The Psychodynamics of Medical Practice [Reprint 2020 ed.] 9780520327191

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The Psychodynamics of Medical Practice

THE

PSYCHODYNAMICS OF

MEDICAL PRACTICE UNCONSCIOUS FACTORS IN

PATIENT CARE

Howard F. Stein

University of California

Press

Berkeley • Los Angeles • London

University of California Press Berkeley and Los Angeles, California University of California Press, Ltd. London, England Copyright © 1985 by The Regents of the University of California Library of Congress Cataloging in Publication Data Stein, Howard F. Psychodynamics of medical practice. Includes bibliographies and index. 1. Physician and patient. 2. Countertransference (Psychology) 3. Medicine, Clinical. I. Title. [DNLM: 1. Countertransference (Psychology). 2. Physician-Patient Relations. 3. Primary Health Care. W 62 S821p] R727.3.S833 1985 610.69'52 84-28046 ISBN 0 - 5 2 0 - 0 5 4 8 0 - 6 1 2 3 4 5 6 7 8 9

To Weston La Barre, in friendship

Contents

Preface

ix References

xiii

Introduction References

1 16

1. Countertransference as a Key to Subjectivity Within the Physician Role References

61

2. Some Common Themes in Countertransference and the Situations That Evoke Them References

113

140

4. "How Could I Eat Uncaring Food?": From Identified Patient to Family Pathology (with Timothy A. Wilson, M.D.) References

65

110

3. The Contest for Control: A Case of Diabetes Mellitus in Multiple Contexts References

18

143

168 vii

viii

Contents

Conclusion References Index

171 184 187

Preface

The subject of this book is the psychodynamics of medical practice, that is, the influence of unconscious factors on patient care. Although this influence transcends specialty boundaries within medicine, this book addresses the role of the unconscious within primary care specialties, family medicine in particular, from which most of the clinical vignettes and cases are drawn. In this volume countertransference is recognized as a legitimate and important subject of clinical concern and discourse, one that encompasses clinical training and practice alike. It is an approach originally introduced by Michael Balint (1957) in Great Britain in the 1950s. Clinical teaching cases taken from the writer's experience as a teacher of medical students, family medicine residents, and physicians' associate students are used to illustrate theoretical issues and management strategies. Psychiatrists, child psychiatrists, psychoanalysts, clinical psychologists, and psychiatric social workers expect—and are trained to expect—that much of the clinical relationship, clinical content, and patient's life outside the examining room or hospital will be influenced by unconscious factors. However, transference and countertransference are generally covered only marginally in behavioral science writing oriented to more procedure-oriented primary care practitioners. Moreover, in medical school and residency programs, students and residents are trained to take charge of situations, to make difficult decisions quickly and decisively. The mandate to act is a role requirement for the physician, not simply a matter of unconscious acting out. ix

X

Preface

Yet the meaning of an act for the practitioner is also part of the act itself, and it is this meaning that determines whether—or to what degree—clinical action is also acting out. In my view, the function of applied psychoanalysis or psychoanthropology in medicine is not only to understand the patient but also to assist the student, resident, or practicing physician in distinguishing between his or her own needs and conflicts and those of the patient who is the ultimate object of therapy—that is, to help diminish the need for exteriorizing defenses in the clinician. Through a deeper understanding of countertransference in everyday clinical practice, we hope to enhance the clinical relationship, clinical assessment, decision making, and clinical action alike. This new way of looking does not displace other perspectives. The approach outlined here is meant to complement current medically standardized assessment and intervention techniques. If this volume succeeds, it will help the clinician and student clinician to be more inclusive, to be able to shift back and forth between different clinical levels, rather than emphasize one level to the exclusion of another. It is humbling to realize that every time we focus our attention, we necessarily distort what we observe and that the correction of distortion introduces its own distortion. This fact of life applies to this work as well. Like all effective interventions, the use of countertransference as a clinical tool of assessment and intervention has its own limitations and toxicities. We can certainly use a fascination with unconscious issues as a defense as well as a liberation. In my closing address to a marriage and family therapy conference in 1979 (see Stein 1983), I reminded the audience that whereas unconscious aggression may play a role in cardiovascular disease and family therapy could help disentangle the Type A and Type B personalities in the family system, unless someone knew how to administer CPR to the heart attack victim first, the rest was of little clinical consequence!

ACKNOWLEDGMENTS No author—no book—is self-made. Over the years I have greatly benefited from the ideas, encouragement, and criticism of anthropologists Joan Ablon, George De Vos, J. Neil Henderson, Robert F. Hill, Arthur Hippler, Otto von Mering, Katherine Parry, and Melford Spiro; psychoanalysts Maurice Apprey, M.A.C.P.,

Preface

xi

Warren Gadpaille, M.D., Martin Grotjahn, M.D., Olga Marlin Komlosi, and Vamik D. Volkan, M.D.; family theorists Donald Bloch, M.D., Murray Bowen, M.D., and Fred Sander, M.D.; family social scientist Lisa C. Baker; psychohistorian Henry Ebel; and colleagues at the Institute for Psychohistory, New York City (listed alphabetically): David Beisel, Lloyd deMause, Joseph Dowling, Jay Gonen, George Kren, Stephen Ryan, Casper Schmidt, M.D., and Alexander Simos. At the medical library of the University of Oklahoma Health Sciences Center, reference librarians Virgil Jones, Phyllis Lansing, and Ilse von Brauchitsch diligently and cheerfully redeemed me from bibliographic perdition. By now I have worked closely with some sixty resident physicians in the family medicine residency programs in Enid, Shawnee, and Oklahoma City, Oklahoma, 1978—1984. Earlier, while teaching in the Department of Psychiatry at Meharry Medical College in Nashville, Tennessee, 1 9 7 2 - 1 9 7 8 , I had the opportunity to supervise psychiatry residents in the department and family practice residents rotating through the psychiatry service. More than any others, they have taught me how to teach clinical behavioral science; they have taught me that not only are they an inextricable part of their patients' data but that I am part of their data as well. The active support of the residency program directors and clinic managers at Enid and Shawnee has been deeply gratifying: L. W. Patzkowsky, M.D., Donald C. Karns, M.D., and Richard J . Thomas in Enid; Daniel Rains, M.D., Robert M. Zumwalt, M.D., and Sue Hill in Shawnee. To Christian N. Ramsey, M.D., Norman Haug, M.D., and Jack W. Parrish, M.D., all chairmen of the Department of Family Medicine at the University of Oklahoma Health Sciences Center (Oklahoma City) during my tenure of teaching in Oklahoma, I express my gratitude for having involved me in residency training and for putting up with an enigmatic Freudian approach to family medicine. I have had the added pleasure of working with Timothy A. Wilson, M.D., Paul E. Tietze, M.D., and James Michael Pontious, M.D., first as family medicine residents and subsequently as faculty colleagues. Within the Physician's Associate Division, former Director William D. Stanhope, P.A., and Director Dan Fox, P.A., have not only tolerated but also welcomed my psychodynamically oriented ethnographic approach to behavioral sciences teaching. I am grateful for their support and for their friendship as well.

xii

Preface

To Lome A. Becker, M.D., head of the Family Health Program in the Department of Family Medicine, I express my gratitude for his kind assistance in funding the typing of this manuscript. To psychiatrist Jerry Sullivan, M.D., I owe a year of ardent discussion in pursuit of an answer to the question which I first posed to him when I began doing clinical behavioral science supervision of family medicine residents: "What ever happened to countertransference?" Both as a psychiatrist and as a physician who had spent many years as a general practitioner before entering psychiatry, he was impressed by the ubiquity of transference phenomena—the past in various interpersonal guises—throughout medicine. Moreover, he was appalled, as was I, at how rarely the issue of physician countertransference was addressed in medical school, residency training, or continuing education. Our fortnightly dialogues led to the theme—hardly surprising in retrospect—that most of the problems in clinician-patient relationships did not have to do with technical or procedural issues in patient management but with those unconscious agendas which physicians and patients brought to the encounter and dumped on one another. If the central theme of this book is how commonly unconscious issues contaminate clinical assessment and practice, it is to collaboration with Dr. Sullivan that I owe my conviction of this theme's prominence in medicine. To Weston La Barre my debt is incalculable. His knowledge is encyclopedic, his wisdom profound, his grace touching—and his commitment to stylistic clarity as unwavering as it is excruciatingly difficult to attain. In La Barre the venerable yet fragile tradition of synoptic scholarship remains alive and flourishing. He will perhaps forgive my likening his gift of phrase and sustained line to the vocal perfection of Dame Joan Sutherland whom he venerates. I would like to express my gratitude to Arthur Kleinman, M.D., of Harvard University, whose close reading of the manuscript and stylistic as well as substantive recommendations have been invaluable. My wife, Margaret Ann Sheehan Stein, has not only lived through the long and difficult gestation of this book but has also typed, read, criticized, and extensively edited this book in manuscript. Parts of the chapter "How Could I Eat Uncaring Food?" were

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xiii

written with Timothy A. Wilson, M . D . , who is currently a family physician practicing in Kansas City and Smithville, Missouri. Oklahoma City, Oklahoma December 1 9 8 4

H o w a r d F. Stein

REFERENCES Balint, Michael. 1957. The Doctor, His Patient and the Illness. New York: International Universities Press. Stein, Howard F. 1983. An Anthropological View of Family Therapy. In New Perspectives in Marriage and Family Therapy: Issues in Theory, Research and Practice, edited by Dennis Bagarozzi, Anthony Jurich, and Robert Jackson. New York: Human Sciences Press. Pp. 2 6 2 - 2 9 4 .

What can I know? What ought I to do? What can I hope? What is man? —Immanuel Kant (Handbook)

Introduction

This book explores the influence of the unconscious in the medical profession and in the clinical relationship. It discusses situations and incidents common to medical students on clinical rotations, faculty and resident physicians—especially those in the primary care specialties—and behavioral scientists in medical education. The physician is viewed as an individual operating within a social system in which personal affective issues are inextricably tied to professional functions with patients, families, colleagues, and staff. The practice of medicine includes the ebb and flow of many interlocking or complementary individual psychologies: for example, dyadic interactions between doctor and patient; group dynamics operative among medical professionals and their various clinical and administrative staffs; familial influences (past and current) on all participants in the clinical encounter; and finally the wider institutional and culturally shared group fantasies about medicine. N o human being is free from affective life. The study of the subjective in medicine is necessarily a study in the polyphony of interpersonal relationships and their inner meanings. This little interplay between clinical relationships and their participants' meanings governs the entire process of medical decision making and action. Unconscious resistance to acknowledging subjective involvement within medicine is as pervasive in clinical practice as it is unaddressed in medical education, for medicine relies heavily on objectivity. Ironically, objectivity is itself a subjective claim. In clinically related research, teaching, and practice, the process of observation, assessment, diagnosis, explanation, intervention, 1

2

Introduction

and prediction of outcome (prognostication) is constantly mediated by a powerful representational world governed by the emotional effects of dimly remembered childhood experiences. Clinical problem solving involves a subtle play between inside and outside. Projection, projective identification, and externalization—frequently found in countertransference—are all part of the human repertoire of defenses. We use them reflexively to ward off psychological pain, conflicting or incompatible ideas, or feelings of helplessness or danger. Confusing inside and outside, we suffuse outside with inside. In this way, however, the clinician can unwittingly become a part of the clinical problem to be solved. The clinical experience becomes an invisible prism through which the physician refracts reality to suit hidden needs. The seemingly objective world of clinical reality can become a screen for subjectivity, and acting out can undergird health action (or inaction). Although the scope and texture of this dynamic process and its implementation in social structure may seem hopelessly contrapuntal, it is my aim in this book to help the reader identify the recurrent themes in this medical-cultural "fugue" and recognize their interplay. Topically, the immediate predecessor of this book is the classic by Michael Balint, The Doctor, His Patient and the Illness (1957). In that book Balint, a psychoanalyst working with groups of primary care physicians in England, explored unconscious influences in the doctor-patient relationship and in the dynamics of clinical case conferences.

WHAT IS COUNTERTRANSFERENCE? Transference and countertransference can be identified dynamically as the same phenomenon: They both refer to how human beings use one another for unconscious purposes. They differ with respect to who is doing so, not what is being done. Transference in the clinical relationship denotes the patient's displacement and exteriorizing of internal issues onto the clinician; countertransference denotes the reverse. Patient care can be anxiety evoking for physicians. The subject matter of countertransference consists of how physicians defend themselves against this anxiety and how they protect themselves in

Introduction

3

types of clinical situations that are most likely to produce it. This book attempts to examine the anxieties which physicians' clinical work invariably elicits and to understand physicians' psychic reality with the same rigor and empathy which we clinicians are professionally expected to extend to patients and their families. The analysis of countertransference thereby becomes a tool of patient care. Although transference and countertransference were originally technical terms introduced to describe certain aspects of the psychoanalytic relationship (from the points of view of the analysand and analyst, respectively), they are more properly facts of life for us all, not limited to psychoanalysis or even to medicine. They signify some developmental and emotionally unfinished business which the present situation reactivates, whereby the present becomes a vessel of the past and the external becomes a repository of inner meaning. In this book I use the term countertransference to mean all nonrational elements of the physician's work (Stein 1983). Originally, the term referred only to the analyst's emotional response to the transference of the analysand or patient. Later it came to include also "the effects of the analyst's own unconscious needs and conflicts on his understandings or technique," that is, the therapist's use of treatment for acting out ("whenever the activity of analyzing has an unconscious meaning for the analyst") (Reich 1951:26). Most recently, the concept has been further extended to encompass the total emotional response of analyst to analysand (or doctor to patient) (Kernberg 1965); however, this usage is still far from universal. This change in meaning is significant. In its newer, broader sense countertransference can be seen as either antitherapeutic or therapeutic, destructive or healing. Whether the ultimate effect of countertransference is beneficial or harmful is determined by whether the physician understands the meaning of his or her own unconscious material beyond simply recognizing its presence—or, stated differently, by how the physician uses this material. Virtually anything in the medical relationship can be either therapeutic or antitherapeutic; if it is to be therapeutic, physicians must be able to assess both their patients and themselves, instead of attempting to defend themselves against their patients.

4

Introduction

Negative and positive countertransference (that is, undervaluing and overvaluing patients) alike can endanger the clinical relationship. The best way for us to keep from either fostering in our patients too great a reliance on us or rejecting patients entirely is to become more aware of our own vulnerabilities and limitations. The more clearly medicine can recognize the roots of the clinical relationship in the earliest parent-child relationship, the better medicine can identify those enormous emotional tidal pulls to which the relationship is subject. The "good" or compliant patient (the object of positive countertransference) is as much in the eye of the beholder as is the "bad" or noncompliant one (the object of negative countertransference). Patient satisfaction and clinician satisfaction are usually part of the underlying problem rather than (as is usually contended) the solution. We often hear the claim that the ultimate frontier in medicine lies in biochemistry or in ethics. It is in these fields that we look for long-awaited breakthroughs or encounter inescapable problems. Countertransference, by contrast, is an abiding facet of medical life, one which we must view less in terms of conquest—as the overcoming of some obstacle, adversary, or noxious substance—than of awareness—often painful awareness. Nearly eighty years ago, William Osier argued for the important role of self-awareness in medicine (Osier 1906). I would add that a lifelong encounter with countertransference is part of the process of acquiring such self-knowledge. Countertransference can turn out to be less of an adversary than we fear; it can actually be a friend who reintroduces us to parts of ourselves. The better our access to these aspects of ourselves, the better our access to the corresponding aspects of our patients and the better we can use countertransference as a tool of patient care. In medicine we designate challenges involving diagnostic detective work or technologically sophisticated procedures as "interesting cases." Perhaps countertransference too might come to be seen less as a threat than as a challenge and as a result attract greater clinical interest.

