Lost in translation? Patient under my skin: psychological challenges of psychiatrists working with difficult patients
- Goda Tikniūtė
- Jan 15, 2018
- 7 min read
Updated: 4 hours ago
Interview with Professor Eugenijus Laurinaitis
One of the most significant challenges in the work of a psychiatrist is managing difficult patients -particularly when they touch on our own sensitive issues. At times, it can feel as though someone is getting under my skin. The theme of this issue, ‘Lost in Translation?’, explores (mis)communication in psychiatry. Today, I am speaking with Professor Eugenijus Laurinaitis about the mental processes that influence the challenges of communication with patients in psychiatric wards.
Goda Tikniūtė: What determines our response to challenging patient behavior (non-cooperation, hostility, other inappropriate/psychotic behavior)?
Eugenijus Lairinaitis: If we are talking about the source of our own distortions, the first of these is our basic emotions, and there are only two of these emotions – security and insecurity. This is our limbic system's reaction to the environment, and it happens in 0.02 seconds, so we cannot control, change or rationalise it. And so, if we feel insecure, the basic effect of this emotion is to seek security. We try to do this in every way possible, and if we are talking about the profession of a psychiatrist, we try to do it in our professional way. First, we establish a diagnosis, and then we use it as an explanatory concept to help us understand the patient. We communicate through the diagnosis. Not with the patient through their experiences, through their perception of the world, but through our diagnostic perception. This helps, but it undoubtedly distorts our relationship, making it immediately formal, much more formal than when trying to listen to the patient. On the other hand, it greatly narrows the patient's perception, because we simply throw most of what they say or show into the diagnostic trash can. And there we no longer dig around and look for what it means, but say, "Oh, this is a psychotic symptom, nothing special." That's not true. Symptoms speak, and we can only hear this language if we learn to turn that feeling of emotional insecurity into curiosity, a desire to somehow understand the patient, what they are saying with these words and actions.
Indeed, what is so special about communicating with a person in a state of psychosis?
When we talk about the psychotic world in which severely psychotic patients live in psychiatric wards, it is undoubtedly extremely difficult, if not impossible, for us to empathize with that world. Moreover, according to some authors, it is precisely this lack of understanding of the world in which the patient lives that is one of the diagnostic criteria for determining that we are dealing with a psychotic patient. So what should we do? We should realize that regardless of the fact that the world in which the patient lives is psychotic, it is determined by his internal psychological dynamics. He interprets it in a psychotic way not just because, but because he feels somehow affected, ignored, manipulated in some way. And very often the delusions of psychotic patients are actually about some kind of responsibility for the world, or they are grandiose and therefore responsible for it, or they are the worst, the greatest criminals, the greatest transgressors of the world order and therefore responsible for what is happening. But one thing is clear: most of the psychotic world is very egocentric, that is, it is focused on the patient's own experiences. And this is where a certain space for therapeutic interventions begins, because one of the things that can really help the patient is reducing egocentricity. That the world is not really as focused on them as they think it is, that they are not really that important. This can be painful for the patient, because there is a reason why their delusions are so egocentric. They help the person with psychosis gain a sense of importance, and being important, as you will probably agree, is important to all of us. Reducing this sense of importance is, on the one hand, therapeutic, but on the other hand, it is a rather provocative intervention. You have to know how to do these things tactfully and gently. I have had more than one or two patients with psychosis in my outpatient practice, so I have to say that, just like in our proverb, "drop by drop, the stone is worn away," in our field of work, by trying to reduce our patients' egocentricity at the delusional level, it is indeed possible to achieve results. Not quickly, not suddenly, but it is possible.
What processes does such an encounter provoke and bring out in us? What are the main challenges to our own mental balance?
We all have some part of the psychotic world in our normal lives. For example, all kinds of superstitions, the idea that everything in the world is connected, that there are forces of fate, that there is punishment for sins – all of this is beyond the limits of tangible reality. And so this can be placed, say, within the framework of religion or tradition, but very often it is placed within the framework of the strangeness and incomprehensibility of the world. And this, too, is a certain psychotic element in each of our psyches. After all, we all have some superstitions (spitting three times over our left shoulder, a black cat crossing the street), without even thinking that this is a certain element of psychosis in the life of a healthy person. And this is why our communication with psychotic patients is dangerous for professionals, because it often provokes these psychotic elements in me, and again, this happens unconsciously.
What are the peculiarities of communicating with patients who have affective disorders?
If a patient is very sad, consciously or unconsciously, we identify with their sadness to some extent, because if we look at the life of each of us, we all have sad moments, we all have some failures, so when a patient talks about them, it triggers memories, and this is inevitable. The extent to which we get involved and the extent to which we realize that these are not the patient's feelings, but our own, is a very important part of professional skills. We need to be trained in these things.
Eugenijus Laurinaitis: "I have had more than one or two patients with psychosis in my outpatient practice, so I have to say that, just like in our proverb, "drop by drop, the stone is worn away," in our field of work, by trying to reduce our patients' egocentricity at the delusional level, it is indeed possible to achieve results. Not quickly, not suddenly, but it is possible."
And what about patients with personality disorders?
Personality disorders are not so common because there are various registers, various groups, which really differ greatly from what we imagine a healthy person to be, and some are quite close. For example, a dependent type of patient may seem completely normal to a professional who also has this personality type, because we are also people, we also have our own biographies, which have shaped us into who we are. And how we react to someone similar to us or very different from our personality really depends on a lot. We can safely say that there are personality disorders that are not very difficult to diagnose and work with, understanding what we are dealing with, such as borderline, histrionic, schizoid, but if we are talking about hysterical types or personality disorders closer to the healthy register, then there may be problems with their diagnosis if we are talking about the interaction between the professional and the patient's personalities.
What can we do to increase our chances of communicating and not getting lost in translation?
We need to understand that these feelings we call "technical" terms such as transference and countertransference are simple human feelings that arise in certain situations for everyone. But it is our duty and our job to strive to benefit the patient in all our professional activities. This means that we must be very attentive to what in our behavior may be harmful or unhelpful to the patient. And so we must tell ourselves right away that stopping countertransference or trying to suppress these feelings in some way is not a productive strategy, because we are only pushing them deeper into the unconscious, where they then act automatically. Our job is to be able to control our behavior professionally, so we must not think about what feelings have arisen in us, but rather what actions we want to take. This is where the main area of misunderstanding lies, because when I start to act under the influence of my countertransference feelings, I am no longer working for the patient, but am trying to help myself somehow calm those feelings, suppress them, soften them or hide them from myself, and so I am no longer working with the patient – I am working with myself. This should be avoided as much as possible, but how? It is possible by observing yourself from a slight distance. In our profession, we should have a kind of small observer within us who asks whether what we are about to do is beneficial to the patient or not. And I must always keep this criterion in mind – the benefit to the patient. The main thing is constant supervision or intervision. Professionals need to talk to each other, but not about patients, but about their perception of patients in their own minds. And they should discuss these more complex problems with colleagues. The best thing that can help is to constantly improve. There is no doubt that continuous improvement is necessary. We will encounter all kinds of patients, and there will always be some who get under my skin.
Thank you very much! □
