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A Psychodynamic Understanding of Modern Medicine: Placing the Person at the Center of Care

Maureen O’Reilly-Landry, ed.

London, Radcliffe, 2012, 233 pp., $49.95, paperback.

A psychodynamic perspective highlights the undersurface of our behavior and conscious thoughts and motivations. Undercurrents of meaning, symbolism, and drives present themselves in the doctor-patient relationship as well as everything else human. In the last decades, psychodynamic and psychoanalytic perspectives have largely been shunned by natural scientists. Psychoanalytic treatments stubbornly defy measurement as treatments are wholly unique to person and circumstance and do not lend themselves to protocol or observable outcomes. However, as Dr O’Reilly-Landry points out: “In discarding all insights derived from psychoanalytic ideas, much has been lost, including the ability to understand complex phenomena as they occur in the world of everyday life, in their natural state outside of the well-controlled environment of the laboratory.” Attention given to concealed feelings and meanings (of both doctor and patient) can improve interpersonal relationships and, thereby, healing and quality of care. The authors describe how “ . . . we know, feel, and express more than we think we do, and that psychological reality can both help and hinder the provision of good clinical care.” Written by a diverse group of psychoanalysts, this book is an excellent guide to welcoming a psychodynamic perspective into our thoughts about patient encounters and modern medicine.

The book presents five sections: (1) an overview of psychodynamic concepts, (2) descriptions of the subjective experience of being a patient and the meaning of living with illness, (3) the relationship between the person of the patient and the person of the health care provider, (4) the new relationships that medical technology creates, and (5) the needs of diverse families when a family member is ill.

The introduction describes general psychodynamic concepts (the unconscious, transference, countertransference, and defense mechanisms). At times other constructs inform an understanding of how people process experiences such as mentalization, object relations, and attachment patterns. An appreciation for attachment theory permeates the book.

Through case reports and the summative experiences of this diverse group—psychologists, psychiatrists, family doctors, and dentists, in diverse settings from dialysis units and NICUs to private practice—the book provides a window to many emotionally complex medical situations. Addressing fairly new psychosocial territory, they discuss coping with the medical technology that astounds the soul—walking around with someone else’s liver or a “birth other’s” baby in your belly, living dependent on a dialysis machine, or being the family of a profoundly premature infant living the first months of life in the NICU.

The intended audience is mental health professionals (psychologists, psychiatrists, and medical social workers) as well as anyone who is interested in how medical care is given or received. The language rarely slips into jargon. Overall, it is highly readable, engaging, and thought provoking. While clearly the book will appeal to mental health professionals and medical anthropologists, it may also be useful to family doctors. Family doctors often find themselves helping patients interpret their medical experience—both surface and deeper meanings. Thinking from a psychodynamic perspective may help family doctors conceptualize the meanings of patients’ experiences—even those meanings of which they may not be aware. For example, in the face of medical noncompliance, exploring deeper levels of resistance and meaning may prove more fruitful than badgering a patient to take medications. Family doctors reading this book may find it daunting to delve into these issues in the context of 15-minute visits, but at least it points to a way to conceptualize sometimes mystifying behaviors on the part of either patients or themselves.

For family medicine educators, the chapter on Balint groups by Sternleib, Scott, Lichtenstein, Nease, and Freedy is an expert introduction to this model of reflective practice. It may also be useful to residents or medical students enrolled in a Balint group as a means of preparation for the process. The psychodynamic perspective works comfortably within a family systems theoretical frame and will be useful to educators responsible for psychosocial teaching in residency programs and medical schools. It may provide a new vantage point from which to teach patient engagement and motivation, communication skills, and empathy training. (However, most chapters don’t provide the checklists, pearls, and skills breakdown for which our residents clamor.)

I plan to use the book in my teaching, especially the chapter on living with chronic illness. Other chapters will inform my clinical care—from a new perspective on my patient who is a liver transplant candidate to a different way to approach conversation with caregivers of elderly parents. This book is a welcome addition to my resource list and adds a missing piece to the literature on the modern medical experience. If we are aiming for truly placing the whole patient at the center of care, we cannot afford to dismiss their inner workings.

Pebble Kranz, MD

University of Rochester Family Medicine Residency Program, Rochester NY

Copyright 2018 by Society of Teachers of Family Medicine