KEY TERMS In the discussion of countertransference throughout this book, terms such as ego defense, projection, externalization, projective

Introduction

5

identification, and explanatory models are used from time to time. Here is a brief overview of this terminology. Ego Defenses The function of ego defenses is to protect us within our internal environment and our interpersonal relations. All ego defenses are symbolic successors to organic defenses: Something that is disgusting evokes nausea and vomiting; the ability to verbalize that wish to be rid of the toxic comes later than the visceral reaction. Such physical processes essential to life as inclusion, exclusion, expulsion, creation of boundaries, and so on become the task of the defenses. In this book I deal principally with one group of defenses—subsuming externalization, projective identification, and projection—the psychic function of which is riddance, the maintenance of boundary integrity, and at the same time the maintenance of a tie to that which is excluded. Through these defenses we are able to retain the "good," pleasurable things inside (ourselves, our families, our professions) and put the "bad," unpleasurable things outside while at the same time keeping them available for use. Developmentally, the sequence from earliest to latest consists of externalization, projective identification, and projection proper. Finally, in the postadolescent, condensations of these occur along with a continuum of unmended or unintegrated self and object representations (the externalization end) and dystonic or unacceptable drive derivatives (the projection end). So the process is as follows: externalization • projective identification • projection proper • condensations after adolescence. In much of the psychoanalytic and psychiatric literature, the terms externalization, projective identification, and projection have come to be used interchangeably. This is an error, for each defense differs somewhat in dynamics and function from the others, which in turn suggests differing strategies of intervention. Although these three share the process of excluding and ridding something from oneself and thereby shoring up a boundary between inside and outside while retaining some sort of tie to what has been exteriorized, it is there that the similarity ends. They differ considerably in the psychological purpose for which they are employed and the relative developmental position at which they come into prom-

6

Introduction

inence. Clinical description, explanation, and intervention will be improved the more aware we are of these distinctions. EXTERN ALIZATION

A great many defenses are used by the unconscious to ward off psychological pain. Of the ego defenses discussed here (projection, externalization, and projective identification), externalization is the simplest. It is a defense used to relocate or attach unacceptable inner aspects of ourselves or unacceptable affects (feelings) to another object or person "out there" who may be seen as a more suitable recipient or receptacle. This riddance of unpleasure, or unacceptable parts of the self, is the origin of a "not me" part of our identity (among physicians, uncertainty, ambiguity, and helplessness are commonly excluded from the self). Children are often heard to say "Somebody must have . . . , " or "I didn't do it . . . , " to which mother might respond, "Who do you suppose that was?" or "I didn't ask 'who didn't do it?' I asked 'who did i t ? " ' Mother thus asks the child to take back what the child threw away. A child who has spilled food on a shirt might say "I fell down" rather than admit that his or her table manners are lacking. In this defense mechanism, the unconscious relocates aspects of the self (usually affects) by translocating them from one place to another. Clinically, when we see externalization we should acknowledge and thereby validate, if not interpret, the self-esteem issues. In externalization, unacceptable aspects of the self are allocated to someone or something where they are then seen to reside. For example, the conscientious family physician may become impatient, frustrated, and angry with a poststroke patient who is not gaining speech and mobility at the rate expected. The physician may feel that somehow the patient is willfully defiant, lazy, interested only in secondary gain, whereas the patient may be doing his or her best. In fact, the physician may need to disavow his or her own wish to slacken the pace of treatment. The patient's condition may further awaken disavowed needs within the physician (for example, to be taken care of, to be more dependent). While disclaiming such selfneeds, the physician may overinterpret the patient's slow recovery as an excessive request for indulgence (Stein 1979; Stein and Kuns 1980).

Introduction

7

PROJECTIVE IDENTIFICATION

Among the most rudimentary in the developmental succession of ego defenses, what Melanie Klein (1955) termed projective identification often continues to influence mental functioning and regulate relationships much later in life. It is activated by anxiety over loss. Here a person first allocates a part of the self to another and subsequently responds to the role partner as though that part originated autonomously within the other, as though it were an intrinsic part of the other (see Volkan 1981). Moreover, externalizer and target often reciprocally come to act as though the part split off from the former is contained in the latter. In its positive aspect, projective identification as a transitory capacity underlies the physician's experience of empathy with the patient; in its negative aspect, it results in the physician's confusion of his or her situation with that of the patient and an inability to let go emotionally of the patient. In this ego defense mechanism, we experience pain, discomfort, something unacceptable inside (such as, envy, hatred, the wish to control) but then translocate this feeling to an object. The intention underlying this unconscious translocation is to control the object in order to preserve a tie. The function of this defense is to deal with our intolerance of separation from the object as well as our persecutory anxiety. Consider the following scenarios: 1. A five-year-old boy could not understand why his grandfather and father were constantly quarreling over ownership of a certain pair of shoes. The tone of the arguments suggested that the monetary value of the shoes was far outweighed by other matters. Only later did the boy understand that his father and grandfather admired each other and also saw each other as a threat. Inherent in the son's oedipal desire to possess the pair of shoes was the wish to "stand in the other's shoes," that is, symbolically to eliminate the father and replace him with himself. To fail to resolve the quarrel was a way of preserving the relationship. The shoes thus symbolized the relationship; that is, they were objects of projective identification. 2. A young man could not allow himself to trade away a moderately new but chronically malfunctioning car. Months of ardently insisting to the dealership that the car be brought to its highest

8

Introduction

advertised standards resulted in only modest success with the car— and immoderate depression in the dejected owner. One day the young man realized that the condition of the car and the decision to keep it or let go of it was entangled in a larger issue for which the automobile had become a symbol. The young man's aging mother had been depressed and functioning poorly at home for many years and had finally been admitted to a nursing home. T o give up the hope that the car could be restored, to renounce the desperate wish to control the mechanics who had thus far failed to put the car in good repair, to dare consider selling (abandoning) the car and purchasing a new one—all these meant that he would have to give up his ill mother, that he was unable to rescue or "repair" her. He certainly could distinguish between his mother and his motor vehicle, but he had unconsciously invested his car with the painful separation issues which he had not resolved with his mother. In using projective identification, we have already delineated a clearer boundary between ourselves and the other than when we employ externalization. Still, this other becomes a container or repository of aspects of the self with which we in turn identify. Projective identification is a defensive and adaptive maneuver in which interpersonal relations act to regulate the internal environment. The other person serves unwittingly as a role for the self by embodying a part of the self which we cannot yet incorporate. We must get rid of it, yet cannot bear to part with it. In families, for example, the adolescent acts out sexually or aggressively in behalf of his or her fascinated yet revulsed parents who cannot include these behaviors in their own self-concept and action (Johnson and Szurek 1952, Zinner and Shapiro 1972). This unconsciously influenced division of labor in families also occurs in clinical relationships. Clinically, when the physician feels the patient is using this defense mechanism, he or she should recognize the patient's mistrust of independence, fear of separation, or envy. In family medicine continuity of care, for instance, can inadvertently become continuity of dependency in the patient, heightening the physician's countertransference caretaking activities and the patient's transference in asking to be taken care of. Here the overly conscientious physician may unwittingly make patients increasingly dependent upon him or her, so that they not only comply with prescriptions

Introduction

9

but also become sick frequently enough to keep returning and needing treatment (I need them = they need me). The patient may represent a part of the physician's own childhood self that wishes to be taken care of, or the clinical relationship may replicate an old family role such as the precocious youngster's responsibility for looking after and cheering up a depressed or chronically ill mother. On the more sinister side of countertransference based on projective identification, the patient may represent devilishness or rebellion in which the doctor dare not indulge but which the patient provocatively engages in. Through the patient, then, the physician may vicariously experience the thrill of adolescent irresponsibility—and, as in morality plays, the vindication that comes when the villain is punished (see Chapter 3, a diabetes case). The gravest danger in projective identification is that the self (or the object) may disappear; the individual may lose him- or herself by becoming someone else or by taking on the person of the object. Many of the disorders seen in the "impaired physician" (such as depression, alcoholism, drug use, suicide) would seem to be characterized by this defense. The highest form of this mechanism is empathy—standing in the shoes of someone else to understand how another feels and experiences the world. PROJECTION

Projection is like a boomerang—the psychological content being discarded comes right back. The ego finds unacceptable some instinctual wish that must be gotten rid of and experiences instinctual anxiety. After delegation, that instinctual anxiety recoils—boomerangs—and thus becomes a phobic object, which comes back to haunt the person. Thus the patient who says "The FBI is after me" describes a process whereby she or he originally experienced hostility toward an important object but considered such hostility unacceptable. The patient then translocated those feelings to another object (the FBI) which, in the patient's perceptions, took on the ascribed feelings. Then this second object returned to haunt the patient, resulting in a recoiling of feeling. In projection, the perception of the unconscious relation between subject and object is reversed: "A drive derivative originally directed at an object can be subjectively allocated to that object, while the

10

Introduction

self is experienced as the object of that drive derivative" (Novick and Kelley 1970:84—85). Projection is more accessible to clinical intervention than either externalization or projective identification, since with the latter two, people really feel that they have been rid of intolerable feelings or ideas, whereas with projection they must keep a radar screen operating lest they unwarily be hit by the boomerang they previously threw. They keenly feel the affect but confuse the source with the object of the affect. Clinically, we should acknowledge the affect (which we must first feel in ourselves) and further identify and interpret the instinctual wish. The physician, for example, who feels frustrated by a hypertensive patient who has failed to take the prescribed medication may not permit him- or herself to feel anger with the patient (let alone to confront the patient with the issue of responsibility) but may instead feel that the patient is suddenly being unduly critical or hostile. Alternately, the physician may feel the need to conduct additional tests to confirm the diagnosis to avert a lawsuit by the patient (putting into action the defense of undoing), or the physician may become abruptly solicitous toward the patient (enacting the ego defense of reaction formation). In simple terms, "I am angry with you" becomes projectively experienced as "You are angry with me." These three unconscious strategies and their various combinations are widely used by clinicians to protect themselves from the intolerable feeling that "there is something wrong with me." These "outering" defenses protect the sense of self-esteem, cohesiveness, competence, mastery, and goodness. They are an unconscious way of balancing the emotional scales so that the clinician does not feel threatened from within. Such commonplace threats as anxiety, separation, loss, aggression, sexuality, and death are safely placed outside the self.

CONDENSATIONS

These defenses have in common an attempt to deal with painful internal states by exteriorizing them and thereafter encountering and trying to master them as if they were located in the outer world. In the postadolescent there is a continuum of unmended self and object representations (externalizations) and dystonic drive expres-

Introduction

11

sions, that is, dangerous situations stemming from mental conflicts (Volkan 1983). The trouble with this rather lineal model, however, is that as people become repositories and roles for one another's disavowed parts of the self, inability to separate, and expression of drives, it becomes increasingly difficult to know where what is purely intrapsychic on the part of one participant to a relationship ends and where mirroring action from another that induces or confirms the person's intrapsychic defense takes over. Humans often play unconscious roles for one another. We habitually use the outside as an arena for the inside, and we often accuse another of doing precisely what we have unconsciously asked the other to do. In relationships governed by the role which each member plays as an object in the other's fantasy life, it becomes not only difficult or impossible to determine who is cause and who effect but also wrong to attempt to do so. In relationships from which there is no exit, it is inappropriate to ask which person will not open the door. Certainly the doctor-patient relationship is vulnerable to complementary exteriorizing where each is vessel for parts of the other. Discussing Shakespeare's Hamlet, Sander (1979) likewise observes that Hamlet's internal oedipal conflict was complicated by a family situation that in reality directly mirrored his unconscious fantasies. Although . . . his conflicts were fairly well internalized, he was also embroiled in a rather severe ongoing pathological family system marked by denial, externalization, projection, and acting out. (P. 15)

Although in postadolescence a variety of inner condensations of externalization, projective identification, and projection do occur, it is important to add to this list those interpersonal condensations in which the unconscious fantasy of individual participants corresponds to part of the transactional context of "interlocking inner psychologies" (Ross 1982:194). It is not all in your head alone! From this perspective on the clinical relationship, we need to ask not only how various forms of "outering" may serve as reactions or responses to others (that is, to what others unconsciously represent to us) but also how people use one another as "containers" (Bion 1963:31) in relationships that are regulated, at least in part, by reciprocal unconscious participation.

12

Introduction

Explanatory Models (EMs) This concept, developed by psychiatrist and anthropologist Arthur Kleinman (1980), denotes the beliefs, values, perceptions, and expected course of action which all participants bring to an illness episode and clinical encounter—the patient, family, practitioner, and so on. All people are guided by interpretive frameworks, or explanatory models (EMs), which they use to make sense out of their experience and to guide their behavior. Kleinman hypothesizes that all EMs address the following issues: etiology (cause), timing and onset of symptoms (why now?), pathophysiology (effect of sickness, how it works), expected course of sickness (severity, duration, type of sick role), prognosis, and expected effectiveness of treatment. Clearly, such comprehensive understandings are not always systematically thought out, consistent, or immediately expressible. Poor clinical communication, poor patient compliance, and physician-patient frustration with each other are often symptomatic of the fact that differing EMs are operating outside of conscious awareness. The more the physician can elicit from patient and family what they think is taking place, what they have been doing about it, and what they think clinically ought to take place, together with the clinician's assessment of these same issues, the more empathic will be the clinical relationship and the more realistic the treatment plan. In the context of Kleinman's model of clinical reality, I would locate a patient's transference and a physician's countertransference within the implicit, out-of-awareness portion of their respective EMs, a portion that subsequently influences the experience of the clinical relationship and actions taken in it. In a sense, the analysis of patient transference and clinician countertransference only helps to complete our understanding of EMs, since they constitute that part of the affectively charged E M iceberg that lies (and frequently lurks) beneath the surface of the clinical relationship. Let me illustrate the functioning of EMs among biomedical practitioners by proceeding from several widely shared EMs to those expressed by a physician-colleague during a family crisis some years ago. Perhaps the most outstanding and official biomedical EM is the doctrine of specific etiology first formulated by Pasteur, Koch, and others. According to this framework, disease is a natural pro-

Introduction

13

cess, caused in a rather lineal sequence by identifiable agents, and treatable by human intervention which reverses the course of disease. Scratch the surface of this EM, however, and we discover a richly symbolic, metaphorical realm in which the body is viewed as a machine, the mind as a computer, disease and treatment as a form of war (witness references to offending organisms, invasive procedures, magic bullets, shotgun use of antibiotics, attack cells, aggressive therapy, and so on; see Burnside 1 9 8 3 , Caster and Gatens-Robinson 1983). Here the metaphorical world of technology and battle is more verbal than written, whereas the naturalistic E M is the official written and spoken medical language. It is important to realize that these widely differing models are used by the same persons in different and sometimes overlapping contexts. I have talked and listened to family physicians, microbiologists, and pathologists alike who sometimes playfully, sometimes angrily, refer to microorganisms as though these were demons possessing the vulnerable body, as though the practice of medicine were a form of combat. I have closely worked with physicians who sincerely believe that they operate stringently according to the scientific E M , yet often when discussing disease etiology and patient management—especially when they become frustrated—they richly imbue disease and treatment with animistic and anthropomorphic attributes (see Spiegel 1971 for a discussion of the ideal versus the operant cultural model). Physicians' EMs not only vary between official/unofficial or formal/informal contexts within medicine but between their home and office situations as well. A clinician may thus attempt to account for a personal illness situation using a far different E M from that which he or she would use with a patient. I think of one conscientious Catholic physician and his Catholic wife (also a medical practitioner) who went through a textbook-perfect pregnancy and gave birth to an infant with cretinism. They knew that from the biomedical point of view, they had performed all the right prenatal care. Yet they also went through a profound period of mourning, anger, self-doubt, self-recrimination, religious soul-searching, and prayer. On the one hand, they did not know why it happened insofar as no positive medical explanation was available; on the other hand, they persisted in their anguished search for an explanation outside

14

Introduction

medicine because the medical explanation (or lack of one) did not satisfy them. T o use a distinction which Foster (1976) introduced, they sought a personalistic account where a purely naturalistic one did not give them peace of mind. They began to invoke such an explanation as "the will of God" to give them peace. Vehemently rejecting some medical colleagues' suggestions that they should place the infant as a ward of the state, they came to accept the child as "a gift from God," "a test of our faith," for which they were perhaps selected (or elected) by God. Not only does this clinician's EM as husband and father differ from his EM as physician but he is also at times most vulnerable to exasperation with patients—and countertransference responses to them—whose EMs resemble his own private rather than professional EM.

SOURCE OF CASE MATERIAL I owe the reader a few words on how I gained the clinical case material reported and analyzed in this book. Since the days of my graduate training in medical anthropology ( 1 9 6 8 - 1 9 7 2 ) , I have worked closely with medical and physicians' associate (P.A.) students, resident physicians, and faculty physicians in medical teaching settings, first as a behavioral scientist in a department of psychiatry ( 1 9 7 2 - 1 9 7 8 ) and most recently in a department of family medicine (1978—present). None of the cases reported here can be said to be the product of a formal study or research design, at least in their inception. I am employed primarily as a clinical teacher and supervisor, not as a researcher. The ordinariness and significance of countertransference impressed itself on me over the course of day-to-day case consultations with residents, supervision of family conferences with residents, attendance at family medicine grand rounds, and so on. It was not only psychotics and drug addicts who elicited emotional responses from medical students and residents but also diabetics, hypertensives, and the aged and the chronically ill, those with diagnoses of anorexia nervosa and obesity—in short, patients with familiar diseases and clinical problems. However, these emotional reactions were rarely dealt with by physician or behavioral science faculty, and the residents relied on their own personal defenses and group humor to cope with the spectrum of emotions which they had not expected to be evoked, for which they had not been trained to deal

Introduction

15

with, and worst of all, which as medical scientists they felt they were not supposed to have, or at least were supposed to keep under control. The discrepancy between the official world view or agenda in medicine and what I observed actually occurring became the basis of my interest in countertransference. The cases in which residents requested my consultation or intervention and those in which I had invited or insinuated my own participation became the eventual "data" for this book. What felt originally to be an exception to business as usual gradually impressed itself on me as an unexpectedly large part of the rule. Professional training in medicine and the behavioral sciences alike directs our attention almost exclusively to the outer world. We are taught to become astute observers of patients and cultures, yet receive little preparation for understanding the influences of the setting and of the observer's out-of-awareness motivations on what we select to observe, how we interpret what we notice, and what course of action we choose. In a sense, observing others is easy. Far more taxing is to learn to observe oneself observing others. Collaboration with medical students and physicians has taught me the importance of being as much concerned with how and why we observe, as with what we observe, for the former heavily influences the latter. T o be a thorough clinical teacher and supervisor, it does not suffice to teach students and residents all about patients, families, and cultures if I do not take the time and effort to become at least as familiar with the internal and interpersonal contexts that influence medical students' and residents' clinical perception and behavior. I must know a group well enough to know where and how to intervene with them. My overarching principle in clinical teaching and supervision derives from what I call an ethnographic orientation to life: The relationship is the teaching, not simply prefatory to it or even heuristically distinguishable from it. For me to help medical students and residents more effectively intervene in the lives and worlds of their patients, I must take seriously the lives and worlds in which students and residents move. The methodology underlying this collection of cases is what anthropologists term the "ethnographic method," one that attempts to understand the contexts and meanings in which people live through immersion in a group, usually over long periods of time. As an anthropologist I use the ethnographic method to describe a

16

Introduction

group, interpret its meanings, and use that tentative understanding to formulate a way of intervening. I have adopted the ethnographic method not only as a way of understanding the culture of medicine interacting with the culture of patients but also to transmit this understanding to medical students and residents so that they in turn may become competent clinical ethnographers. For I believe it is a clinically useful supplement to other assessment and intervention skills, one that is capable of discovering new relationships as well as confirming old and expected ones. It permits clinician and researcher alike to grasp the complexity of symptom formation, persistence, and treatment. Finally, it teaches us that the case is not altogether located "out there" within the patient, family, and patient's culture but that we are always part of the case ourselves.

