دانلود رایگان مقاله انگلیسی روانپزشکی روان شناختی، مدل بیوپسیوشوسیوسی و بیمار دشوار - الزویر 2018

INTRODUCTION

Psychiatry is the medical specialty that focuses on disorders of the mind, especially disturbances in thinking, behavior, and emotions. Psychoanalysis refers here not to a form of individual psychotherapy, but rather to a theory of mind that attends to an individual’s unique developmental trajectory within a familial and cultural context, with attention to the important impact of unconscious factors on human thought and behavior. Given these 2 definitions, we can think of psychodynamic psychiatry as the area of intersection between the domain of psychoanalysis as a theory of mind and the domain of general psychiatry. Psychodynamic psychiatry offers a perspective that allows us to engage, understand, and be useful to difficult-to-treat patients.1 All of us have experienced work with patients we come to view as difficult to treat or, as they are sometimes called, “treatment resistant.”2 There are patient-specific and disorder-specific characteristics that make patients difficult to treat, but that which is difficult often resides not in them, but in us, and in the limitations of our treatments.

Using Enactments

The capacity to use enactments involves 3 steps: detect, analyze, and use the enactment.30 We detect enactments by attending to our free-floating responsiveness in sessions. Analysis of enactments requires unpacking their meaning. What are we caught in? What are the bits of projective identification unfolding between therapist and patient? Analyzing an enactment requires that one know one’s blind spots and hooks, and often is facilitated by consultation with a colleague or supervision. Using an enactment may involve engaging a patient in serious discussion of the details of what you are both caught in, with due caution about undue disclosure of the therapist’s life history. Often the unpacking of an enactment, with each party owning their role in the tangled situation that has emerged, leads to a deeper and more intimate engagement. In other situations, therapists may simply realize they are caught in repeating behavior that they need to understand, contain, and stop repeating, without necessarily discussing the issue with the patient. Ultimately, the best protection against destructive enactments, in therapy, but also in other kinds of clinical work with difficult patients, is (1) to have the experience of a personal analysis or therapy to learn one’s hooks and blind spots, (2) supervision or consultation, (3) careful negotiation of a therapeutic alliance that includes exploration of what unfolds in the treatment relationship (whether or not it involves therapy), and (4) developing the capacity to “take” the transference that is offered from a stance of warm, empathic, nonjudgmental technical neutrality.