Liliana Liviano Wahba
São Paulo, Brazil
Sociedade Brasileira de Psicologie Analitica
Analytical psychology has a contribution to make towards an issue in need of renewal that contemplates different countries and populations. One of the health areas affected by the Western splitting between object-subject, thought-emotion, logic-feeling, is that of the medical sciences. This is seen both in the doctor’s activity and in the training offered in medical schools, where only the biomedical healing model is valued. The doctor’s participation in the market economy and in the health care system puts him/her under pressure from which he/she can hardly escape. There are frequent reports of students and interns collapsing both physically and psychologically, as well as an alarming rate of suicides.
At the University of São Paulo Medical School, I belong to a team that teaches Medical Psychology, which is geared to enabling the student to make the medical activity more effective. To this end, the students are stimulated to introduce subjectivity into medical care. The work promotes training in attitudes consistent with an integral form of medicine by sponsoring a wide-sweeping view of the human being and human relationships based on an understanding of the other and of oneself.
The purpose of the group is to discuss themes related to their professional activity and their relationship with patients and peers. Each professor uses the framework of his/her background and specialization, which in my case is the analytical psychology method. Discussions are carried out to help widen the doctor’s consciousness, to lessen the gap between what is done and what is felt, and to assist both self and patient as far as healing and prophylaxis are concerned.
The first known experience of this kind are the Balint groups, idealized by Balint in the 1950s, where doctors discussed the emotional disorders of their patients and the doctor’s reaction towards them. It is important to organize such groups because the technological advance and the number of discoveries which make it necessary for permanent up-dating have made the medical specialization highly competitive and fragmented, thus breaking the patient into sectors of study and intervention. The most usual situation is to have a segmented doctor treating a segmented patient. A great deal is expected of doctors, who tend to react defensively. This leads them to keep dominating control over their patients and also to try to control life and death.
The biomedical model used at medical schools emphasizes objective language and the thinking and sensation functions of consciousness. If, on the one hand, this background and training is fundamental for the profession to be practiced with competence, on the other hand, it leads medical students to ignore their own or their patients’ feelings and subjective language, and to mistrust information that is not objectively quantified. They also disdain the psycho-physiological field, dividing the individual into two parts: the malfunctioning body, and psychological motivations and fears that are supposed to “only hinder” the doctor’s work and must be controlled.
However, it is progressively evidenced that medical procedures including psychological understanding enhance treatment efficiency, and that interpersonal attitudes taken during medical consultations influence the clinical behavior of the doctor during diagnosis and treatment. Attitudes that inspire confidence, besides encouraging the patient’s acceptance and adhesion, are also considered clinical instruments. Paying attention to the patient’s subjective communication allows the doctor to perceive less evident aspects, which help in detecting and preventing harmful – and sometimes lethal – effects. Such aspects are hardly ever recognized in medical education.
The aim of educational analytical group work is to stimulate subjective communication and the valuing function of consciousness – the feeling function – so as to encourage the development of a number of attitudes to be adopted by medical students and interns. These attitudes concern interpersonal communication, the professional role and image and the relationship with patients. The purpose of the group is to discuss themes relative to professional inner and outer attitudes and relationships with patients and colleagues.
Exercises stimulating feelings of empathy, readings from literary pieces, and imagining situations and interactions through guided imagery seek to understand transference-countertransference and the amplification of symbols by showing the healing roots of archetypal medicine. One such archetype reveals the healer-intruder polarity (Whitmont, 1993), besides the wounded healer. There is a scaring effect in the threat of iatrogenic (doctor-induced) harm. Understanding the archetypal fundamentals of the profession enables the doctor to deal with his/her activity and responsibilities in a more successful adaptation.
In embodying the healer archetype with its wounding aspects and offering his own illness propensity as a simile, the healer also embodies and provides the sickness-inducing, intrusive aspects of the archetypal illness field. (Whitmont, 1993, p. 209)
The student’s emotions and fantasies are considered in an analytical frame and through symbols related to the doctor’s role and activity. Since psychotherapy is not involved here, interpretations are only made concerning defenses that interfere with the group dynamics, as negativism, hostility or apathy, without delving too much and exposing the dynamics of personality, personal history and intimate content.