REFERENCES Balint, Michael. 1957. The Doctor, His Patient, and the Illness. New York: International Universities Press. Bion, W. R. 1963. The Elements of Psycho-Analysis. London: Heinemann. Burnside, John W. 1983. Medicine and War—A Metaphor. JAMA 249(15):2091. Caster, John H., and Eugenie Gatens-Robinson. 1983. Commentary Letter on Metaphor in Medicine. JAMA 250(14):1841. Foster, G. 1976. Disease Etiologies in Non-Western Medical Systems. American Anthropologist 78:773-782. Johnson, A., and S. Szurek. 1952. The Genesis of Antisocial Acting Out in Children and Adults. Psychoanalytic Quarterly 21:323—343. Kernberg, O. F. 1965. Notes on Countertransference. Journal of the American Psychoanalytic Association 13:38—56. Klein, M. 1955. On Identification. In New Directions in Psycho-Analysis, edited by M. Klein, P. Heimann, and R. M. Kyrle. New York: Basic Books. Pp. 309-345. Kleinman, Arthur. 1980. Patients and Healers in the Context of Culture. Berkeley, Los Angeles, London: University of California Press. Novick, J., and K. Kelley. 1970. Projection and Externalization. The Psychoanalytic Study of the Child 25:69-95. Osler, W. 1906. Aequanimitas. London: H. K. Lewis. Reich, A. 1951. On Countertransference. International Journal of Psychoanalysis 33:25-31. Ross, John M. 1982. Oedipus Revisited: Laius and the "Laius Complex." In The Psychoanalytic Study of the Child, edited by A. J. Solnit, R. S.

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Eissler, A. Freud, P. Greenacre, and P. B. Neubauer, vol. 37. New Haven: Yale University Press. Pp. 169-200. Sander, Fred M. 1979. Individual and Family Therapy: Toward an Integration. New York: Jason Aronson. Spiegel, John. 1971. Transactions: The Interplay Between Individual, Family, and Society. New York: Science House. Stein, Howard F. 1979. Rehabilitation and Chronic Illness in American Culture: The Cultural Psychodynamics of a Medical and Social Problem. Journal of Psychological Anthropology 2(2):153—176. . 1983. The Influence of Counter-Transference upon the Clinical Relationship and Decision-Making. Continuing Education for the Family Physician 18 (7): 625-630. , and Michael D. Kuns. 1980. Disabled Veterans. Physician Assistant and Health Practitioner 4(9):9-12. Volkan, V. D. 1981. Transference and Countertransference: An Examination from the Point of View of Internalized Object Relations. In Object and Self: A Developmental Approach, edited by S. Tuttman, C. Kaye, and M. Zimmerman. New York: International Universities Press. Pp. 429—451. . 1983. Personal communication. Zinner, J., and R. Shapiro. 1972. Projective Identification as a Mode of Perception and Behavior in Families of Adolescents. International Journal of Psycho-Analysis 53:523-530.

• I • Countertransference as a Key to Subjectivity Within the Physician Role

In this chapter I explore the process and consequences of exteriorizing internal states in the physician-patient relationship. Easily onehalf if not more of all problems brought to me by residents or which residents identify in case conferences and consultations as problems in patient management or compliance are those in which residents' own subjectivity has become part of the patient's problem. Here the physician may well be struggling with his or her perception of or reaction to the patient or may attribute the difficulty to a characteristic located inside the patient. In either case, on this repeated discovery I greatly modified my approach to residency training. Countertransference became a clinical issue for residents only after it had first become a personal and then clinical issue for me; for example, after interpreting my own emotional reactions to a resident or a case presentation or my observation of a patient encounter or family therapy session. In a sense, I created the problem—or at least stimulated an awareness that something else might be taken into account that could explain the physician's difficulty with a patient, family, or staff member. Attention to countertransference first improved my own efficacy as a clinical teacher and intervenor and subsequently enhanced the clinical efficacy of residents for whom I had identified countertransference as worthy of attention. 18

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19

Gradually, I learned to observe students and residents as closely as I observed patients and families. I further had to listen in a different way to residents' verbal and written accounts of patients' problems and the effect of various interventions, for in describing patients they were also disclosing themselves. They were interpreters—which means selectors—of information that bore emotional significance for them, not merely conduits of information. In clinical teaching I was not originally interested in countertransference. At first, the patient was as much the exclusive object of my attention as it was that of the physician. Initially, then, my focus of interest not only overlapped with that of students and residents but also in directing our collaborative effort outward I inadvertently colluded with their wish to avoid looking inward. Only gradually did I come to observe that data that had decided clinical implications often emanated from the physician as well as the patient. Subsequently, students and residents as well as patients became my most important teachers and coinvestigators. I have learned to help students and residents to pay greater—deeper—attention to patients by paying such attention to them. This chapter is an ethnographic odyssey in which I describe how I discovered the importance of countertransference in the daily work of the family physician and the significance of the unconscious in the dynamics of the physician role. In approaching the physician role from as closely to inside as I could approximate through time, empathy, and good will, I hope to persuade the reader that the unconscious meaning of this role is an important component of the social role itself and a silent contributor to the quality of patient care. If the physician's self is an integral yet largely unconscious part of the physician role, the analysis of physician countertransference becomes a key to subjectivity within that role. This chapter analyzes how unconscious agendas of the doctor manifest themselves in clinical communication. It discusses countertransference in individual (dyadic) patient encounters, family conferences or counseling, and medical group settings and considers ways by which countertransference may lead the physician to misidentify the clinical problem. The cases illustrate how imperceptibly the physician's inner distress can be transformed into a problem which the physician may label exclusively as one in patient management. Unwittingly, patient care can be used by the clinician as a defense against

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the patient (that is, against what is evoked within the physician by the patient). Countertransference, however, must not be viewed as altogether an individual physician's response to an individual patient (or family). On the one hand, medical education and the subsequent accoutrements of the institution of medicine offer the student and practitioner potent symbols with which to defend him- or herself against subjective involvement in the practice of medicine, thereby augmenting personal defenses against intimacy. On the other hand, a powerful current of social expectations, demands, and wishes relentlessly floods American medicine, an institution that in many respects serves as a contemporary idiom of the sacred. Much of medical countertransference arises from modern practitioners' attempt to comply with society's magical wishes, demands, and expectations and their frustration when they fail. In this chapter vignettes from my work in clinical teaching and supervision illustrate each of these facets of countertransference.

LISTENING: HEARING THAT MAKES A DIFFERENCE One of the most underestimated of medical instruments is listening (Langs 1978); that is, the investigator's own subjectivity is a vital instrument both in assessment and in treatment. Ironically, the flight from empathy into a detached pseudo-objectivity attests to our involvement by its compensatory opposite. Diagnostic taxonomies are often used by physicians as powerful isolating defenses against fully hearing, understanding or responding to the deeply felt in themselves or in the patient. One resident, terrified by an acutely anxious patient, wanted immediately to label him as schizophrenic and begin hospitalization to reduce his own overwhelming anxiety. It is not the need for differential diagnosis that is at issue but its often unconscious emotional significance for the physician. In using empathy, whether clinically or in research, we feel along with the patient, informant, subject, or group. Here lies both the promise and the danger, for to feel along with another we also feel within ourselves. That "surge of insight that turns the surface picture topsy-turvy" (Binion 1981:3) can be exhilarating or profoundly threatening. Whether in medical practice or in any form of

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21

research, inhibition against empathizing with another can be interpreted to mean that what we are afraid to find out about ourselves, we do not want to know about another. For observer and observed, life is a Pandora's b o x . Only to the extent that the observer can tolerate learning the content of his or her own unconscious can the observer be dauntless in the face of another's. W h a t we have rendered inanimate is sometimes a very much alive but feared part of the self. W e project our defensive blind spots o n t o the patient or the subject of research and miraculously discover that what he or she cannot tolerate to see is truly not present or dismissed as irrelevant. Through a gradual trust in our o w n unconscious process, we need to rely less on those traditional answers, questions, and controls as authoritarian defenses and more on the patient's or subject's free associations (and, of course, our own as a measure of what is taking place within the patient). Clinically and methodologically, we learn best to lead by following the patient's lead and in turn help the patient or subject to have the courage to follow that lead. Ironically, the " s o f t e r " way of free association—contextualism and holism—is much more true to life than the " h a r d e r , " officially scientific heuristic methods that rigorously control or eliminate significant—because a n x i e t y - e v o k i n g — context.

Vignette 1: A Case of Group Countertransference Precisely because countertransference is hidden from consciousness in clinical situations, we discover and recognize its power only by stumbling on it, by feeling disturbed by it, or by having someone else identify it. T h e same occurs within groups such as clinical conferences. Consider the following vignette. In a joint case conference attended by family physicians and pastoral counselors, held in November 1 9 7 9 , a clergyman first summarized the situation of Millie, one o f his parishioners, an eighty-five-year-old w o m a n for w h o m he serves as legal conservator. Millie has been living at her present address for the past forty years, owns her home and some 1 6 0 acres of farmland. Quite frugal, she has led a satisfying single life and was quite active in her church until the summer of 1 9 7 9 . She has lived alone for the past ten years. T h e minister described Millie's increasing difficulty

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and confusion in the preceding year in managing her own business affairs and her experience of a serious loss of recent memory. In the late summer and early fall of 1 9 7 9 , she began to hear sounds and voices, feared that her home had been taken over by cockroaches, and manifested other paranoid behavior. (The minister, after several thorough home visits, determined that there were no roaches teeming.) Following his case summary, the group of family physicians and pastoral counselors spent some forty-five minutes discussing what to do with Millie (her " m a n a g e m e n t " ) before one participant noted that from the minister's summary the patient's onset o f symptoms had been sudden. H e wondered if Millie's symptoms might indicate something new and unexpected—or if this might at least be worth looking into. T h e group's initial unspoken basic assumption or fantasy (Bion 1 9 5 9 ; deMause 1 9 7 9 ) had been that old age equals senescence, debility, dependency, bizarre behavior, vague paranoid trends, and the like. Until the equation was itself challenged, the group approached the solution of the problem as though Millie conformed to the cultural-medical stereotype of aging as synonymous with gradually accumulated arteriosclerotic damage, minute CVAs, and so on; that is, the group replaced Millie-the-person with a depersonalized image of her that defied her very history! Until age eighty-five she had managed her affairs quite capably. It was only the group countertransference projected o n t o the definition of the problem, and thereby its solution, that had prevented the group from noticing earlier that Millie's pathology was something new and ««expected, rather than a worsening of a marked trend. Cognitively, the group's explanatory model (Kleinman 1 9 8 0 ) of what was going on diverged from facts or aspects that the group had excluded for its own unconscious reasons. T h e group then turned to a brief analysis of its motivated misperception: that we are indeed slaves to our models of the world, that often we wish to perceive the elderly as decrepit and useless so that we can put them out of sight and mind as frightening reminders of our own frailty, that our assumptions and expectations not only distort but also create the reality we perceive to be true. T h e breakthrough in this case came not from our faulty analysis of the patient but from an analysis of our resistance to perceiving Millie as a person instead of a stereotype about a social category, the aged. T h e outcome of this case—as though medical outcomes were

Countertransference

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23

something other than stepping-stones in life rather than end points—was that no discernible pathology was found. With generous doses of regular visits by the minister to her home and realitytested reassurances that her home was not infested with insects or the dead, Millie returned to her "premorbid" life and, at eightyseven, is as active as ever. Millie's minister had persisted in his commitment to her, whereas the rest of us had given her up as socially dead. What this additional turn of events suggests is that the more we allow ourselves to be moved by the unexpected (that is, by what is potentially strange and threatening to us), the more our efforts in patient management will be what the patient needs rather than our needs to defend ourselves against the patient.

COMMUNICATION: AN ARENA OF HIDDEN AGENDAS Beyond the importance of cognitive learning and behavioral skills in medical education, an adequate therapeutic relationship contains the skills and techniques of treatment. The latter are necessary but not sufficient for good treatment. Likewise, an adequate medical education is founded on a system of teacher-student relationships that contains the specific information and tasks to be learned. Devereux (1967) boldly writes, "I hold that what cures our patients is not what we know, but what we are, and that we must love our patients" (p. 21). Stated differently, what we know is contained in what we are; that is, how we use what we know expresses who we are. A virtuoso display of communication techniques is more likely than not an attempt to remove or conceal the self of the clinician from the encounter. Skills and techniques marvelously implement compulsive defenses against becoming too familiar with what the patient might be saying or meaning beneath the presenting complaint—that is, too familiar with that part of the patient that reminds us of conflicting areas of wish and fear in ourselves (La Barre 1978; Stein and Kayzakian-Rowe 1978). Yet countertransference maneuvers which we use to hide ourselves only betray us. As Devereux (1967) writes, "the concealment used necessarily reveals a great deal about that which is concealed and also about the one who resorts to that particular concealment" (p. 22). Techniques and skills can only be therapeutic if the therapist means, is, what

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he or she does. There can be no attentive position that, if only properly rehearsed, will be experienced by the patient as genuine interest. To acknowledge the power of transference/countertransference phenomena is to admit that we—as humans, not as physicians alone—do much that is counter to our conscious intentions, that we are not altogether in control of our thoughts and deeds. The very ordinariness and unpredictability of countertransference make it threatening to professionals who wish to believe that through our education, experience, and will, we are in charge of our affairs—not to mention our ability to influence our patients, clients, and students. It is one matter to acknowledge that patients will transfer their own situationally inappropriate emotions and demands upon the clinician but another to accept that the clinician will do likewise to the patient. For to accept the inevitability of countertransference is to diminish the distance between clinician and patient (or teacher and student), to recognize that the present situation is influenced by other than immediately observable or measurable characteristics in the relationship, and to admit the possibility that the clinician is disturbed, although perhaps in a different way from the patient (Devereux 1980).

Vignette 2: "If I Were the Father" The subtle but powerful role of projective identification in group process is illustrated by the following case conference. At a family medicine behavioral science conference, well attended by faculty physicians, resident physicians, pastoral counselors, and social workers, a family practice resident ably summarized the first six months of family therapy which I had supervised. The fear of separation and loss dominated family life; much of the family relationship possessed a symbiotic quality, punctuated by spasmodic clinging and pulling away. When therapy first began, the residential family consisted of the husband and wife in their midthirties, his two sons from a previous marriage, her two sons from a previous marriage, and a one-year-old daughter from their present marriage. Shortly after treatment began, the father and his two natural (biological) sons were involved in an automobile accident in which his youngest son died. The entire family plunged into

Countertransference as a Key to Subjectivity

25

unabating self-recrimination. They refused to allow the boy to be dead. Although the case history and treatment history were complex, the conference group single-mindedly focused on details of the accident and on the question of guilt, sin, and responsibility. A young family physician who recently had his first child was outraged at the father for allowing his sons to ride in the car without their seat belts fastened, condemned parents who let their children ride in the back of pickup trucks, and took the rumor that the father had been drinking before he drove to be established fact. Clergy from Catholic, Baptist, and Disciples of Christ faiths emphasized that the father needed to confess his sins, to receive forgiveness and absolution from a priest (since he is a Catholic) and from himself. A middle-aged family physician whose wife of some forty years had recently died impatiently advised, "There is a time for everything. It is time for them to bury the dead and get on with living." Within the span of less than an hour, the group's agenda selected from the case what was important to the group and redefined it in terms of the group's needs. Temporarily, we had become the case, doing battle with our feelings over separation, loss, and blame. For the group, the events immediately surrounding the accident together with the father's culpability and guilt constituted the entire case. Everything else receded into the background—including, for instance, the wife's oppressive guilt for having an argument with her husband before he left the house on the fateful night of the accident and the pretraumatic family pattern that determined how the loss would be experienced. The group interpreted the case as though it were a group Rorschach card. Members injected their deepest concerns and fears into the situation and interpreted what course the treatment should take in terms of these projections. Group members would preface their comments with "If I were the father, I'd feel. . . , " or "If it were me, what I'd have to deal with . . . " They proposed to counsel the father as though he were them, based on the shared assumption that the father's conflicts and modes of conflict resolution are or ought to be identical with those of the speaker. Late into the conference two group members asked whether indeed the father did define his state as being one of sin and wondered whether the group was superimposing its agenda upon the

