Reading the Ability of a Patient to Change His or Her Life

February 2007, Vol. XXIV, No. 2

Half of what I do in the clinic with our residents is help them find the drugs for their patients that will provide the greatest benefit and the least harm. This is a subject that is generally well taught and sometimes taught exceptionally well.¹ The other half of what I do is help the residents find the words that reach the patients in their circular histories, in their feelings, and in their readiness to take action for themselves in a different way. This is a subject that is hardly taught at all.

Last week I was asked for help by a colleague who supervises psychiatric nurses in the outpatient clinic. He finds that their time is poorly spent. For example, they have many longtime patients who complain of physical pain and who have repeated virtually the same sentences for years. My colleague wanted to know whether I had a way to sort out which patients would end up like this and which patients would “wake up” and work for a different life.

Fortunately, I make this decision all day long in our resident clinics in an average of 10 minutes, so I could give him a very clear answer. He asked me to write out this reply, because it is something of a secret in psychiatry. Why? I think it is because psychodynamic thinking has largely disappeared from our field. What I call The Common Dynamics of Psychiatry² are largely unknown.

The common dynamics are a great force in the lives of our patients. All of the patients have anxiety, which is a signal of danger, and all of them have depression, which is a signal of defeat. All of them tend to find give-and-take with the world too painful to bear and deploy defenses in order to live in fantasy. Most of our patients give a lot more than they get back, and then they force compensation in fantasy. These defenses compensate the patient by denying the painful reality of their lives in favor of illusions. For example, drinking dulls reality and so does obsessing about details.

Something very different can happen if the patient has an ally who can face with him or her what is going on between the patient and his world, and how he might move in an opposite direction.³ Fortunately, the patient's ability to change direction in this way can be tested in a very brief opening of about 10 minutes. David Malan⁴ used to call it “trial interpretation.” I will now illustrate how I go about such a reckoning, with 2 case examples.

The young businesswomanThe principle of the single example. To reach the patient quickly and powerfully, you need key details that will arouse great feeling in her. Strangely enough, the simplest way to get there in no time at all is to ask something like, “What is bothering you the most right now? Just off the top of your head, tell me whatever occurs to you.” The patient is relatively unguarded against such a question because she has no idea that her single example is the story of her whole life. Why this turns out to be the case is a matter of considerable theoretical interest. James Mann⁵ once called it “the present and chronically recurring pain.” I have explained it in terms of the fractal principle of chaos theory, which is that certain structures recur on every scale of time and space.³ The reader with more time can follow the theoretical argument there.

Now, it is also true that about half of our patients will decline an invitation to give an example of what bothers them. They will say, “Nothing,” or “My drug is pooping out,” or some such thing, which puts us back to supplying them with more of our neurotransmitter agents. Thus, the defenses do operate against openness.

Case Vignette
A young businesswoman, presented to me by a resident as having dysthymia, had been depressed for as long as she could remember, without suicidal ideation, inability to function, manic phases, drug or alcohol dependence, or psychotic elements. I asked her for an example of what got her down. Two things, she responded: going to work in her business, which is boring, and taking care of her boyfriend, who is always sick.

The principle of the best of times and the worst of times. Something about our field brings about a flattening of the history, as if what we are seeing in the room is always the case. It almost never is the case, but merely a typical social performance. Things have always been much grander and also much more catastrophic. If we can find these 2 extremes, the drama of the case will be greatly heightened, and with it, the depth of feeling.

I asked this young woman when she had last been well. In college, she replied promptly. Coming back from a year abroad in Europe, she had loved being back with her friends, studying sociology with a great professor, and writing papers that were well received. Suddenly, recalling this junior year, we had a different young woman, sitting forward in her chair, with considerable enthusiasm for her life.

So, I asked, how had she lost her happiness? Well, she came here and started in an influential position in a corporation and worked 80 hours a week and came home to a boyfriend who had a chronic illness, whom she grew tired of taking care of.

The principle of compensation in fantasy. Now, she sank before my eyes into her dismal state. How had she accepted such a crestfallen condition? I think she has the most common defense of all: long lists of things to do, that keep you incessantly on the move, will keep you from feeling what is wrong. You will always be “in your head.”

The principle of exchange. For millions of years, aboriginal humanity was selected for its ability to engage in relatively equal exchange with its small band of relatives. Now, for the past few thousand years, humanity has been in the modern condition of relative anonymity, with its special talent in a vast market. From this perspective, it may be less surprising why an individual rushes ahead and becomes miserable. What he is selected for now runs against the natural selection of millions of years.⁶

“Of course, you are miserable,” I said to this young woman, “for you are getting a terrible exchange in work and in love: compared with college, where the exchange was fruitful in both, now you pour out a ton of effort and get back boring procedures and a sick and weary boyfriend.” The contrast between the best of times and the worst of times could hardly have been clearer for her, in terms of what had befallen her exchange with the world.

The principle of the dream-drop. Having heightened the bifurcation in her history to the point of maximum drama, I was in a position to “drop into a dream” with her,⁷ to get a point of view from her unconscious mind that was opposite that of her conscious mind. Often, we get a drop into considerable energies, ready to go 180 degrees from the life of miserable exchange.

