodynamic theory is based on the idea, cast by Sigmund Freud and modified later by others, that behavior is influenced by forces derived from processes of which individuals are not aware. Although these unconscious forces keep thoughts and emotions out of consciousness, they are at the same time dynamic and affect peoples’ choices, emotions, and behavior throughout life. Psychotherapeutic treatments, such as psychoanalysis and related therapies (see Chapter 11), are based on this concept of the dynamic unconscious.
This chapter introduces and explains the language of psychodynamic theory. The discussion focuses on the concepts of individual defense mechanisms and transference reactions between doctor and patient. At first glance, the relationship between these intellectual constructs and everyday medical practice may seem obscure. However, understanding these ideas can help physicians decipher and respond to seemingly inconsistent, hostile, or even self-destructive behavior in their patients.
Freud’s Theories of the Mind
Early in his career, Freud developed the topographic theory of the mind to explain his ideas about behavior. Later in his career, he developed the structural theory.
In the topographic theory, the mind contains three levels: the unconscious, preconscious, and conscious. The unconscious mind contains repressed thoughts and feelings that are not available to the conscious mind. The unconscious uses primary process thinking, a type of thinking associated with primitive drives, wish fulfillment, immediate gratification, and pleasure seeking. It has no logic or concept of time. Primary process thinking is seen in young children and in adults with psychotic illnesses (see Chapter 12).
The preconscious mind contains memories that are not immediately available but can be accessed easily. The names of the cranial nerves, not on the tip of a medical student’s tongue but accessible for exams, are examples of preconscious material. The conscious mind contains thoughts that a person is currently aware of. It operates in close conjunction with the preconscious mind but, unlike the preconscious mind, does not have access to the unconscious mind. The conscious mind uses secondary process thinking (logical, mature, and time-oriented) and can delay gratification.
One question that the topographic theory raises is whether it can be known that the unconscious mind really exists. Freud suggested that one piece of evidence for the existence of the unconscious is the presence of dreams, which represent gratification of unconscious instinctive impulses and wish fulfillment. Other examples of the unconscious are the phenomena of parapraxes or Freudian slips—errors of speech (or of hearing) that reveal one’s true but unconscious feelings and hypnosis—a psychotherapeutic technique that bypasses the conscious mind to reveal material in the unconscious (Table 8-1).
Table 8.1 Freud’s Proof of the Unconscious
|Dreams||A man who has personally unacceptable sexual feelings for his therapist, Dr. Freud, dreams that he is walking naked down a street named “Sigmund Road”|
|Parapraxes||A woman who unconsciously fears the responsibilities of a new and lucrative position states, “My new job is a landmine … I mean a goldmine”|
|Hypnosis||Under hypnosis, a woman who has no conscious memory of the event reveals that she was sexually abused as a child by her father|
In Freud’s structural theory, the mind contains three parts: the id, ego, and superego. All three parts are essentially unconscious. The id, present at birth, contains instinctive sexual and aggressive drives. It is controlled by primary process thinking and is not influenced by external reality. The ego controls the expression of the id and adapts it to the requirements of the external world primarily through defense mechanisms (see later text). The ego enables one to sustain satisfying interpersonal relationships and, through reality testing (i.e., constantly evaluating what is valid and then adapting that to real life), enables a person to maintain a sense of reality about his or her own body and the external world. The superego, which also controls id impulses, develops at around age 6 years and represents moral values and conscience.
Conflict arises when the drives of the id threaten to overwhelm the control of the ego and superego. When this situation occurs, the ego pushes the id impulses and unacceptable emotions deeper into the unconscious by the active defense mechanism of repression. Unfortunately, material pushed into the unconscious does not sit quietly. Although the person may be unaware of its content, this material affects his or her emotional state, causing psychiatric symptoms (such as anxiety and depression) and dissociative and somatic symptoms. Freud developed a treatment technique, psychoanalysis, to recover and consciously address this repressed material (see Chapter 11). He observed that when patients were treated with psychoanalysis, their distressing psychological symptoms dissipated. Freud strongly suspected that psychotic illnesses such as schizophrenia were not caused by unconscious conflicts. He surmised, correctly as subsequent investigation confirmed, that psychotic illnesses were organic and, as such, could not be helped by psychoanalytic treatment.
Like defending themselves against physical pain, people protect themselves, although unconsciously, from emotional pain. The techniques they use to do this, which Freud called defense mechanisms, work by keeping conflict out of the conscious mind. This protection serves to decrease anxiety and thereby helps the individual maintain a sense of safety, equilibrium, and self-esteem.
People in need of medical and psychiatric care commonly use defense mechanisms to deal with the fear and pain associated with their illnesses. As such, these mechanisms can serve a useful purpose for the patient. However, defense mechanisms that prevent a patient from seeking care or complying with treatment recommendations can ultimately be harmful.