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family. However, these two members (the presenting clinician and myself) were summarily rebutted. The group excluded an enormous amount of data from the resident physician's presentation so that the prevailing group diagnosis could be confirmed: Data were selected to conform to the group definition of the problem. For instance, several group members felt that the presenting physician had grievously erred in not contacting or referring the father to a Catholic priest. However, the physician had earlier noted to the group that both the man's wife and mother had made an appointment with the priest for him but that he had balked—precisely because he rebels against the tendency of others to try to control him by arranging his life "for his own good," often behind his back. At the conclusion of the case conference, I devoted most of my time to analyzing our group process rather than refocusing on the case, for we had become the case. Our fantasy about the case had supplanted the case. Without disentangling the projection process, we would end up treating ourselves in the person of the patient or family. A postscript to this case, which occurred some six months following this conference, further enlightens us about its subject. The senior physician who had urged that the family pull itself out of the doldrums told me with anguish that his own marriage was near an end. With considerable insight into his situation, he said that the loneliness after the death of his first wife was so great that he quickly remarried. Above all, he wanted to keep home and family together as if nothing had happened. The prospect of a Christmas without a full home was intolerable. His new wife seemed such a perfect choice: She even "favored" his deceased wife and could fit into her clothes. With painful hindsight, he saw that he had been trying to mold her into the woman he had lost to death but whose death he could not accept. He saw that he had tried to replace his wife rather than go through painful mourning. His urgency for getting on with life stemmed from his inability to mourn. More recently, he found himself remembering and grieving over the woman he had strenuously tried to forget. At the case conference half a year earlier, he had experienced the case as though he were reliving his wife's death. The case and himself became indistinguishable. He strongly reacted to the case material, stringently calling for a return to normal in the pathological family to sustain his own repression. The family's situation, so

Countertransference

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27

near to his own, reminded him of his own, and he had responded as though they were him. Later, realizing the price which his own denial and repression had exacted from him, he no longer demanded it of himself or of the family in treatment. His attitude toward the family changed from irritation to compassion. Once he could allow himself the vulnerability of sorrow, he could see that the family we were treating was resisting the same feelings as he had—only the behaviors were different. This physician's initial response exemplifies what psychoanalysts call the "return of the repressed." In repression, an unacceptable idea, fantasy, wish, impulse, or feeling is excluded from conscious awareness. It is either never allowed to be conscious in the first place (primary repression) or it is expelled from conscious awareness (secondary repression). The return of the repressed consists of the reawakening of feelings and ideas that we thought ourselves to be rid of or simply not to exist in ourselves. This return is often experienced as terrifying and overwhelming. Often a current situation resembling (to the unconscious) a past trauma rekindles the earlier repressed memory. This case illustrates that such a powerful and unwelcomed visitation by ghosts of the past can occur in groups as well as in individual doctor-patient encounters. A pervasive climate of countertransference could be said to have characterized the group during the case conference: witness the flight from grief, the group's own inability to mourn, as evidenced by their preoccupation with blame, responsibility, guilt, and sin. The senior physician, together with the group, like the family being presented, had fled from grief into (often persecutory) action. Patient encounters, case conferences, family sessions, and medical team meetings are all occasions in which patients, families, and clinical material may induce in clinicians and clinical teachers feelings and reactions similar to those experienced by the patients and their families. We can thus take the patient's and family's emotional temperature by administering the emotional thermometer to ourselves. For our individual or group response to the return of the repressed to be therapeutic, we must be able to identify and empathize with others and to acknowledge and understand our own often unhappy (if not unacceptable) feelings rather than avoid them. Analysis of countertransference, whether individual or group, is unwelcome because it disrupts action. It asks us to remember in

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words and feelings what we prefer to react to only in deed. It calls into question established rituals unconsciously designed to keep troublesome affective issues at bay. Still, it is clinically helpful to determine, for instance, who needs the surgery (does the patient require surgery or does the physician need to operate?), who needs the medication (will medication help the patient or will it make life easier for the physician by disposing of the patient?), who is depressed, anxious, hostile (the patient or the physician), and so forth. Knowledge of hidden issues served by countertransference provides a level or domain of data that could not—by virtue of its spontaneous nature—be part of prior conscious clinical assessment or strategy. Countertransference introduces novel information into the patient encounter (at the most discomfiting times). Its intrusiveness reminds us that much of what we need to know—about the patient's meaning to us and about the patient through us—may lie beyond our protective familiarities and comforting complacencies. By harkening to the seemingly rude voice of countertransference, we might press beyond our deceptively simple models of disease and treatment and learn the disturbingly significant, not merely confirm the expected. Indeed, the clinical use of countertransference consists of a familiarity with and trust in the unexpected—which is to say the unconscious. In analyzing countertransference, we learn how and why we resort to familiar models of etiological explanation (cause of disease), diagnosis (classification—of what and of whom), divination (prognosis), and treatment to prevent us from being disturbed. We resort to categories of conventional knowledge, concept, and technique to reassure ourselves that we know precisely where to look, what to look for—and what we might neglect with impunity (or so we think). Our often frail sense of competence rests upon our avowed certainties. Yet our ««certainties could teach us much— about ourselves and about our patients. What we may unconsciously neglect or minimize in medicine is the humanity we share with patients. In my experience, the most common subjects of medical countertransference among family physicians are—predictably—intensely personal ones that correspond to the culturally most vexatious emotional issues as well: aggression, death, loss, grief, separation, sexuality, intimacy, control, autonomy, dependency, self-reliance,

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time, and integrity of the self (for example, self/other boundaries). What I have written elsewhere concerning family medicine ought to apply to any medical healing and caring relationship—which in turn would bring countertransference issues to the core of the relationship: Family medicine unabashedly returns the philosophical issue of human suffering to the center of medicine, without feeling compelled to reduce suffering to pain. In attempting to answer the question "What is disease?" we are led to address the question "What is life about?" The proper subject of family medicine is less exclusively "disease" and more inclusively "life." (Stein 1981:6)

METHODOLOGY: THE RETURN TO COUNTERTRANSFERENCE IN THE DOCTOR-PATIENT RELATIONSHIP In family medicine, physician countertransference exerts a profound influence in the clinician-patient relationship, affecting the process of clinical evaluation, diagnosis, prognosis, and treatment. T o propose this is not to consign countertransference to the category of psychological medicine but rather to observe how profoundly psychological is the whole of medical relationships. The principles of mental operation which Freud originally discovered in the context of the transference neurosis are shown to apply not only to labeled psychopathology but as well to the "psychopathology of everyday life" within the shared cultural world of medicine. Close and constant attention to the family practice resident's countertransference can simultaneously improve patient care and the quality of the resident physician's own life. I did not deliberately set out to conduct a formal study of the role of the unconscious in medicine. Instead, the "study" unfolded as I performed day-by-day duties in teaching, advising, consulting with, and supervising family practice resident physicians in clinical behavioral science. This is little different from the experience of applied anthropologists who in the course of performing certain services for groups or agencies discover issues or problems of which the group or employer may be unaware but that nonetheless influence their behavior. In my own case, the discovery that countertransference was a commonplace influence on clinical behavior led

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me to be alert to it when discussing cases with physicians or when participating in physician-patient-family sessions. M a n y problems for which residents sought consultations with me and identified as patient problems or difficulties in patient management turned out to mask or be influenced by the physicians' own problems. W h a t began as a consultation in which the physician requested help in understanding someone else ended much of the time with the key to understanding lying within the physician, that is, in what the patient evoked in the physician about him- or herself that made the physician uncomfortable. Often in these instances, the patient is invested with qualities which the physician experiences as emanating from the patient (see Klein 1 9 4 6 , 1 9 5 5 ; M o d e l l 1 9 6 3 ) . T h e scope of countertransference in patient encounters within family medicine impressed itself on me in my routine w o r k with family medicine resident physicians in Enid and Shawnee, Oklah o m a , residency training programs, and during numerous consultations in which I have been involved in the O k l a h o m a City program. Since M a r c h 1 9 7 8 I have participated weekly on Fridays in the Enid Family Medicine Clinic program, beginning with family practice rounds at 7 : 3 0 A.M, through clinic and family consultations, which end some twelve hours later. In the Shawnee Family Medicine Clinic program, beginning with the winter of 1 9 7 9 , I have participated in a similar although more limited fashion on alternate Mondays (that is, t w o or three times per month). Since 1 9 7 8 I have worked closely with a "sample size" o f some sixty second- and third-year family medicine residents and twenty-five attending (faculty) family physicians. I emphasize that what is reported here as the result of some ten years' research is part of no official research project. I did not set out to discover or to demonstrate the importance of countertransference. T h e discovery was serendipitous, as all discovery must be. As a psychoanalytic anthropologist, I find that an ethnographic attitude of free-floating attention to clinical teaching has been an invaluable clinical tool. By not knowing what to look for, we stand the chance of finding the unknown and not merely reconfirming the k n o w n — w h i c h is to say, the reassuring. Also, as has frequently happened in the history of science, the significant is usually at odds with the prevailing view of h o w the world and human relations are and should be ordered. W h e n we must strive to prove what we wish to assume, we are likely attempting to protect ourselves from

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knowledge that is painful—and which at an unconscious level we already know. Countertransference is one such type of knowledge. The clinically crucial process of ruling out competing but misleading alternative diagnoses must be balanced by the equally crucial process of ruling in significant context. Yet such context is rarely affectively neutral—which is precisely why we so often fail to consider it clinically pertinent. We cordon off the personal from the professional. To consider, for instance, the possible role of dependency strivings in peptic ulcer disease, aggression in cardiovascular disease, or the conflict between holding on and letting go in ulcerative colitis is to open ourselves to the possibility that in disease our very self and not only our body may be vulnerable. Science and medicine progress only with a constant tension between familiar structure and uncertainty. We think immediately of the Viennese internist-family physician Josef Breuer, who in the course of treating Anna O. recognized that her hysterical symptoms had psychological meanings; of the young neurologist Sigmund Freud who came to take his patients' words, dreams, fantasies, and feelings seriously; of theorists and family therapists of the Palo Alto school—Don D. Jackson, Jay Haley, Gregory Bateson, Paul Watzlawick, and John Weakland—who in paying attention to the form of verbal communication found pathological communication to be highly patterned; of Murray Bowen, a psychiatrist whose observation of schizophrenics hospitalized together with their families led to a model of family pathology; of Salvador Minuchin, a psychiatrist whose keen observation of family interaction led him to emphasize the importance of the interpersonal use of space, body language, and sequencing of verbal communication in creating and sustaining family pathology; and of the British analyst W. R. Bion who through working with small psychotherapy groups came to recognize that certain shared basic assumptions underlie group cohesiveness. Surely, contexts such as these merit our attention in biomedical education and practice as much as in the disciplines their discoverers have spawned, for they are part of the human condition.

Vignette 3 : Mothering Tendencies Some years ago during family practice grand rounds (at which residents and faculty physicians review all currently hospitalized patients' diagnoses and management plans), a resident was notice-

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ably frustrated with the lack of progress of a hospitalized forty-yearold alcoholic male under her care. Since the format and function of rounds is to review a large number of patients in a short time and to drill the residents in assessment, differential diagnosis, and biomedical management, I deferred commenting on the case until later. Following rounds, I asked the resident whether we might discuss the case. She began with a history of the present illness. The precipitating event for the patient's most recent alcoholic binge (the first in eight months) was a truck accident. He had wrecked the truck but had not been fired by his employer. Instead, the patient left the job convinced that he was a failure. A pattern evident in the patient's life is a sequence as follows: He tries to do something well (such as hold a steady job), has a mishap, becomes convinced that he is no good, becomes depressed (an expression of self-hate), consumes alcohol, and subsequently attempts or contemplates suicide. He considers himself to be a perfectionist. Trying to please others to shore up his poor selfimage, he feels that others consistently let him down and that the world fails to comply with his need to be perfect. He has held good and steady jobs. However, he sabotages himself or uses some incident to prove that he is no good and therefore does not deserve what he has earned. As the resident and I discussed the case, the initial focus was on patient history, a review of management history, and similar patient-centered issues. The resident then somewhat sarcastically brought up her own "mothering tendencies." I asked her to continue. She said that she had found herself in frustrating situations like this with other men whom she had tried to help. In fact, this patient reminded her of one of her brothers. The only daughter among four children, she is also the eldest. She characterized her oldest brother as unreliable, as one who always gets himself in trouble and needs to be rescued; her own role was to rescue him. The resident described both her patient and her brother as "sort of paranoid," feeling persecuted, feeling that the world owes them something and that they have somehow been cheated out of what is rightfully theirs. Both in her family and in her clinical situation, the resident feels called on to provide a remedy. Only by taking care of them can she feel good about herself. We expanded the scope of our discussion to include her entire

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family. Her mother had numerous illness episodes when the resident was young and asked her daughter to take full responsibility for the care of the three brothers. The resident felt guilty when she could not help her brother and responsible to her mother for the brother's behavior. Trying hard to help, she also felt obligated to help. Yet she could not control his behavior even when she had to. This led to her feeling frustrated and depressed. Just as her patient felt himself to be a failure, her inability to control him or to help him made her feel a failure—angry with him and depressed about herself. Although the resident had initially hoped that I, as behavioral science consultant, would provide a solution for her— injecting into our relationship the conflict and the wish for rescue that the patient had initially imposed upon theirs—she came to see how her relationship with the patient had become a replay of her relationships in her family of origin. Having rediscovered clinician countertransference in operation, she was able to delineate more clearly the boundary between her family of origin and her current clinical relationship, which she had partially confused. The resident and I then briefly discussed her strengths and vulnerabilities, less as they applied to this specific case than as they characterized the resident's style of response to types of patients and situations. Over time, with this patient and others, she felt less compelled to indulge her mothering tendencies, to feel totally responsible for patients' welfare and actions. Some months later she remarked to me that although she liked psychiatry, one of the main reasons she did not go into it but chose family medicine instead was that she wanted to have more control in medical situations than seemed possible in psychiatry. She was also discovering how much of an illusion—one fostered by family, profession, and culture—absolute control is, and she gained considerable insight into why she had invested herself in that illusion. There is no success story to the case part of this narrative. The patient was eventually lost to the clinic. However, through consultations on cases involving the management of difficult hypertensives, diabetics, and the like, we found that the issues of control, responsibility, and guilt recurred in the resident's feelings about these noncompliant patients. Over a number of months of regular consultations (never defined as therapy), we constructed an elaborate "genogram" (Pendagast and Sherman 1977)—a schematic representation of the multigenerationally extended family,

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one structurally akin to a family's genealogy, a physician's family history of disease, and an anthropologist's kinship diagram but used to understand a family's emotional relationships over time. I further used this eliciting technique as a stimulus for the resident's free associations and my subsequent interpretations about her family and her place in it. We were gradually able to discover many of the emotion-laden premises derived from her family experiences and role that often became sources of frustration in patient care. For example, when she was still preadolescent, her mother had become seriously ill and had been hospitalized for a long period. The burdensome role of mother of the household had become hers. From such experiences, both her expectations of others and her expectation of herself had increased—just as the consequences of being unable to fulfill those expectations (through the misbehavior of others) were burdensome. We discussed the bouts of depression that resulted from her inability to live up to her internal and family standards. She quickly came to notice how the conflicts, values, and roles that originated in her family experience came to influence and occasionally interfere with patient care. As she was able to address and to some extent resolve some of these issues in our discussions, she also noticed that the issues of control, responsibility, and guilt that had been associated with her mothering tendencies were less dire. They began to emerge less frequently and have less urgency in clinical situations, and they diminished as issues in our regular consultations. She was able to consider alternate strategies that were more tied to the present clinical situation than to the past family context. Her emotional separation from an internalized past made more accurate her assessment of the here and now, one less clouded by condensations of externalization (to control a repudiated part of the self), projective identification (to control another in order to preserve the relationship), and projection (to control a disowned impulse). Is it entirely coincidental that during this time she decided to marry? Having referred to the genogram while discussing this vignette, I would like to consider briefly its value as a teaching tool—about emotional forces in the life of the medical student or resident as well as in the life of the patient. The genogram is a clinical and research data-gathering instrument having wide currency among family physicians, family systems researchers, and family therapists. It is a system of mapping three or more generations of a family

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according to blood and marital ties (some genograms include emotionally significant godparents, neighbors, even pets) to determine recurrent family emotional patterns that influence roles, predisposition to disease, response to disease, attitudes toward compliance, and so on. In a sense, the term genogram is a misnomer, for the purpose of constructing a genogram with a patient or family differs considerably from the purpose with which a physician usually constructs a strictly biomedical family tree. T h e physician has tended to view the family tree from a predominantly genetic point of view; that is, by identifying patterns of mortality and morbidity over several generations of a family, the physician can obtain a sense of what he or she believes to be genetic predispositions and thereby better treat and counsel family members or make informed predictions about the future course of family history. Family systems researchers, family physicians, and family therapists, however, tend to be at least as interested in learned emotional patterns and their consequences in disease and response to disease as in genetic proclivities. F o r their purposes, the schematic might be more aptly termed a "phenogram." An additional difference lies in the fact that the physician usually obtains the data for the medical family tree, constructs that medical history, and subsequently uses it as an information source on which he or she might base decisions about medical care. However, the physician or researcher w h o constructs a genogram with a patient or family tends to involve them more actively in its construction and interpretation; for example, I often use the genogram with patients, families, and residents as a point c>f departure for their free associations and memories about family members and relationships. These emotion-laden facts are often clinically as important as the type of facts we gain by having a genealogically complete map of the family. W h o a person remembers and forgets is a different type o f clinical fact from a thoroughgoing catalog of family members. In constructing a genogram, the process of interpretation and treatment is part of eliciting the data themselves; the more people discover about themselves and their family forces, the more they are able to m a k e connections and thereby m a k e changes in patterns of interaction. T h e clinician or researcher often constructs a genogram with the patient or family, not merely after the patient or

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family has provided the data. The genogram is much like a projective Rorschach or Thematic Apperception Test, except that the act of construction and interpretation go hand in hand and the clinician or researcher often provides feedback to patient or family as the data are being recorded. Furthermore, the genogram may be used by physician/researcher and patient/family as an instrument for building rapport, as the physician/researcher shows an interest in the patient's/family's life, not merely its disease. I should add the perhaps obvious point that just as there are times to use the genogram, there are times not to use it, for the best intention can easily backfire. As in all therapy, timing is of the essence, the timing in terms of the patient/family as well as that of the clinician/researcher. Many patients who come to the doctor for a sore throat or earache are in no mood to have their family lives probed: They wish to be treated and discharged. The astute physician, however, attuned to the possibility of family issues influencing disease onset and the course of illness and treatment, can gradually and unobtrusively accrue a genogram from the patient/family over a series of visits during a single illness episode or many illness episodes of one or several family members. Family studies and family medicine, having discovered the merits of the genogram in assessment and intervention, will have the more difficult task of learning the art of when and when not to use it and how to employ it most unobtrusively (akin in psychotherapy to confrontation and interpretation).