The group learns to make connections instead of splitting when dealing with polarities such as efficiency versus empathy, objectivity versus contact, technology versus integration, power versus impotence, detachment versus love, among others.
Students surprise themselves when they begin to learn to cope with feelings and the possibility of understanding a patient as an individual, and not merely as the display of a disease. It is also observed that strong defenses arise in facing the challenge of uncommon attitudes in medical learning. Nevertheless, students usually start to question various radical “truths” brought to the groups. Training the function opposite to the culturally dominant one and broadening horizons through these techniques enhance consciousness and flexibility of the medical persona and allow new attitudes to develop, which can be very helpful in medical education and in treatment.
Medical Psychology classes are given to third-year medical students, usually aged around twenty. In their first year they start with lots of idealization and great expectations about treating people whom they reckon they will cure – and save. Little by little, problems with impatient professors, difficult classes and having to learn to study in a different way, loss of prestige among older colleagues, intense competition, pressure to chose a specialization, experiencing the fast, impersonal rhythm of attendances, in addition to impotence in so many cases – all this makes them dispirited and frustrated. They are mostly very young people of high intellectual caliber who dedicated themselves intensely to their studies in their adolescence so that they could enter the biggest university in the country. They lack the experience of life and emotional maturity to endure the frustration and burden of responsibility they begin to feel. A period of disorientation usually occurs, after which they learn to employ the usual defenses of doctors and model colleagues. Psychology is seen with reservations and irony. It is also feared as an instrument to validate their mental health; magical thought, regressed and immature, is associated with the prejudice towards anything to do with the psyche. To give an idea of the work done, I shall describe some representative moments and exercises.
The choice made receives a jolt due to the dis-idealization and feelings of impotence that threaten to destroy the image of the doctor. Defensive omnipotence begins to appear in some students, along with a dose of aggressiveness and cynicism which unfortunately grows all the stronger as the course proceeds. It is important that they be helped in this phase to confront these feelings of frustration, impotence and fragility.
An exercise in directed imagination proposes that they return in time to the moment when they first thought of becoming a doctor. Reports cover a wide range, from conviction during adolescence to childhood fantasy, model from parents, hasty choice just before the university entrance examination, economic motivation, social prestige, and so on.
Several subjective aspects of the choice are revealed, and the students can express their certainties and indecisions: the projections, cultural introjections, prejudices and family and group expectations that weigh them down. The group accepts some doubts concerning vocation; their identities are strengthened, and more realistic objectives planned.
A second stage of the exercise involves selecting representative figures – real or imaginary – of good and bad doctors. Then they identify characteristics linked to both. This enables them to reflect on the idealizations and archetypal matrix of the profession, the meaning and the ideal of curing, the satisfaction when they succeed in doing so, and the pain of the losses inherent to medicine.
Doctors are usually terrible patients; besides not admitting sickness in themselves, they distrust other doctors and hospital procedures. Negating sickness comes from negating impotence and fragility, feelings that they consider affect the safety and determination they need to perform their functions. It is a constant challenge to teach students that defenses such as rationalization, negation, projection and repression can be replaced by self-knowledge and acknowledgement of values and limits. As for the mistrust, this is the result of learning iatrogenic consequences and the possibility of error.
The students are stimulated to tell of experiences with personal and family diseases, focusing on feelings and sensations. The identified emotions are written on cards and these are drawn to choose one. Then small groups perform a fictitious consultation in which the chosen emotion is represented, which ends with a parallel being drawn with consultations and situations observed in hospital.
Another exercise proposes describing the feared patients, who are generally aggressive, uncooperative and give up, with no chance of cure or about to die. All the groups describe the patient’s characteristics and project their difficulties in this description. Next, asked what they feel about such patients, they are led to reflect that the feared patient is the one who arouses the very same feelings that the doctor is afraid of: impotence, desires, anger, fear, anxiety.