And so it was with her. She had a simple but powerful wish-fulfillment dream.⁸ This is the simplest form of the dream, uncensored by the dream work of defenses. She dreamed of working as a professor and being excited to be in a new life. We talked a little about graduate school in sociology, and she told me of her ambition to use her knowledge to wake up students to what is meaningful in life, instead of allowing it to be taken over by what is trivial and finally meaningless.

Of course, this was just a start, since this opposing current to the usual faltering had its own dangers to negotiate.³ At least we had a patient who was ready to work. Of course, not all patients are capable of dropping straight into a dream after the first meeting. Let us look at another case, to recapitulate the working principles.

The temporary-agency workerCase Vignette
This patient was presented to me by a resident as a person complaining chiefly of exhaustion, or lack of motivation, for the past summer. She continued her jobs for a temporary agency, but she did little else. She seemed to be depressed, but she lacked any of the complications we look for. She had no vegetative signs, no suicidal ideation, no psychotic or manic phases, and no alcohol or drug use. Nor did she have any other physical complaints that would suggest a condition secondary to organic medical illness (the usual screening laboratory tests were scheduled, along with a physical examination by a primary care physician). I discovered right away that this was one of many episodes of this condition since her adolescent years, but I took the simplest route to clarifying the “present and chronically recurring pain” by attending to the present version, as argued by my very, very brief set of principles.

Asked for a single example, off the top of her head, of what was bothering her the most, this woman told me that she had been asked by her mother to go on vacation and had acquiesced at once, even though she hated being with her mother. What followed was a miserable week, which was followed by several more miserable weeks of self-blame (marked by the Gustafson sign³ of pointing 1 or 2 fingers at her head).

I could see that she was going to run on in self-blame for the remainder of our time if I let her (the compensatory fantasy here is the punishment of guilt, which has its own gratification). So immediately, I posed the opposing current to dwelling on guilt and said to her, “You seem to know nothing about providing room for yourself to consider a proposal before you accept it” (the principle of exchange). She thought about it briefly and reported with some pride that her husband had urged her to go to a family reunion, but she thought about it and declined to go. She told him that he would have a good time, and she would have a bad time, and therefore he should go himself!

I was impressed with her readiness to consider her exchange and to say “no.” What about saying “yes” to what she wanted for herself, I asked. I was quite astonished when she now came forward with having designed a house in high school and many similar projects, including a book of house designs, in the last few weeks. How had she managed to do this? Well, her therapist before me, who was leaving, had challenged her to finish it and submit it. Suddenly, from having no energy to complete anything, she had more than she needed in a burst of enthusiasm. I commented that it seemed to make a great difference that she had a person in her corner (the ally effect).

There was much more I wanted to go into, but that would have to wait for the next meeting. I wanted to know about her acquiescence to miserable exchanges in her family of origin, and I wanted to know about the lack of support for her original work (the principle of the best of times and the worst of times always applies to childhood). I also wanted to drop into her dreams, and I invited her to jot down what was on her mind every evening and what followed in the dream night.

Of course, this too was only a beginning but, again, we had a patient ready to pursue the hard work of therapy with considerable force mobilized. She, too, would slip many times, for the exterior world would dim the interior, when she acquiesces again, and the interior world will dim the exterior when she gets high and mighty in her originality and then balks at crossing over to show it to anyone. It will take a while to get her exchanges consistently right. Yet, it is already evident that she can move along a new trajectory to a better life, given the kind of help I have outlined.

Dr Gustafson is professor of psychiatry and chief of the brief psychotherapy clinic at the University of Wisconsin. He has written 9 books on psychotherapy, including the most recent, Very Brief Psychotherapy (Routledge, 2005), and is writing a 10th, The Great Instrument of Orientation. His Web site is http://psychiatry.wisc.edu/gustafson. He reports no conflicts of interest regarding the subject matter of this article.

References1. Pies R. Handbook of Essential Pharmacology. 2nd ed. Washington, DC: American Psychiatric Press; 2005.
2. Gustafson JP. The Common Dynamics of Psychiatry. Madison, Wis: James P. Gustafson, Publisher; 1999.
3. Gustafson JP. Very Brief Psychotherapy. New York: Routledge; 2005.
4. Malan DH. Individual Psychotherapy and the Science of Psychodynamics. London: Butterworths; 1979.
5. Mann J. Time-Limited Psychotherapy. Cambridge, Mass: Harvard University Press; 1973.
6. Gustafson JP. The scarcest resource in the world is attention. Available at: http://psychiatry.wisc.edu/gustafson/docs/TheScarcestResourceintheWorldIsAttention.pdf. Accessed November 26, 2006.
7. Winnicott DW. Therapeutic Consultations in Child Psychiatry. New York: Basic Books; 1971.
8. Freud S. Interpretation of Dreams. The Standard Edition of the Complete Works of Sigmund Freud. Vol. 4. London: Hogarth; 1975 (originally published 1900); New York: WW Norton; 2005.

Evidence-Based References

• Malan DH, Heath ES, Bacal HA, Balfour FH. Psychodynamic changes in untreated neurotic patients, II: apparently genuine improvements. Arch Gen Psychiatry. 1975;32:110-126.

• Prochaska JO, Norcross J. Stages of change. Psychotherapy. 2001;38:443-448.