PATIENT MANAGEMENT: THE INFLUENCE OF THE UNCONSCIOUS IN CLINICAL COMMUNICATION Not long after I started to teach in the Shawnee, Oklahoma, residency program, I began to have frequent and fruitful discussions with psychiatrist Jerry Sullivan, a former general practitioner now serving as a faculty physician. Our talks quickly focused around the subject: Whatever happened to countertransference? Why has countertransference been given such short shrift in undergraduate medical education and residency programs—even in psychiatry? Why did we "lose" it? I would argue that something gets lost only when it disturbs us sufficiently to try to lose or get rid of it, that is, repress it. We are loath to know what we know—so we say it

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is unimportant. Yet the more we try to forget, the more we act on what we think we have forgotten. Then the residents bring us, as it were, the residue from their forgetting; namely, refractory patients, management problems. In large measure, by helping them to sort out what their problem with the patient is, what the patient's problem is, what the patient's problem with the resident is, and the resulting problem in the transaction, we solve the problem—but only by identifying the problems correctly. In family practice grand rounds, hospital rounds, observation of patient encounters in the family medicine clinics, in consultations with family medicine residents about difficult cases and problem patients, in supervised sessions of family and marital assessment and counseling, in videotaped patient-clinician interactions, and in home visits for family evaluation and therapy, countertransference in family medicine (and, for certain, medicine as a whole) became of paramount importance for me. "Know thyself" is not only an activity of philosophers but also a principle for all those whose professional activities focus on human interaction. In medicine, such knowledge influences clinical behavior, observational skill, empathy, therapeutic technique, and outcome. Perhaps predictably, I found that countertransference was most apparent in cases involving ethnic and class differences between physician and patient; death and dying; decompensation into psychosis; poverty and welfare; sexual attractions and repulsions; disorders of eating, boundaries, and self-control from obesity to anorexia nervosa; family and marital conflict—most commonly expressed in a dread of not knowing what to do when sitting down with a family and the terror of being "eaten alive and spit out" by the family; the presence of unacceptable feelings of anger toward the patient; and physicians' need to have at their disposal instant answers for patients with whom they are conducting counseling or psychotherapy (as contrasted with the ability to listen, withstand the patient's anxiety, and help the patient toward insight and working through). Both my own academic training as a medical anthropologist and my expectation that I would be consulting with clinicians about clearly circumscribed patient problems (or easily resolved physician misunderstandings of patient-meanings, expectations, values, and the like) failed to prepare me to recognize and address the widespread occurrence of physician countertransference.

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At issue is not whether the physician will have unconscious fantasies, conscious fantasies, resistances, conflicts, and needs that will be evoked by the encounter with the subject matter of medicine and that will influence how that subject matter is understood but how the health professional will respond to this inescapable fact of clinical (indeed, human) relationships. Stated differently, the issue is not whether the clinician will have subjective responses to the patient but whether the clinician will be aware of the inner meaning they have for him or her—and therefore whether they will be under conscious control for use as a tool in clinical understanding rather than a weapon of defense against the patient. Hippler (1982) underscores the need "to explicate a way to tie such awareness of self with specific understandings of the outer world, and not merely to become more aware of the self" (p. 177). Subjectivism, which could be used as an autistic defense, can also be used as a way of knowing the world. We each have some stake in having and keeping certain people and categories on the nether side of the emotional railroad tracks, so to speak. For the most part, we do so inadvertently rather than deliberately. It is only through the understanding of those medical parapraxes that transform patients into "crocks," "albatrosses," "turkeys," "Piss Poor Protoplasms," and "trolls" (the list is lengthy) that we can come to admit those whom we have dismissed back into the human race. We continually relocate our internal issues externally and readily come to see our own difficulties firmly located in others. Here "location" is more aptly seen to be "allocation." The problem patient and difficult patient (and so on) are simultaneously a problem clinical relationship and a symbol of the physician's (or student's, or teacher's) inner divisions. Often the behavioral scientist can assist a physician in the clinical relationship only by first inquiring into what that clinical relationship means to the physician. Western scientific medicine is not immune to the human proclivity to work out inner problems through others. We all use others as vehicles or targets for our fantasies, anxieties, conflicts, idealizations, and symptoms to maintain our inner stability. We unconsciously assign objective status to subjective states and inner experience to the world and others for safekeeping and control at a distance. Inquiry into the role of psychodynamics is not a mere

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icing on the cake of "real medicine"; psychodynamics are the leavening of the cake. The outer world of nature and human relationships comes to mirror our inner attributes. Reality is experienced inside out. As Devereux (1980) writes, "Man tends, in one way or another, to see reality as a projection of psychic forces and materials" (p. 282); and La Barre (1980) insists that "we perceive everything through glass colored by personal and persistent cultural pasts. We don't know the now because we so stubbornly refract it through the immortal past's prism" (personal communication). Reality is a very recent notion and adaptation to reality an incomplete attainment. Our hope lies in the fact that we are beginning to realize the extent to which the unconscious mediates commerce with one another and with the world.

Vignette 4: A Patient Management Problem as a Red Herring The readiness with which a problem presented as one in patient management can serve as a vessel for highly personal issues in the physician is illustrated by the following example. A family physician well into his second year of residency and already a warm, skilled counselor complained of an inability to achieve any positive results with several depressed women ranging in age from fifty to the mid-seventies. Usually confident that he could take on the world with a good chance of winning, he was frustrated with his failure to get these women to recognize their problem, to improve, and thus no longer to need treatment. He asked me to give him an answer. I first asked him how these patients made him feel. He answered at length: Frustrated. I make suggestions, and they come back with some remark about how they've tried it and it didn't work. N o matter what I try, they keep coming back, and they don't get better. You go through medical school and they fill you with all this stuff about doing the right procedure, dramatic change, success, cure—you do something and you expect results. But nothing I do with these women works. It just gets me frustrated. You see all the success you have with antibiotics or by repairing somebody with surgery, then you run into this.

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Subjectivity

You know that I can't stand people who can't pull themselves together when they're down. I had to work hard for where I got, so did my family. I have a hard time understanding people who expect others to do something for them all the time and take care of them. It's like they don't want to get out of their depression and expect you to do everything for them. (I interjected that what he was saying sounded like the way he earlier had talked about people on welfare, except that with these women, they could well afford to pay their way. He smiled, slightly embarrassed about the unexpected conjunction of his politics and medicine, continuing:) I don't see the point in giving handouts to people who won't help themselves. I don't have a lot of empathy for people who won't do their share. Reassurance isn't much my style. I like to see people accomplish something. During the remainder of the consultation, we briefly explored h o w his family, ethnicity (Czech), and religion (Catholic) influenced his perceptions, expectations, and behavior as a physician. H e began to recognize his own stake in patient care. W h e n his techniques with the depressed women failed, he rejected the women, finding fault with them, projecting the failure so that it would be theirs rather than his. W e found the uncompliant patient to be the uncontrolled(-able) portion of the physician—a portion of himself that he found difficult to deal with. O u r discussion of his disappointment and anger was a turning point in the consultation. His wish to have his sense of competence and self-worth mirrored by his patients' appreciation and recovery had been profoundly frustrated by patients who mocked his desire by essentially telling him, " Y o u ' r e no g o o d . " Unconsciously, he was using his patients to accomplish for him what he needed to do for himself. It was as though the patients came to the clinic for him as much as he was there to help them. H e needed them to validate his self-worth at the same time as they asked him to validate theirs. W e concluded that although these depressed women still were burdened with problems, his ardent need to cure them—and to help them accomplish his goals in his way—further burdened them with his own problems. H e left considerably relieved, paradoxically better able to help his patients because he did not need to try so hard to help them, perhaps more likely to have their affection because he did not need to work so hard to win it. This physician still rails from time to time against those patients and social classes w h o , according to his perception, will not " k n u c k l e d o w n " and live their lives as he has led his. But there is

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always an exaggerated bluster to his occasional condemnation. Increasingly, over the months, he has begun to wonder " h o w people get to be like that. They're not born that way. I wonder what kind of family or childhood they had that made them so screwed u p . " His tirades have diminished in intensity and frequency as he gradually has been able to identify with patients w h o m before he could only condemn. By putting himself in their place, allowing himself to be vulnerable to their vulnerabilities, he allows himself to listen better and thereby to intervene more effectively. A conflict or disparity in values, goals, and the like between health practitioner and patient are often difficult to surmount or reconcile precisely because they serve as defenses. Nevertheless, for psychodynamic issues that are raised theoretically and didactically to be of clinical value, they must be experienced personally. T h a t is why, even today, the early Berlin Psychoanalytic Society's tripartite emphasis on personal analysis, seminars on theory, and clinical supervision remains my own ideal (remote, to be sure) for medicine as a whole. Unofficially, my role as preceptor and supervisor has been accepted as quasi-ethnographic and quasi-therapeutic; that is, it is an ongoing, often peripatetic analysis as much of the resident clinician's fantasies, wishes, fears, and conflicts as it is a conversation or consultation exclusively about the patient. Although admittedly a novel, if not marginal, approach to the teaching of medical behavioral science, its starting point in the dynamics of the physician-patient relationship is sound. I would add that only the breadth of an open-ended ethnographic method combined with the depth of an open-ended psychoanalytic attentiveness to human motivations in interpersonal relations permits the discovery of the centrality of countertransference in medicine. I see my role as observing ego to help resident physicians and student colleagues become competent observing egos of their own mental functioning and of that of their patients. In doing so they become clinical ethnographers of the human condition, which they share, willy nilly, with their patients (Stein 1 9 8 2 c ) .

THE ONGOING CLINICAL TASK: DEFENSE OR INTEGRATION? Although psychoanalysis itself does not ensure the production o f sterling character, still, the disturbingly large grain of truth remains that unless we k n o w our fantasies, conflicts, anxieties, and the like,

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we will tend to act toward the patient as though the patient represented some person or persons in our past or some unconscious part of ourselves. Another way of putting it, we will not treat the patient as a human being separate from ourselves but will in effect treat an extension of ourselves "discovered" in the patient. This is the essence of countertransference. Nor do we ever resolve countertransference once and for all (as physicians may wage successful wars against disease adversaries). In scientific medicine, our conviction that (a) what we do is based on rational, verifiable principles in conjunction with (b) our belief (wish) that we are in control of our thoughts and behavior make acknowledging the existence, let alone the pervasive influence, of the unconscious unacceptable. What is more, because we isolate cognition and medical decisions from feelings, we have little access to and therefore little control over the influence of those feelings. Our private, group, institutional, professional, and cultural bulwarks against these feelings are themselves preventive defenses against countertransference, a kind of anticipatory countertransference. When we "accidentally" let slip our feelings—through words, tone of voice, gestures, impulsive actions—we often feel surprised if not overwhelmed by such lapses in self-control. It is such a cultural environment that first spawned the behaviorism of J . B. Watson and B. F. Skinner and that now nourishes a wide spectrum of medical, behavioral, and family therapies that discount the unconscious. Clinically as well as culturally, we are an intensely pragmatic people. We seek solutions that work quickly and with mechanical ease. We prefer problems which we can whittle down to size. In our imagination at least, hard science tends to be tangible, concrete. In American culture, if you cannot touch it or see it, it is not there or worth bothering about. The human body, the self, relationships, and the world are frequently described in terms of the machine and the computer, two organizing cultural metaphors (Hayden 1984; Stein 1982e; Stein and Hill 1984; Stein and Kayzakian-Rowe 1978). Even classical Freudian psychoanalysis became truly acceptable to American appetites only after it had been properly domesticated (that is, acculturated to American psychological style: briefer, more focused and goal oriented, with greater emphasis on ego than id, and so on). Culturally based clinical models greatly oversimplify clinical reality, a simplification that in turn confirms the culture which such models

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serve. For people hastily packing to catch the next plane, rushing to avoid the freeway rush, or half digesting the morning news with the morning coffee, the nebulous realm of inner meanings has little place. Paradoxically, perhaps, our freedom and autonomy are enhanced to the degree to which we know that we are not free of unconscious influence. We are in part the source of the very object we observe and the data we screen. Through overinterpretation, we impose outer structure to achieve inner order. We may order tests of various kinds (cognitive, medical, and so on) to validate our defenses, hoping if not expecting to transform probability into certitude. We may see what is not there, overlook, severely edit, amplify, or selectively emphasize part of what is there. Our perception of clinical reality is not unerringly governed by the here and now; it is influenced by our internal representations, which subjectively organize the world. At the root of transference/countertransference lie many of our errors of omission and commission. What seems extraordinary about countertransference is its ordinariness. What is frightening about countertransference is its unexpectedness, the power of its expression, and the lack of control we exercise over it. It strikes us unprepared. Subjective input is always a part of objective outcome. Countertransference influences any clinical relationship in a global sense, colors the assessment and diagnostic process, determines how we shall treat the patient, and affects the prognosis and treatment outcome. Through countertransference, for instance, we may unwittingly assess, diagnose, and treat others for our own discomfort with them—and remain unaware that we are doing so, that is, we may treat others for the dis-ease they evoke in us. The problem of compliance often becomes one of control: Who will control whom? But this is an oversimplification, for compliance becomes an issue in controlling another only after some portion of the physician is first extruded and allocated to another (such as the patient). Compliance thereby becomes the problem of controlling some dangerous part of the physician's self as it is experienced in another. Just as "the parent uses the child to 'cure' himself, demanding that the child control himself because the parent cannot control himself" (Shatzman 1983:834), the physician may unconsciously use the patient to control him- or herself. Certainly, countertransference is only one possible explanation

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of situations of noncompliance in medicine. Indeed, in understanding what we tend to label as noncompliance with medical regimens, it is as important to rule in and rule out alternate explanations for the patient's behavior as it is necessary to do so for disease when conducting a differential medical diagnosis. Emphasis on countertransference explanations of noncompliance to the exclusion of others may inadvertently focus far too great attention on the physician and divert attention from patient factors in the clinical situation. In asking "Why doesn't the patient comply?" we take a physician-centered viewpoint, which if used moderately would help us inquire into the physician's personal investment in the clinical interaction. It is equally important, however, to inquire also "Why does the patient do as he or she does?" which is to elicit the patient's point of view of the illness episode. T o make compliance the exclusive focus of patient behavior is to fail to distinguish between what practitioners believe the patient ought to do (the medical explanatory model) and the patient's own frame of reference (the patient's and patient's family's explanatory model). Moreover, it has the effect of discounting the patient's world: we need not concur with a patient's or family's medical understanding and illness strategy to respectfully acknowledge it. Patients and their families diagnose their maladies, just as the physician diagnoses the patient's disorder, and they often come to widely disparate conclusions about what is wrong, what the cause is, and what to do about it. When the patient's and family's behavior differs from that recommended or prescribed by the physician, we label that as noncompliance (Sackett 1976). But this label often mistakenly reduces a complex issue to our perspective on that issue; that is, it focuses entirely upon what patients fail to do in terms of departures from behaviors which clinicians feel they should do. It is here that countertransference muddies the waters further, often equating noncompliance with defiance, often making an issue of difference with the patient into one of control over the patient. This tends to mask other issues that lead patients to behave differently from ways in which the physician assumes, expects, or wishes (see Chrisman 1 9 7 7 ; Sackett and Snow 1 9 7 9 ; Stein 1 9 8 2 b ; Trostle, Hauser, and Susser 1983). Patients' and families' logic, expectations, roles, organization of ego defenses, illness strategies, value priorities, and access to health service may differ from those of the physician. Moreover, patients may concurrently or sequen-

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tially use multiple health resources in an illness episode, often to the chagrin—and intensified countertransference—of the primary care physician who seeks to be the gatekeeper and organizer of services in the health care system. One way of diminishing our countertransference in these inevitably frustrating situations is to be as conscious as possible of our own expectations of the patient while attempting to elicit the patient's rationale and agenda for his or her own pathway to care (see Chrisman 1 9 7 7 ) .