Mature and less mature defense mechanisms
The type of defense mechanism used by an individual is closely associated with that person’s coping style and personality (see Chapter 24). For example, a person who tends to become childlike and demanding when stressed by illness is coping by using the defense mechanism of regression (see later text).
Defense mechanisms can be less mature or more mature. Less mature defense mechanisms protect the person from anxiety and negative personal feelings, but at significant social cost. Mature defense mechanisms serve the same function but without important social cost. For example, a man, using the less mature defense mechanism of displacement, deals with his unacknowledged anger toward his employer by verbally abusing his own office assistant. In contrast, using the mature defense mechanism of sublimation, the same man could deal with his anger by engaging in a strenuous game of racquetball.
Mature defense mechanisms may even have social benefits. When a man with low self-esteem donates time to visit patients in the hospital, he is using the defense mechanism of altruism to feel better about himself. Other mature defense mechanisms in addition to sublimation and altruism are humor and suppression.
Humor involves expressing personally uncomfortable feelings without causing emotional discomfort. For example, a patient who is uncomfortable about his erectile problems makes jokes about Viagra (sildenafil citrate). Using suppression, a defense mechanism that includes some aspects of consciousness, a person deliberately pushes anxiety-provoking or personally unacceptable emotions out of conscious awareness. For example, a prostate cancer patient who mentally purposefully changes the subject when his mind wanders to the possibility of relapse, yet seeks appropriate treatment for his illness, is using suppression as a defense mechanism.
Common defense mechanisms in medical patients
Repression is the most basic defense mechanism; the other defense mechanisms are used only when repression fails. Repression is closely related to the defense mechanism of denial, and both are commonly used by medical patients. In repression, a patient unconsciously refuses to believe an aspect of internal reality. In denial, he unconsciously refuses to believe an aspect of external reality. For example, using repression, a cocaine abuser does not feel badly about the addiction because he fails to remember, or admit to himself, that the length of his drug use spans years rather than months. Using denial, he believes (although there is evidence to the contrary) that he can stop using the drug at any time.
Undoing and regression are other defense mechanisms often seen in medically ill patients. In undoing, a patient believes that she can magically reverse past events caused by “incorrect” behavior by now adopting “correct” behavior, such as by atoning or confessing her transgressions. For example, a woman who is terminally ill with AIDS caused by intravenous drug abuse decides to stop using the drug and join a support group in which she reveals how she stole money to obtain the drug. When she is hospitalized for complications of her illness, this same woman may show regression by reverting to childlike behavior patterns like whining, pouting, and insisting that relatives pay more attention to her.
Rationalization, intellectualization, and isolation of affect
Educated and uneducated people use defense mechanisms to avoid negative emotions. However, educated people tend to use defense mechanisms that employ the mind’s higher functions. These mechanisms include rationalization, intellectualization, and isolation of affect. In rationalization, an individual unconsciously distorts his or her perception of an event so that its negative outcome seems reasonable. A blind person who believes that he now has supernormal hearing is using this defense mechanism. Intellectualization involves using cognition to avoid negative emotions. The pilot of a doomed flight who explains the technical details of the engine failure to the passengers is using this defense mechanism. Using isolation of affect, an individual does not consciously experience any emotion when thinking about or describing an emotional event. The person who expresses no emotion when talking about the loss of a loved one has isolated his emotions from the sad event.
A 35-year-old surgeon loses his left arm above the elbow in an automobile accident. During his recovery, the surgeon tells visitors and colleagues that the loss of his arm was unfortunate but ultimately beneficial to work as a doctor. He says that it helps him understand the experience of his amputee patients. The surgeon also frequently explains in detail the technical aspects of the accident and surgery to others. The surgeon states, seemingly without emotion, that he understands that the loss of his arm means that he can no longer practice surgery.
This surgeon is dealing with the devastating loss of his arm by using several defense mechanisms. Using rationalization, he gives a seemingly reasonable explanation (i.e., the loss was ultimately beneficial for his practice) for his personally unacceptable feelings of grief at the loss of his arm. He also avoids unacceptable emotions by focusing on the technical and medical aspects of the accident and surgery using intellectualization. Finally, although he says that he understands the significance of the loss of his arm, the doctor does not show and in fact does not consciously experience any emotion (isolation of affect) when stating that he can no longer practice surgery.
These defense mechanisms have probably served the doctor well in his work by allowing him to perform his job during stressful emergencies. They may also have helped him in the short term to cope with the loss of his arm. However, their excessive long-term use can prevent him from dealing with his real feelings about the loss of his arm. Failure to deal with his true feelings can ultimately hamper his adjustment to the loss and hence his full recovery (see Chapter 25).