According to Whitmont, the iatrogenic effects and the possibility of causing harm instead of curing are inherent to the archetype of the healer; recognizing this negative power helps the conscience to be careful and to try to avoid this risk. A Brazilian myth from the African Yorubá Nagó religion is narrated in order to stimulate associations and amplifications around the symbols it contains. The god Obaluaé – bearer of the cure and smallpox – can both punish and heal humanity. The limited chances of cure and medical intervention in extreme cases are discussed. While several disciplines approach the ethics of using technology and interventions, none addresses the issue of power, especially inner power, and how it affects each of us psychologically.
Training during the university course is aimed at making doctors competent, skillful and well informed. Few professors mention relational qualities in these skills, other than politeness and a bit of formal kindness. It is taught that clinical reasoning should be objective and neutral, and that in order to attain a standard of efficiency, emotions and feelings have to be banned. So, feeling is forbidden in the profession – and loving even more so.
It becomes obvious to the students that feelings are a hindrance and can only be repressed. The feeling function, instead of receiving special training to help in empathy, remains inferior, primitive and regressed. In this way, complexes are activated by means of this inferior function, producing unsuccessful relations with patients and their family members and colleagues, together with problems in their private life. This nurtures prejudice, intolerance and rigid convictions, all born of undifferentiated, automatic values. The worst of all is the loss of an instrument of the medical activity that is important when used skillfully.
The students show a common tendency: when any conflict arises, they look for rules on what to do and how, but gradually they all learn to express what they feel in the situations reported, realizing that the choices multiply. They also learn to listen to others subjectively, which is the essence of empathy.
To illustrate this, when the theme of sexuality in the doctor/patient relation is approached, the possibility of either party being seduced is explored, together with the possible reactions. Although contradictions and some inhibitions appear, the students usually conclude that the solution is to repress all desire and maintain a medical posture and professional ethics. Then they are asked to imagine that they are the script-writers of the “Emergency Room” serial and to write an installment showing a case of seduction. The subsequent analysis of the scene aims at stimulating reflections on the significance and limits of repression and the values involved. A survey that I carried out with questionnaires and counting the verbs used revealed that at the end of the course the verb “to feel” was heard significantly more.
One of medicine’s greatest losses is fragmentation and its many consequences, including collusion with anonymity described by Balint, which frees doctors from feeling entirely responsible for the patient.
Fragmentation also reflects the scission experienced by doctors, the radical separation between persona and shadow which prevents them from loosening a generally defensive, inflexible and often arrogant persona.
An exercise dynamizing the play between persona and shadow involves representing a scene from a conflictive consultation. When the presentation ends, the two students who play doctor and patient have to tell what they imagined and felt in the scene but did not show. Talking through characters enables them to project what they would not feel free to say spontaneously, and the models incorporated usually appear, together with some prejudices established among them. They are made to realize the contradictions and usual attitudes that conceal them, inhibit the expression of individuality and make self-esteem difficult.
Integration is the goal: inner integration, integration with colleagues, patients, the medical act. Our goal is to open the dialectic that defines the process of individuation, the dialectic between conscious and unconscious, within the limits allowed by a framework of learning.
Two students’ dreams elucidate this work: “There is a car accident. I’m in the car with my girlfriend. She is bleeding badly from her injured arm. I take her to the school hospital, it pains me to leave her there, it’s so horrible, the smell is unbearable, the doctors are squashing the patients in a grinder. There are bits of a body, the head on one side, limbs on the other.”
After a headache from some tension in the student union, a student tells the following dream: “A healer that I did not know said he would cure me. He put his finger on my forehead and I felt a deep calm, my body seemed so light and my mind so clear. He irradiated goodness and wisdom.”
In their own interpretation, the students felt that the dreams represented the dissociation and fragmentation of medical teaching and activity, and healing through integration.