Vignette 5: "This Will Sure Look Bad for Me" Consider the following case summary, which illustrates how a patient can become a psychological battleground for the medical hierarchy. A female Caucasian in her mid-thirties, overweight and diagnosed as a borderline diabetic, had been hospitalized for a hysterectomy. During the glucose tolerance test before surgery, hospital personnel had difficulty in drawing blood from her arm. Her veins were difficult to find and finally collapsed after much probing, forcing laboratory personnel to draw blood from each of her fingertips and " m i l k " the blood from her fingers. Almost three weeks later, she still had a dark bruise on her right arm where they had unsuccessfully searched with the needle. On the morning of surgery, her physician said to her, " I f they have trouble putting in the IV [fluids and electrolytes], just tell them to forget it. We'll put it in in the operating room after you're under." When the nurse came to her room to insert the IV, she had difficulty finding the patient's arteries, as both the patient and the surgeon had expected. After probing unsuccessfully a number of times, the nurse said to the patient with exasperation, " I just am not getting anywhere. I don't think I can do this." The patient then relayed the doctor's message that the IV would be inserted in the operating room. The nurse replied, " T h i s will sure look bad for m e . " The patient shrugged as if to say, " H o w can I help that?" The patient said, "I take complete responsibility for my veins. It is not your fault if they're hard to find." T h e nurse, however, decided to call still another person (an anesthesiologist technician) to come to the room and try to insert the IV. The patient reiterated, " . . . but the doctor said it could wait." T h e anesthesiologist technician also had difficulty, probing several times

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before finding a location in the patient's wrist above the thumb in which the IV needle could successfully be inserted. This case highlights communication difficulties among health professionals and the consequences for patient care. Health personnel often fail to convey information directly to one another and end up communicating through the patient. They are concerned about looking bad in the eyes of the medical hierarchy—a fear that mixes reality and externalization. In this case the patient became a proving ground for the nurse who feared losing face to herself and others. The failed cure or the failed procedure is often experienced as the failed clinician. The patient is expected to mirror the clinician's goodness, technical prowess, and so on. When this does not happen, when something goes wrong, the clinician becomes frustrated with the patient. The patient is then experienced as an obstacle—if not a defiant adversary—to treatment or cure, uncooperative even if trying to cooperate. More than a challenge, the patient becomes a proving ground on which the clinician attempts to fulfill or to restore personal ideals and ambitions (Kohut 1972). What began as a realistic problem becomes, through regression, a problem of repairing a sense of shame. Also, the clinician must often contend with the enormous amount of rage that he or she feels toward the patient. What Spiegel (1971) writes of the psychiatrist pertains to all clinician-patient relationships: "As the patient comes to stand for a rejected and bad part of the therapist, his ego tends to give in by finding a way to characterize the patient as deserving of rejection. However, the therapeutic part of his superego will still be strong enough to insist that such a rejection be justified on technical grounds, or at least clothed in professional jargon" ( p p . : 3 3 2 - 3 3 3 ) . In the preceding case, the patient was made to feel that she was responsible for the IV not "taking" so that the nurse would be spared the painful feeling of being inadequate in the eyes of the doctor. The nurse thus summoned reinforcements rather than acknowledge defeat. Here the patient was experienced as an extension of the nurse's need to succeed and appear competent to the physician. She could not back down. It would have felt too humiliating, even if in reality it were not. This case illustrates how the clinician can mistake a countertransference reaction to the patient for a flaw in the patient. Unraveling source from target in the tangled skein of clinical

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relationships is often difficult, for transference by patients often appears to the clinician to be conscious seductions, willfulness, obstinacy, defiance, power plays, manipulations, and dramatizations. Physicians often experience transference as intentional rather than unconsciously motivated and as personally directed toward them rather than toward a screen on which the unconscious content takes shape. Patients t o o may experience countertransference as willful and a personal affront rather than as a slip of the unconscious onto a suitable screen. Each participant to the clinical transaction may come to see the other as the problem, the solution, or both. Conscious intentions or messages are unwittingly negated or disqualified by the persistent unconscious messages transmitted by dissociation and projection. Transference/countertransference phenomena reveal our divided and repressed humanity. W h e n we deny or otherwise disavow undesirable aspects of ourselves, we find that they attempt to return uninvited, often to haunt our official, public selves. W e then take flight from each attempted return of the repressed. First discovered in the classic analytic situation, transference/countertransference not only lie at the heart of therapeutic communication but also are intrinsic to human relationships. They are not the professional property of dynamic psychiatry, but belong to all of us by virtue of the nature o f our mental functioning. Precisely because transference/countertransference phenomena are the product of unconscious resistance and repetition (Freud 1 9 1 0 , 1 9 1 2 ) , insight into them is painful. Y e t such painfully acquired insight is necessary if we are clinically to meet the needs of our patients and not impose our conflicts on them. W e often defend ourselves against countertransference by rationalizations: " I only meant . . . " ; " I didn't mean to say that . . . " ; and the like. Instead of listening to these uninvited cues about ourselves and p a t i e n t s — cues that might hold the key to therapeutic intervention—we are frightened and embarrassed by them. Clinically, we can easily disavow the subjective and fortify our attention to the objective, only dimly aware of the degree to which our subjectivity affects that objective clinical reality (see also Kleinman 1 9 8 0 ) . T h e trend in medicine has not only been a scientifically laudable specialization along the lines of new discoveries but also a functional compartmentalization, a division of labor that fails to integrate what is c o m m o n to all within each. T o make matters

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worse, we seem to be in a cultural retrenchment (repression) from what we know dynamically about ourselves. Like jokes and parapraxes, transference/countertransference phenomena illustrate the psychopathology of everyday life, pathological only to the extent that we ignore them rather than harken to what one part of ourselves is trying to tell us—or what the patient or clinician is trying to tell the partner in the relationship. As La Barre ( 1 9 7 8 ) observes, " H e [the psychiatrist or the clinician] must constantly ask 'What am I doing in saying this or asking that?'—that is, he must carefully watch his own countertransference to the patient" (p. 2 6 9 ) . Reich ( 1 9 5 1 ) writes: In [countertransference] the patient represents for the analyst an object of the past on to whom past feelings and wishes are projected, just as it happens in the patient's transference situations with the analyst. The provoking factor for such an occurrence may be something in the patient's personality or material or something in the analytic situation as such. This is countertransference in the proper sense. (P. 26) Based on discussions with Otto Fenichel in 1 9 3 8 , she then adds a more comprehensive understanding of the concept of countertransference: . . . all expressions of the analyst's using the analysis for acting-out purposes. We speak of acting out whenever the activity of analysing has an unconscious meaning for the analyst. Then his response to the patient, frequently his whole handling of the analytic situation, will be motivated by hidden unconscious tendencies. Though the patients in these cases are frequently not real objects on to whom something is transferred but only the tools by means of which some needs of the analyst, such as to allay anxiety or to master guilt-feelings, are gratified, we have used the term countertransference. This seemed to us advisable because this type of behaviour is so frequently mixed up and fused with effects of countertransference proper that it becomes too schematic to keep the two groups apart. (P. 26) Living with and using our countertransference is a lifelong t a s k — a developmental task for myself as much as for anyone. Over time I have found that many residents who once discounted the possibility that countertransference applies to them now use it, not only in their clinical work, but in their family lives as well. H o w a patient makes us feel—what the patient evokes in us—is a key to knowing

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what the patient is feeling: Our only obstacle is acknowledging that we feel and what we feel. The integration of personality and the fostering of that integration within the patient is the main task of countertransference as a clinical tool.

IDIOSYNCRATIC AND CULTURALLY INSTITUTIONALIZED COUNTERTRANSFERENCE To limit discussion of medical countertransference to instances that occur one patient at a time would constitute an incomplete analysis. It would omit a crucial institutional and even wider cultural level that permeates the clinical encounter through medical education, peer interaction, and cultural pressure. This level is not reducible to individual defenses implemented by the physician alone. Cultural or group fantasy (deMause 1982; La Barre 1962) augments individual fantasy; group defense buttresses individual defense. What we cannot do alone we strive to do together to protect ourselves from being overwhelmed and fragmented by those anxieties we share. In groups lie our safety, our certainty, our identity. Groups and their organizing symbols serve as mutual defense pacts. Shared cultural fantasies not only confirm our private fantasies because they correspond to them (Spiro 1982) but they also allow us to disguise our private fantasies so that they appear outside rather than inside. In those areas of life where we feel most vulnerable, group consensus comes to serve as the measure of truth. Shared conviction becomes the determinant of reality. All groups' adaptation to reality is mediated by their anxiety-alleviating activities, which often distort that reality in the process. In an attempt to serve a therapeutic function, groups often employ (literally and symbolically) persons, groups, and the physical world to diminish anxiety and keep the group together. One common unconscious strategy for achieving this is for group members to agree on external fantasy targets and objects, which in turn are used to safeguard the internal. These various objects in the environment serve as safety deposit boxes of sorts for individuals' inner emotional accounts. In doing so, however, we unconsciously endow the world with features of our inner emotional landscape. Subsequently we confirm our inner conviction (and allay our inner anxiety) through the sharing of our perception of reality (see

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deMause 1979; Devereux 1980; La Barre 1972; Hall 1977; Stein 1982a; Volkan 1979). Since often we create and join groups to better defend ourselves against anxiety, the shared inner objects of that anxiety become even more inaccessible to analysis. This perspective takes the psychopathology of everyday life to the level of the group. It implies that we must not only be prepared to recognize individual symptoms but be prepared occasionally to recognize cultural symptoms as well. In Western medicine and elsewhere, I believe that we must distinguish between what might be called the idiosyncratic countertransference of the clinician and institutional or social countertransference. This does not connote a dualism of personality and culture (see Devereux 1967). Rather, it corresponds to the fact that medical models and therapeutic techniques implement widely shared defenses and that countertransference in the conventional sense consists of a second line of defense, so to speak, when the institutionally available defenses fail (what I have earlier referred to as a return of the repressed). We must improvise new defenses and symbolic vessels to contain them when those that have been culturally sponsored prove inadequate. Heuristically, both clinical and institutional types are equally countertransferential; their distinction consists of when each comes into play and the degree of acceptability to consciousness of each. An example of how contemporary healer, client, and cultural public can unknowingly collude in an alliance to repress dynamic insight through attention to conventional physical symptoms is the wellness or fitness movement. As I have discussed at length elsewhere (Stein 1982d, 1982f, 1982g), a prevalent but socially proscribed preoccupation with bodily functions, body integrity, loss, and death, such as is found in hypochondriasis (Adler 1981) is replaced by a new socially proscribed form for the same preoccupations, that of wellness and fitness (see also Carlyon in press). The new, positively valued symptom is in many respects an inversion of the older, negatively valued symptom. What is true at the level of individual problem solving also holds for clinical efforts (and other types as well) undertaken by whole societies; namely, that we perpetuate underlying shared unconscious conflicts in the act of offering new solutions to them. We offer and embrace new symptom for old, leaving intact and unresolved what the symptom represents. Here medical countertransference, patient transference,

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and powerful social transference constitute the full system that keeps the symptom going. Medical ritual can be thought of as a conscious compromise formation designed to prevent a return of the repressed; countertransference in the conventional sense is precisely that return of the repressed which the ritual failed to control. The former occurs as a function of the ego defenses, the latter as a function of what the ego defends against. Culturally institutionalized systems of medical explanation and action (diagnosis, etiological explanation, treatment) can themselves be dynamically understood to have the psychic function of shared defense against the average expectable patient. For the most part, however, in this book and elsewhere countertransference is discussed principally in the conventional, that is, individual, use of the term. Vignette 6 : Perceptions and Distortions The following vignettes highlight the way in which the physician's unconsciously influenced perception of clinical subject matter affects his or her attitude toward the material and thereby the learning process. At a behavioral science conference in family medicine in 1980, a public health official and a nutritionist had just completed a thorough presentation on the WIC program (Women, Infants, and Children—a federal nutrition program), clarifying issues of eligibility and availability to the family physician as a community resource. Lively, even hostile, discussion followed. A number of resident family physicians objected to "handouts" of "free food" to people whom they perceived to have abrogated their own responsibility. Although the nutritionist emphasized that WIC is not a welfare agency, nonetheless many of the participants registered their disapproval with what they perceived to be a welfare-style program of rewarding irresponsibility and indolence. With the collaboration of the public health official, I permitted these highly emotional issues to surface and be dealt with in the group discussion, rather than suppress them as tangential to the official subject and inconsiderate to the guest speakers. The group process focused on that aspect of the subject that was most emotionally immediate to the physicians (though certainly not to the presenters). I used the example of this group process to illustrate how conflicts in communication—even among different types of health

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practitioners—often arose from differences in attitudes, values, and expectations that often go unsaid. This further illustrated group countertransference to stereotyped categories of people and pointed out the consequences of distorted perception for patient care. This brings me to a related vignette, which chronologically follows the previous one. During the conference, one participating family physician had been particularly outspoken against what he perceived to be the W I C program's lack of emphasis on the patient's responsibilities and its priority on food over education. That same afternoon I had a consultation scheduled with him and gave him the opportunity to "ventilate" further on a subject very dear to him. From later composite notes, I quote him at length: I don't see how patients can be so inconsiderate. It's as though some of them think that the doctor is only there for them, at any time they want him. They act like he doesn't deserve a life of his own, that they can call him about anything anytime, day or night. I don't see how they expect that of a doctor. In my family, you only called a doctor if something got real bad and you first waited to see if it would go away on its own. We didn't even think of calling the doctor first off. We were taught to be considerate of his time. If someone had a tummy ache, we wouldn't just call the doctor on the phone in the middle of the night and get him out of bed. We learned to wait. If I had a tummy ache, I didn't even tell my parents right off. I'd stay in bed and try to bear the pain, and see if it didn't subside on its own. We didn't go running to mother or dad with every little pain. We had respect for their time. We learned that if you weren't dying, then it could wait. If you just give to people without seeing first if they really need it or could benefit from it, then they're not going to be responsible later. That's why I'm against handouts. Sure I'd like to help mothers give their infants better nutrition. We try to do that in the clinic all the time. But it won't help them just to keep giving them free food. They'll just come back for more. They'll sit through the education just so they'll continue to get the free food. I don't think the education makes that much of an imprint on them. Instead of giving handouts with the taxpayer's money, why not offer them the education alone? Instead of giving away food, teach them how to earn money for themselves. Without mentioning names, I've seen people earning the same amount of money as my wife and I going down for food stamps and getting them. The same with WIC. They don't do any kind of verification of your story. If you go down to Public Health looking ragged enough, and drive a beat-up old car, they'll take your story. Here we try to lead

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an honest, hard-working life, and we see these people doing everything they can to try to milk the system—and we're the ones who are paying for it. You read every day of people who fake their income taxes. Everybody tries to get away with as much as they can. M y father and my grandfather before him earned every cent they had. They never asked for anything from anyone. They helped out people, I don't mean they were stingy. But they made sure you needed it before you got it. That's what I meant when I said that you had better be real good and sick before you made any noise about it to them. Then, too, in my family, before you looked for any help outside the family, you first tried to work things out at home. Like when we were sick—the doctor was the last place we'd go, when nothing else worked, or if it looked like a matter of life and death. People want things too easy. I'm not saying that people should be miserable, but they should learn to take the knocks and not expect life to be a bowl of cherries. A little pain never hurt anyone. It teaches you to look out for yourself better. I just get mad when people take advantage of the system.

One could do much with this rich material, but I want to emphasize two points: First, this physician is regarded as generous to a fault with his time and medical services to patients and staff members alike. He has made the religious admonition "It is better to give than to receive" into a personal creed. His resentment of those who (in his mind) elect to receive rather than to give comes out in the countertransference: " Y o u ought not have what I cannot want." As a result of wishing to press uncompliant patients into the mold of his own autobiography, he contemptuously rejects those who, for whatever reasons, refuse to fit. Second, an issue rarely addressed in family medicine (and other specialties and subspecialties as well) is the extent to which family physicians are being asked by individuals, families, and society to redress every hurt, to solve every problem—and to do so quickly. The reformist idealism of the family medicine movement is matched by a certain overexpectation on the part of both family physicians themselves and the public. The Utopian character of family medicine also invites massive transference from patients above and beyond what arises in any individual medical encounter. For the sake of completeness, I should add that there appears to be a generational distinction between younger and older family physicians in where they place such values as generosity and avail-

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ability to patients in their respective value hierarchies. The younger generation of faculty physicians and residents with whom I have worked has more internal and familial conflict over limit setting in patient care, whereas the older generation has more internal and familial conflicts that are consequent to having placed patient care far above personal and familial considerations. Younger physicians want to give comprehensive and continuous care to their patients and to preserve a separate if not inviolate personal and family life. It must be said, however, that the physician quoted earlier and countless others with whom I have worked are quite realistic in reporting that increasing numbers of people are taking advantage of the medical system—and of the physician's devotion and generosity. Much is written about physician exploitation of patients' vulnerabilities. Much remains to be written about patients' exploitation of the physician's dedication, their demanding sense of entitlement—and about the struggle between them that ensues for the recovery, if not exclusive possession, of self-esteem. Like religion (Kardiner 1939, 1945; La Barre 1972; Whiting 1961), folklore (Boyer 1979), art (Devereux 1971), and politics (deMause 1982; Lasswell 1930), medicine is heir to childhood's hurts and impermanence. In its magical side, medicine everywhere concerns itself also with the repair of childhood, not only with the restoration of the body. In this sense, medicine, like religion, is a secondary institution (Kardiner 1939, 1945) into which is poured the emotional residue of growing up in a family. More is involved in this process, however, than the mere riddance of some noxious aspect of the self. For in projection, projective identification, and externalization alike, we remain profoundly attached to what we expel and may form a more or less permanent relationship to it, now located within another person, group, or thing. In this current partner, we frequently find unwitting collusion. The patient who is looking for the perfect parent in his or her physician and the physician who assiduously tries to effect cures in patients to control his or her own inner chaos are both examples of the psyche's search for a fit between inner and outer, intrapsychic and interpersonal. It must be added that not only is much of the clinician-patient relationship preverbal (and therefore verbalized only with difficulty) but also that much of the nonpsychoanalytic clinical relationship involves touching (from the laying on of hands in the physical

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examination to the invasiveness of surgery) as well as discussion. Little wonder that the modern descendant of the shaman-healer is seen (and often sees him- or herself) as a powerful parent figure in whom the patient invests, as the Christmas carol says of the redemptive Christ-child, "the hopes and fears of all the years." Just as our parents originally mediated the great mysteries of life, now in later infirmity we ask of the doctor to do so in our behalf—hoping from the physician what we once hoped from our parents: that at the very least they would not do us harm (from whence the medical motto). In the language of object relations theory, the physician serves as a container or reservoir as well as a target into which patients and the public put their contents of externalization, projective identification, projection, and condensations of these for safekeeping, safeguarding the inner environment from pain, anxiety, and guilt. The instrumental and scientifically based practices of the physician are thus deeply imbued with expressive meanings—those of both physician and patient. The patient delivers into the doctor's hands a body heavily invested with self-issues and self-parts. Although contemporary physicians often refer to procedures as a form of repair of the organism (modeled on the repair of the machine), we should remember that the repair of the self and the restoration of the severed early relationship is often part of the implicit, unconscious therapeutic agenda or contract—one realistically impossible to deliver in health care. When medicine tries to satisfy magical expectations, it comes to collude in irrationality. For reality cannot live up to unconscious wishes. Medicine cannot cure death, loss, separation, and life's many other anxieties. Yet technologized medicine finds itself increasingly invested with the awe and terror of the sacred. Medicine is increasingly heir to childhood fantasies, wishes, and roles—as though a doctor could be the parent or family we never had but for whom we long. I am concerned lest the family medicine and family therapy professions undermine their painstaking clinical work by enacting a rescue fantasy for the American family. Medicine's continued effort to comply with patient and public neediness (as well as to exact compliance from them), to produce a satisfaction that connotes health or gratitude (or the relief from litigation), unwittingly escalates this neediness and only further heightens expectations.

