Summary and My Analysis of a Paper

THE DIFFICULT PATIENT by R D HINSHELWOOD


Summary

Difficult patients in turn influence the staff who care for and treat them. As a result, the staff retreat emotionally from their patient and from their experience into what is called a ‘scientific attitude’ implying objectivity. At times this attitude has met with an opposite reaction – one that emphasizes the patient as a suffering subject rather than as an object.

This paper will attempt to suggest that more subjective observation can prompt productive reflection – not only on the patient’s experiences but also implications for the psychodynamics of the ‘scientific attitude’ of psychiatric care itself. All workers have personal reactions to and feelings for the patients in their charge. It is now widely accepted that analysts and mental health professionals in general have inevitable emotional reactions to their patients – the staff may have difficulty in coping with this experience.

The ‘difficult patient’ is not a DSM category – rather it is a way of describing the state of the professional during the encounter. The term difficult is an ‘evaluation’; that the professional does not like the patient or something about the patient. He suffers a disagreeable or difficult feeling which is a subjective experience and denotes attitudes and feelings which can be studied informatively from a psychodynamic point of view.

Let us look at 2 types of patients and implications regarding them… In the case of people with schizophrenia, the problem is a loss of meaning itself, together with a synthetic attempt to replace meaning in a manner, which appears to be ‘mad’.

At first the patient is perceived as an object, then is dismantled as a set of symptoms and pathologies, followed by being reconstructed into a case, and finally reinvested with the subjectivity of a person again. So many patients seem to fail at the last step.

In the case of Schreber, his family conceived child rearing as a mechanical process of correct growth. This is so devoid of meaningful contact. This leads to a risk of depersonalization. It resembles the risks a person with schizophrenia runs in clinical psychiatry – on one hand the person is removed from the world of ordinary human rapport an on the other he faces the professional’s nonplussed retreat into a scientific mode of understanding.

In the case of Severe Personality Disorder (SPD), instead of the distanced apathy or incomprehensible ‘meanings’ characteristic of people with schizophrenia, the relationship is too intensely suffused with human feelings – usually unpleasant. People with SPD directly and deliberately (although unconsciously) interfere with the caregiver’s feelings. The caregiver feels intruded upon and manipulated – he feels provoked, hostile, persecuted and abused. The professional here is despite his training in danger of being overwhelmed. The professional may react very strongly to this and may suffer mental disturbance leading to resignations, illness, anxiety, anger, guilt, inability to continue with a patient, despair, envy, helplessness and exhaustion when faced with the patient’s ‘devaluation’.

With SPD the patient is labeled not mad but ‘bad’ and this confirms the life experience of such patients whose caregivers have proved rejecting or worse. A lot of these patients have a history of abuse and this justifies their suspicion that caregiver turns abuser. Hence, the difficult patient creates difficulties for the caregiver in a ‘personal sense’; forcing the professional to resort to behaviors which risk rebounding in deleterious effects on the patients, creating a pair of unfortunate vicious circles.

People with schizophrenia invite depersonalization and can no longer be seen as a person while people with SPD cannot be seen as a patient. As the SPD patient creates a situation of mutual abuse, the professional moves from diagnosis to moral evaluation such as ‘hysteric’ or ‘psychopath’. Difficulty arises when the assumptions made by the professional is challenged by the patient, one that the professional can offer ‘meanings’ which the patient can learn, and two that the professional can help people unable to help themselves.

The schizophrenic’s malady is to assault coherent meaning while the SPD patient reinterprets help as the threat of abuse or exploitation which leads to both parties feeling violated. This leads to a threat to the professional’s identity and he reacts by claiming to stress the scientific attitude more. This has two advantages; one that it is reputable and links to the achievements of scientific medicine, and two, it supports emotional neutrality.

However, this leads to with the schizophrenic a jeopardizing of the fourth step in which the patient is reinvested with subjectivity as a person again. With regard to the SPD patient, since the professional feels intrusively exploited, he desperately seeks an advantage – by condemning, rejecting and physically discharging of the patient. In both cases there is mutual detriment of professional and patient.

In conclusion, owing to the intensity of personal reactions, the ‘scientific attitude’ has to be most strongly struggled for. However, apart from objective growth, one should not neglect the subjective mode of understanding which comes from the professional’s own relating to the patient; and the scientific rigor of such subjective enquiry should be as great as in the objective research work.


COMMENTS and ANALYSIS by Amit Saraf

The author has so beautifully brought out the obvious processes of projective identification and countertransference. The difficult patient is an ‘evaluation’ and not a DSM category – it describes the ‘state’ of the professional in the encounter. The psychotic’s personality is a mosaic of improvised fragments. The patient can compress these fragments but cannot fuse them and as a result splitting and projective identification are used as substitutes for repression and denial. Also the professional may find the psychotic aspects and vulnerabilities of the patient resonating with his own psychotic aspects and vulnerabilities. This could be a countertransference issue.

In the case of schizophrenia the depersonalization is so obviously a retreat into the scientific attitude disregarding the patient as a person. This retreat is countertransference as its coldly worst, and seems to be a form of sadomasochistic complementary countertransference where the analyst is acting out some of the characteristics of the patient’s internal objects, specifically the ones devoid of meaning and therefore to be banished. This causes a retreat into depersonalization.

In the case of SPD there is a very strong projective identification into the professional who becomes possessed by, controlled and identified by the projected parts used by the patient as a defense and a primitive way of object relationship. As a defense it serves to create a sense of psychological distance from unwanted, often frightening aspects of the self. It also allows the patient to experience it through the object since it is too threatening to experience it himself.

As per Robbins, the therapist is forced into the experience of a victimized child feeling worthlessness and fear. The patient has emptied these feelings out of himself and into the therapist and thus can regain a momentary feeling of psychic equilibrium. The devaluation has protected the patient from painful self-representations. What is important, is how the analyst allows himself to have the experience, digest it, formulate it, and communicate it.

As Heimann put it, “the analyst’s countertransference is not only part of the analytic relationship, but it is the patient’s creation, it is part of the patient’s personality. The emotions roused in the analyst will be of value to his patient, if used as one more source of insight into the patient’s unconscious conflicts and defenses.”

As Feldman puts it, “What is projected is not primarily a part of the patient, but the fantasy of an object relationship. This is the reason the therapist is tempted to act out. The need is to understand these projections and what the elements of the fantasy relationship are. Verbalization, exploration and understanding then provide a vehicle to work through the various conflicts, fears and pains associated with those fantasies.

As Ogden puts it, under optimal conditions the recipient of the projection can reprocess the feeling evoked and return it to the projector in a more manageable form, a communicable form.

For Bion, therefore, the implication is that projective Identification can be a communicative activity – “a way of transmitting meaning by evoking empathy”. It is a way of seeing ‘thinking’ in terms of an emotional experience. One can learn about oneself and about others through Projective identification. The recipient is a ‘container’ and bad or intolerable feelings are transformed and made tolerable by the recipient and projected back into the projector.

As per Bott-Spillius, this process of transformation is the alpha function and eventually the projector will introject this function of transformation, and thus develops a means of thinking and tolerance of frustation. When the patient’s own alpha function is re-established and his anxieties contained, the whole process of normal thinking can begin. Therefore, the analyst under attack, needs to have ‘Negative Capability’ – to be an observer to his reactions instead of reacting – to hold the paradox without resolving it through a ‘flight to split off intellectual functioning’.

Hence, countertransference can be used as an advantage – as a communication.