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MEDICINE AND THE SACRED Medicine stands as one among many vulnerable social symbols invested with heightened expectations. Contemporary medical malpractice litigation in the United States is an increasingly frequent expression of patient transference. The current consumerist, patient advocacy, holistic medicine, and self-help movements have neglected this problem of patient transference in their search for vindication. The physician-patient relationship is rarely governed simply by cause and effect. More often it is governed by an unconsciously influenced role complementarity. The patient's perception of him- or herself as victim and of physician as malevolent would-be (but fallen) God is thus worthy of our closer inspection. Recently Newsweek (31 August 1981) introduced its cover story with the headline "When Doctors Play God." The cover art depicted a contemporary fantasy based on Michaelangelo's God and Adam in which the Deity wears a stethoscope and man is the patient. I find the phrase "Doctors Play God" to be a curious one, for in addition to recognizing the sacred aura surrounding scientific medicine, it accuses medicine of single-handedly assuming the role of God as though patients and society did not also demand that role of medicine. As patients we often accuse medicine of what we first impute to and solicit from it. What medicine arrogates, society delegates. Patients' quarrel with medicine is not that it pretends to be God (though that is what we say) but rather that it does not (and cannot) live up to that perfection we attribute to and expect from God. On the one hand, we accuse physicians of playing God, yet on the other hand, we expect them to be superhuman if not supernatural in their qualities and abilities—omniscient, omnipotent, omnibenevolent, available at all times—which is to say that we prefer our physicians to be more perfect than any (ambivalent) parent could be (Kohut 1972). The widespread belief among so-called primitive peoples that the person empowered with the ability to heal magically can also kill magically and that curative power is dangerous and suspect (Devereux 1980) is also present in our sophisticated, technological society. We might say that the accusation that physicians play God is an attribution to medicine of the wish to be cared for by a perfect undifferentiated father-mother—which, incidentally, is the identical paranoid inversion of affects Freud (1911) discovered in his analysis

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of the patient Schreber. From the point of view of reality, physicians ought to be concerned, for at times they are indeed targets of patients' negative transference (narcissistic rage, vendetta over loss, and so on). This is not to discount physician countertransference but to point out how reciprocal exteriorizing, which has received little public mention, influences physician and patient roles and participants' perception of themselves and their role partner. If negative transference and countertransference can make the doctor seem like a dangerous, sinister figure and the patient like an evil, manipulating character, positive transference and countertransference can not only enhance the patient's faith in the doctor and the physician's interest and devotion to the patient but also can make each seem more perfect than is actually the case. Such setups bode ill for subsequent letdowns, for the greater the idealization, the more profound—and angrier—the disillusionment if and when it comes. Discussing the action of the placebo effect, for instance, Katz (1984) writes: If physicians themselves are the placebos, then they are powerful therapeutic agents in their own right. Their effectiveness is probably augmented by the positive transferences patients bring to their interactions with physicians. It is also likely that the placebo effect is unconsciously mediated. Deep in patients' unconscious, physicians are viewed as miracle workers, patterned after the fantasied all-caring parents of infancy. Medicine, after all, was born in magic and religion, and the doctor-priest-magician-parent unity that persists in patients' unconscious cannot be broken. The placebo effect therefore attests to the power of the unconscious. (P. 40)

From the viewpoint of doctor, patient, and society alike, the belief in the omniscience, omnipotence, and omnibenevolence of the scientific healer is both indispensable and hazardous for all participants. What Edelwich and Brodsky (1982) write of psychotherapy obtains for all healer-client relationships universally: Therapy is a place where great hopes are raised—and sometimes dashed. It is a place where people may be thrilled or very disappointed with each other. The atmosphere of therapy lends itself to intense feelings, both good and bad. Here are two people w h o meet repeatedly, in some cases frequently, to discuss things that people usually talk about only with their most trusted intimates (if at all). (P. xvi)

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We could say that in abjuring the intimacy of the clinical relationship for that of objectivity, professionalism, control, and protective distance from patients, modern biomedical physicians considerably diminish their capacity to heal (see also Candib 1981). For they can best heal who permit themselves to suffer from their patients, not they who have the demeanor of an Aristotelian unmoved mover who interposes medicine between him- or herself and the patient. Kerenyi (1959) writes of Asklepios, the Greek god of medicine, son of Apollo: "He is assailed as it were by the sufferings of man which it is his vocation to assuage" (p. 23). To heal, we must first open ourselves to being "wounded" by the patient, that is, express a willingness to serve as a safe receptacle of the patient's suffering, to become emotionally touched or moved by the patient, and thereby to help the patient feel understood (rather than protecting ourselves from the patient by fending him or her off like an emotional hot potato). To help the patient, the physician must be able to feel along with the patient. The physician does not merely keep what the patient has given but returns it with empathy and lack of moralistic judgment, enabling what has been delegated to the physician to be integrated more readily in the patient.

GRACE, INTIMACY, AND THE CLINICAL RELATIONSHIP In a published interview (Candib 1981), G. Gayle Stephens, an intellectual leader of family medicine who had participated in a seminar with Michael Balint in 1969, emphasizes the importance for the family physician of becoming aware of the relationship between one's self and one's clinical work—including its consequences for clinical work. He contrasts procedural and episodic medicine (to which we would now add the industrial-corporate model, as is expressed in Diagnostic Related Groups, or DRGs) with the medicine that follows from the more difficult emotional engagement with patients "at the very extreme of your capacity, and maybe beyond your capacity" (p. 5). He expressed his earlier fear that "psychological-psychosocial issues in practice" are "too mysterious and too complex—that family physicians shouldn't get mixed up in them" (p. 5), accompanied by the fantasy that this work was for someone else, namely, the psychiatrist, to do. He continued:

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There was a fantasy in me, as well as in many of my colleagues, that people with psychological problems are fragile, and that you shouldn't probe around or you'll break them. That fantasy has some interesting psychological implication for the doctor—power and killing people, hurting people and all that. But Balint forthrightly dispelled that myth; he wouldn't even listen to it, and said in essence: "You know, you don't lack the time, you don't lack the skills—what you really lack is the nerve, the heart, to want to have this kind of intimacy with your patients." And he convinced me that that was so. At least that is the way I remember it. (P. 5) Just as countertransference can lead to defensive maneuvers that wreck the therapeutic alliance, countertransference can also be used by the physician to help the patient overcome suffering and terrible isolation. Here Stephens reintroduces the unlikely notion of g r a c e — borrowed without apology from religion—as a vehicle for inner and familial reconciliation. I don't necessarily mean that in a supernatural category. There is grace of people to each other, you know. . . . It means that there is no equality in the bearing of pain and suffering; there is no way you can ever equalize it. . . . somebody somewhere along the line has to find a way to deal with an inequitable amount of pain and suffering. Grace goes far beyond acceptance as a psychological construct. I can agree to "accept" you with all your faults, but there's a little more reservation about that: "I can accept you but . . ." Grace in its ultimate form says that there is nothing you can do to keep me from feeling a certain way about you. . . . Unconditional positive regard. Anything goes. The patient can bring anything to the doctor; nothing's too terrible, nothing's too shameful. It's all OK. That's a very important foundation of what I think family doctoring is all about. (P. 4) N o w developing the capacity for grace in any human being is as difficult as it is necessary, healing, and liberating. W e could say that the rigors of psychoanalytic training prepare the physician for the evanescent and imperfect capacity to extend grace to another human being. Yet that same preparation is designed to help the trainee to recognize the facility with which he or she can withdraw grace, so to speak, from the patient. W e may imperceptibly reject the patient, yet experience the patient as having fallen from grace. Even small threats to the stability of the self, to our defenses (anticathexes) against inner conflict, in any human relationship can lead

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to the self-protective withdrawal of empathy and thereby annul that protective bond of grace in which acceptance is unconditional. We idealize the Deity with the attribute of unerring perfection and constancy because of the utter impossibility of these qualities among us mortals. Unabating, unconditional grace is a wished-for state we project backward in time onto an idealized mother love and outward into immortal eternity and the Deity's love for humanity. Those who bestow grace must empty themselves of needs in relation to others; they must be vigilantly abstinent; they must not need others for their own desires. Analytic training is essentially a preparation for abstinence in relation to the patient (or analysand) and for the use of the analyst's own (countertransference) fantasies as they are evoked by the patient—but only for insight into the patient via the analyst, not for self-indulgence. The analyst must use the intrusion of his or her own unconscious into the patient encounter as a key to recognizing, understanding, and interpreting unresolved conflicts in the patient's own life. The more the physician seeks direct personal satisfaction from patient care, the more it is likely that emotionally charged issues will be avoided or acted out instead of felt and verbalized. What is notably absent in medical training, yet essential to a truly healing relationship, is an understanding of and access to those inner (unconscious) meanings prompted by the patient's behavior. Without this, the physician tends to make his or her positive regard punitively conditional, if not to withdraw it entirely (say, by abrupt referral or termination). In the Judeo-Christian tradition, we speak of the Deity turning away his face, the subject of Martin Buber's (1979) Eclipse of God. But the issue is universal, in healing relationships as in religion, by virtue of the fact that during our infancy the human face—especially the eyes—was the countenance that accepted or rejected. As essential as grace is to the positive countertransference side of the physician-patient relationship (and to all relationships), it is not and cannot be a state, a once-and-for-all accomplished fact. Only as we in the clinical professions come to live with our own imperfection can we accept imperfection in our patients and help them to understand intolerance in themselves. The use of exteriorizing defenses is commonplace in all human communication. Although countertransference always creates problems in terms of its consequences for patient care (together with the boomerang effect), it only disturbs physicians—that is,

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becomes an internal issue that prompts conscious examination rather than being more or less automatically acted out—when they can comprehend the meaning in themselves of what in a momentary lapse they had rid themselves of in order not to see. In other words, the greater capacity we have for intimacy with the self, the greater capacity we have for intimacy with another and therefore the greater our sense of disparity when we have momentarily cut another off. The more we can recognize the " m e " in " n o t m e " and include the " n o t m e " in the " m e , " the more we can acknowledge the humanity of others and help them achieve internal integration as well. The fact that family medicine has acknowledged the importance of the clinical relationship in all clinical work bodes well for the more self-aware approach to countertransference in medicine.

NOTE Portions of chapters 1 and 2 were published in "Physician-Patient Transaction Through the Analysis of Countertransference: A Study in Role Relationship and Unconscious Meaning," Medical Anthropology 6 (3) (1982):165-182. © 1982, Redgrave Publishing Co.

REFERENCES Adler, Gerald. 1981. The Physician and the Hypochondriacal Patient, New England Journal of Medicine 3 0 4 ( 2 3 ) : 1 3 9 4 - 1 3 9 6 . Binion, Rudolph. 1981. Soundings: Psychohistorical and Psycholiterary. New York: Psychohistory Press. Bion, W. R. 1959. Experiences in Groups. London: Tavistock. Boyer, L. Bryce. 1979. Childhood and Folklore: A Psychoanalytic Study of Apache Personality. New York: Library of Psychological Anthropology. Buber, Martin. 1979. The Eclipse of God: Studies in the Relation Between Religion and Philosophy. New Jersey: Humanities Press (orig. 1952). Candib, Lucy. 1981. An Interview with G. Gayle Stephens, M.D. Family Medicine 13 (6): 3—6. Carlyon, William H. In press. Disease Prevention/Health Promotion: Bridging the Gap to Wellness. Health Values. Chrisman, Noel J. 1977. The Health Seeking Process: An Approach to the Natural History of Illness. Culture, Medicine and Psychiatry 1:351—377. DeMause, Lloyd. 1979. Historical Group Fantasies. Journal of Psychohistory 7 : 1 - 7 0 .

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. 1982. Foundations of Psychohistory. New York: Creative Roots. Devereux, George. 1967. From Anxiety to Method in the Behavioral Sciences. The Hague: Mouton. . 1971. Art and Mythology: A General Theory. In Art and Aesthetics in Primitive Societies, edited by Carol F. Jopling. New York: E. P. Dutton. Pp. 193-224. . 1980. Basic Problems of Ethno-Psychiatry. Chicago: University of Chicago Press. Edelwich, Jerry, and Archie Brodsky. 1982. Sexual Dilemmas for the Helping Professionals. New York: Brunner/Mazel. Freud, S. 1910. Five Lectures on Psycho-Analysis. Fifth Lecture: Transference and Resistance. Standard Edition of the Complete Psychological Works of Sigmund Freud (SE). London: Hogarth Press. . 1911. Psycho-analytic Notes on an Autobiographical Account of a Case of Paranoia. SE. . 1912. Papers on Technique. The Dynamics of Transference. SE. Hall, Edward. 1977. Beyond Culture. Garden City, N.Y.: Doubleday/ Anchor. Hayden, Gregory F. 1984. What's in a Name?: "Mechanical" Diagnosis in Clinical Medicine. Postgraduate Medicine 75:1. Hippler, Arthur E. 1982. Review/Abstract of Ethnography and Psychoanalysis: Comparative Ways of Knowing (by E. B. Brody and L. F. Newman, Journal of the American Academy of Psychoanalysis 9 [1981]: 17—32). Abstracted in Transcultural Psychiatric Research Review 9 (3):176—177. Kardiner, Abram. 1939. The Individual and His Society. New York: Columbia University Press. . 1945. The Psychological Frontiers of Society. New York: Columbia University Press. Katz, Jay. 1984. Why Doctors Don't Disclose Uncertainty. Hastings Center Report 14(l):35-44. Kerenyi, C. 1959. Asklepios: Archetypal Image of the Physician's Existence. Bollingen Series LXV 3. Princeton, N.J.: Princeton University Press. Klein, Melanie. 1946. Notes on Some Schizoid Mechanisms. International Journal of Psycho-Analysis 27:99-110. . 1955. On Identification. In New Directions in Psycho-Analysis, edited by M. Klein, Paula Heimann, and Roger Money Kyrie. New York: Basic Books. Pp. 309-345. Kleinman, Arthur. 1980. Patients and Healers in the Context of Culture. Berkeley, Los Angeles, London: University of California Press. Kohut, Heinz. 1972. Thoughts on Narcissism and Narcissistic Rage. Psychoanalytic Study of the Child 27:360-400.

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La Barre, Weston. 1962. Transference Cures in Religious Cults and Social Groups. Journal of Psychoanalysis in Groups 1(1):66—75. . 1972. The Ghost Dance: The Origins of Religion. New York: Dell. . 1978. The Clinic and the Field. In The Making of Psychological Anthropology, edited by G. D. Spindler. Berkeley, Los Angeles, London: University of California Press. Pp. 259—299. . 1980. Personal communication. 20 September. Langs, Robert. 1978. The Listening Process. New York: Jason Aronson. Lasswell, Harold. 1930. Psychopathology and Politics. Chicago: University of Chicago Press. Modell, A. H. 1963. Primitive Object Relationships and the Predisposition to Schizophrenia. International Journal of Psychoanalysis 44:282—292. Newsweek. 1981. When Doctors Play God. 31 August. Pendagast, Eileen G., and Charles O. Sherman. 1977. A Guide to the Genogram Family Systems Training. The Family 5(1):3—14. Reich, Annie. 1951. On Counter-Transference. International Journal of Psychoanalysis 32:25—31. Sackett, D. L. 1976. Introduction. In Compliance with Therapeutic Regimens, edited by D. L. Sackett and R. B. Haynes. Baltimore: Johns Hopkins University Press. Pp. 1—6. , and J. C. Snow. 1979. The Magnitude of Noncompliance. In Compliance in Health Care, edited by R. B. Haynes, D. W. Taylor, and D. L. Sackett. Baltimore: Johns Hopkins University Press. Pp. 11—22. Schatzman, Rochelle I. 1983. Comment on "The Myth of Altruism" (by Henry Lawton, Journal of Psychohistory 9[3], 1982). Journal of Psychohistory 10(3):381-387. Spiegel, John. 1971. Transactions: The Interplay Between Individual, Family and Society. New York: Science House. Spiro, Melford. 1982. Oedipus in the Trobriands. Chicago: University of Chicago Press. Stein, Howard F. 1981. Family Medicine as a Meta-Specialty and the Dangers of Overdefinition. Family Medicine 13 (3): 3—7. . 1982a. Adversary Symbiosis and Complementary Group Dissociation: An Analysis of the U.S./U.S.S.R. Conflict. International Journal of Intercultural Relations 6:55—83. . 1982b. The Annual Cycle and the Cutural Nexus of Health Care Behavior Among Oklahoma Wheat Farming Families. Culture, Medicine and Psychiatry 6(1): 8 1 - 9 9 . . 1982c. The Ethnographic Mode of Teaching Clinical Behavioral Science. In Clinically Applied Anthropology: Anthropologists in Health Science Settings, edited by Noel Chrisman and Thomas Maretzki. Boston: D. Reidel. . 1982d. "Health" and "Wellness" as Euphemism: The Cultural

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Context of Insidious Draconian Health Policy. Continuing Education for the Family Physician 16(3):33—44. . 1982e. Man the Computer. Continuing Education for the Family Physician 16 (3): 19. . 1 9 8 2 f . Neo-Darwinism and Survival Through Fitness. Journal of Psychohistory 10(2):163-187. . 1982g. Wellness as Illusion. Delaware Medical Journal 54(11):637—641. , and Robert F. Hill. 1984. American Medicine and the Enchanted Machine. Guest editorial. Continuing Education for the Family Physician 19(8):428-430. , and Soughik Kayzakian-Rowe. 1978. Hypertension, Biofeedback, and the Myth of the Machine: A Psychoanalytic-Cultural Study. Psychoanalysis and Contemporary Thought 1 (1): 119—156. Trostle, J. A., W. A. Hauser, and I. S. Susser. 1983. The Logic of Noncompliance: Management of Epilepsy from the Patient's Point of View. Culture, Medicine and Psychiatry 7:35—56. Volkan, Vamik D. 1979. Cyprus—War and Adaptation. Charlottesville: University Press of Virginia. Whiting, John W. M. 1961. Socialization Process and Personality. In Psychological Anthropology: Approaches to Culture and Personality, edited by F. L. K. Hsu. Homewood, 111.: Dorsey Press. Pp. 3 5 5 - 3 8 0 .

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Some Common Themes in Countertransference and the Situations That Evoke Them

Familiarity over time with any historical group (such as a family, institution, hospital ward, therapy group, all-encompassing culture) leads invariably to the identification of recurrent themes or patterns. Initially, the issue is one of descriptive accuracy: Am I certain I am not selecting only what I wish to see? Am I perhaps overemphasizing certain things and minimizing, if not altogether omitting, others? Are these patterns and themes truly pervasive or do they cluster mainly in one segment of the group? After we have been able to address all of our self-disciplined self-doubts, we may begin to act as if these themes and patterns are truly present—especially if they continue to force themselves on our perception, that is, if they start to feel redundant. The next phase (although the descriptive phase really never ends, since ideally we look for confirming or disconfirming data all the time) is attempting to explain or account for what we have observed. In this chapter I consider a number of frequently encountered themes in physician countertransference, the kind of situations in which these themes come to be played out, and explanations for their presence (as opposed to others). The medical reader will surely detect in my ethnographic account so far the familiar medical methodology of clinical pattern recognition and differential diagnosis (which combine a labeling of the kind of phenomenon we are dealing with and the most likely explanation of the cause and history of that phenomenon). Although the subject matter of this 65

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chapter may be initially foreign to many medical readers, the method I use is virtually identical to theirs. The central countertransference themes I discuss here are aggression and control; loss, dying, and death; oedipal conflicts; stigma in medicine; and what might be called countertransference by omission, that is, countertransference themes which I might observe but which physicians have not regularly brought to my attention or which they have preferred not to discuss. Finally, I briefly address a paradox of contemporary medical education, which ensures that the subjectivity that is not taken account of in medical training will result in the return of the repressed in later practice.

ANGER AND CONTROL: CLINICAL TABOOS OR CLINICAL TOOLS? Faced with failure to cure disease or to prevent death, physicians often reproach themselves saying, " W e ' r e just not aggressive enough." Feelings of clinical inadequacy heighten aggressive fantasies applied to the solution of clinical problems—which, should success not materialize, are directed toward the patient. Such aggression does not simply follow on the heels of frustration to achieve goals (as in the frustration-aggression model in psychology), but rather aggression is released when the physician's idealized self is imperfectly mirrored by the environment and his or her ambitions are thwarted (see Kohut 1 9 7 1 , 1 9 7 2 ) . Aggression is mustered in defense of self (see Rochlin 1 9 7 3 ) . This would also seem to explain at least partially physicians' difficulty in saying no to patients (for example, turning a patient down, denying a patient's request) or giving up effort (as with a dying patient). As one family physician said, " T o say no is to admit defeat" (from notes of 1 April 1 9 8 3 ) . The reversal of disease process, patient recovery, satisfaction, and compliance are measures of physician competence; saying yes is often used by the physician as a means of receiving reassurance from the patient.

Vignette 1: The Problem of Anger and Aggression Clinicians at times resort to various compromises, ruses, and rationalizations to express or discharge anger toward patients with-

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out appearing—in their own eyes and in others'—to be doing so. One resident relates the following, not atypical, case: A woman comes to the emergency room at 3 A.M. with a complaint of nausea and vomiting, or perhaps insomnia, complaints which she could have made by phone or by walk-in at the clinic some six hours ago. Now it's part of the physician's duty that, when on call, he is to come to the hospital when summoned. But some patients really take advantage of you. It doesn't much matter to these experts at manipulation what you say. If you tell them you're angry with them, or tell them they're angry with you, it won't make a difference. So what you can do is give this lady a Phenergan suppository, or have the nurse administer it to her. First of all Phenergan really works. Secondly, you're not hurting her. Thirdly, you're able to stick it to her and get some of that anger out. It even says in the Bible, "Be angry, but sin not." So, I'm satisfying her needs and taking care of my own at the same time. What's wrong with that? (From notes of 27 July 1981) W h a t Devereux ( 1 9 6 7 ) writes of the anthropologist applies with equal force to the physician: The scrutiny of alien cultures [read: "different" patients] often forces the anthropologist [read: physician] to observe, out in the open, much material which he himself represses. This experience not only causes anxiety but is, at the same time, experienced also as a "seduction." It suffices to think in this context of the problems which may confront an anthropologist, obliged to support his aged parents out of a small income, who happens to be studying a tribe where filial piety obliges one to kill one's old parents. (P. 44) T o Devereux's example the physician in this culture could surely add a number of additional "seductions": the indulgence of impulses, the enticement of exploitation, the attractions of dependency wishes, the blandishments of aggressive fantasies, the spell of pure subjectivity. W e can only be seduced by another whose actions correspond to our own forbidden wish. W e are never so repulsed as when we are attracted, and we envy those who get away with deeds we ourselves dare not commit. This accounts for why, on occasion, clinical judgment can be so moralistic. Moral condemnation finds its way into a scarcely disguised punishment of the patient. W e must punish others to sustain our own repressions—our hostility safeguarding our vulnerable selves (Rochlin 1 9 7 3 ) .

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Moreover, when we do acknowledge the power of the unconscious in the physician-patient relationship, it is usually the patient's transference to which we pay attention, insofar as it influences the patient's unrealistic expectations, demands upon the physician's time, compliance, outcome of treatment, and so on. We give little attention to those beliefs, attitudes, values, expectations, explanatory models, needs, fantasies, and conflicts that we unconsciously bring to, impose on, and act out within the doctor-patient relationship. The unspoken assumption is that patients will indulge in transference because they lack sufficient education and the objectivity that comes with professionalism, whereas physicians have put themselves through the rigor of medical school and residency and have trained themselves in the proper therapeutic distance, selfcontrol, detached neutrality, and communication skills. Physicians tend to see transference as a weakness or indulgence to which patients succumb but to which physicians are immune. For it is of the essence of medicine—not only in the biomedical model of the West but everywhere—to strive to master the natural and supernatural forces of life and death, a tall order for any human being. Inhabiting a world seen as both arcane and awesome, physicians come to be viewed and view themselves as masters of nature; they are even expected to be above nature. Yet the personal and social cost of trying to embody these austere expectations is attested to in widely cited data on the higher than average morbidity and mortality of physicians on such indices as alcoholism, suicide, heart disease, and so on (Time 16 February 1981) (see Scheingold 1981, for a report on dreams of family physicians). In this respect, the physician comes to the patient encounter with no better training than does the patient, for the type of training provided in medicine—even now—does not equip the physician to recognize, work through, or use countertransference. Medical education rarely addresses what the physician has in common with the patient but instead works to instill a sense of difference, in role as well as in person. Medical training furnishes profoundly confirming instrumentality and authority to the wish, if not conviction, that "I am in control" ("of the situation and of myself") or "I should be in control," while making the physician especially vulnerable to being out of control. Compulsion sows further obsessiveness, and both heighten the danger of failure. The solution intensifies the original problem.

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What Schatzman (1983) writes of social workers applies in full measure to physicians: The social worker's desire to help is recognized as a manifestation of the social worker's need to control irresponsibility and disorderliness in himself, thereby gaining self-approval, and possibly the approval of society (parents). We see the undesirable impulses in his intense efforts, in his extreme efficiency, in his "selfless" devotion to duty, in his moral rectitude. The need to strenuously control his o w n impulses is revealed by the sternness of the demands he places on himself. (P. 382)

For the physician, the conquest of disease and the control of the patient often not only serve the unconscious function of defending against loss and separation anxiety but also have as their aim the control of impulses and the exercise of fantasies of omnipotence (as a means of repairing the loss). Medical power is often brought in the service of preserving a tie that in turn serves as a representation of a relationship. A component of that relationship is thus rooted in projective identification. For the physician, as for the divine, perhaps the paramount issue lurking behind control is that of saving or redeeming. He or she needs to be in control to be able to save the patient. Through the patient, the physician can redeem the buried self, repair the injured mother, restore the lost mother-infant unity, rescue the despoiled parents—all buried in the unconscious. Medical compliance issues cannot and must not be reduced to characteristics of the physician's personality. The physician may indeed be far more realistic than the patient (or patient's family) yet feel severely constrained by the patient's actions—and still be publicly held responsible for the outcome. Realistic issues, however, can likewise intensify psychological ones. I recall an incident in which a family physician ordered his nurse to administer an injection of refrigerated penicillin to a patient whom he suspected of having a venereal disease. He justified himself by saying, "Maybe that'll teach him a lesson." Likewise, when a boy had been brought into the emergency room after having ingested several ripe holly berries, the physician delayed the gastric lavage, prolonging the youngster's discomfort, and rationalized his action by saying, "Maybe this'll teach him not to do it again." With patients who are noncompliant or who frequently resort to the hospital emergency room for their care, physicians may couch

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retaliation or punishment in conventional medical procedure. For instance, they might aggressively employ the interview technique of confrontation. Alternately, they may resort to a variety of intrusive, if not painful, clinical measures to punish the patient: the rectal exam that is so often deferred in more routine physicals in the clinic and hospital, the prescription of a suppository, or the administering of an injection rather than oral medicine. It should be of little surprise that in a culture preoccupied with excremental functions and their control, much of medicine's anxious (and most creative) humor concerns ways of confounding patients' anal sphincter muscle from without. In any case, the goal is to turn the tables, to exact an emotional eye for an eye and tooth for a tooth, to make the patient as uncomfortable as the patient makes the physician. The momentarily triumphant feeling of "I gotcha" turns a sense of inferiority into one of superiority, of powerlessness into power, or passivity into activity. The physician who has felt exposed and degraded by another now has a moment of revenge. By punishing the patient, the physician can at least temporarily reestablish a sense of control, regain status in his or her own eyes, and set the emotional scales in balance. In " T h e Dedicated Physician" Searles (1979) makes the point that the therapist may unwittingly torment his patient by his very determination to cure him no matter what—that is, no matter what the patient must be put through. The obverse of clinical altruism is a sadomasochistic quality in the physician's relationship with patient (not to mention staff and family). Not only does masochism mete out punishment to the self for unconscionable aggression but also self-effacement and selfless devotion to patients often becomes self-destructive. The face of an exacting, unforgiving, and unrewarding (since virtue is supposed to be its own reward) altruism is often revealed as the mask of masochism—which in turn masks the anger against which it defends. The prohibited impulse to hurt is imperfectly reversed (by reaction formation and undoing) into the compulsion to heal. Consequently, empathy toward the patient is impaired to the degree that clinical work serves for the physician the function of the repair of the self and the shoring up of repression and reaction formations (see Lawton 1 9 8 2 ; Symposium 1983). For physicians, unconscious determinants of role choice resonate mercilessly with chronic role stress to make anger and aggression a formidable problem. T o make matters worse, the physician's code

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of professionalism makes it even more difficult for a physician to discuss his or her feelings among medical peers (aggressive humor is virtually the only outlet). The sense of isolation further bottles up and intensifies the aggression—and the fear of its expression. Just as in preliterate societies healers were suspected of being also (at least potentially) witches, so in Western society physicians are suspected for their potential malevolence as much as they are respected for their curative powers. Moreover, just as in traditional cultures the decompensated healer lays bare the aggression which he or she can no longer control, perhaps the high incidence of drug abuse, alcoholism, depression, and suicide among physicians might be in part explained by the underlying aggression that can no longer be masked by the need to combat disease (see Devereux 1980). Medicine's fundamental maxim would seem to bear out this speculative interpretation. Primum non nocere, "First do no harm," is a universal proscription, whose existence attests to its opposite. Where there is no temptation or danger, there need be no rule or taboo. If clinical success helps to shore up a physician's obsessional defenses, clinical failure often unleashes a merciless superego rage within the physician—one that commonly finds an outlet in the "flawed" patient. The worst offenders of physicians' sense of adequacy are patients categorized as hypochondriacs, depressives, the chronically ill, the terminally ill, drug addicts, and alcoholics. What Adler (1981) writes of the hypochondriacal patient is surprisingly appropriate for many health practitioners: Their sense of self-worth is shaky and easily disrupted, and they are vulnerable to feelings of incompleteness in that a solid sense of their identity depends on the presence of another person. Often, without conscious awareness, they turn to the other person to provide functions that are not solidly established in themselves. (P. 1 3 9 5 )

Just as patients may seek from their clinicians and from treatment affirmation of their worth and completion of their wholeness, clinicians may seek similar validation from their patients through the patient encounter. Physicians often experience clinical failure as a personal assault. "The failed patient is the failed physician" is a frequently heard judgment of physicians themselves. The means to avert failure and to recover from failure both come to rest in the

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patient; that is, the patient can come to mirror the clinician's needs, expectations, fulfillments, and disappointments and to function as an extension of those aspects of the clinician now experienced as located within the patient. The patient whose disease is diagnosed as being out of control can also be experienced by the physician as an uncontrollable part of his or her own self. When the patient cannot (because, as we often feel, the patient will not) confirm the self-worth of the clinician and complete the clinician by recovering or complying, the clinician commonly expresses some disguised form of anger toward the patient. That anger is an attempt to eject some " b a d " part of the physician into the patient and be rid of it by being rid of the patient. If the patient on whom the clinician depends to complete that solid sense of identity, that wholeness of self, does not do so, then the clinician commonly finds some way to protect him- or herself against feeling incomplete—for example, by denial of loss and grief, rejection of the patient as having a poor character, and so on. In my experience, those patients whom clinicians "turf" (refer to another physician or service in order to be rid of the patient) are invariably assigned zoomorphic, demonological, or part-object sobriquets: "gomers," "turkeys," "albatrosses," "crocks," "trolls," "SPAS" (Subhuman Piece A—of—Shit). These terms are by no means restricted to difficult patients having only mental problems and functional complaints but include "management problems" who have organic and chronic disease as well. The medical quest for diagnostic exactitude in naming the disease involves more than the search for scientific truth, for diagnostic accuracy is a means toward the eventual mirroring—or its failure— of goodness, wisdom, and benevolence through cure of the patient. A veteran family physician angrily said, "We're always afraid something is going to happen and we're going to be blamed for i t . . . We're chained to a $ 2 5 , 0 0 0 machine [ultrasound, for assessing pregnancies]. Are we going to let lawyers practice medicine?" (from notes of 2 9 April 1983). The public is as obsessed with diagnoses as is medicine—and for similar reasons of using medicine to mirror and repair the cohesiveness of the self. Imperfection in such mirroring and "putting Humpty Dumpty back together again" is reflected in physicians' alternate turfing and appeasing of difficult patients and in the public clamor for revenge in the form of malpractice litigation. As a result, physicians become increasingly aggressive

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in treatment and endeavor all the more strenuously to achieve patient satisfaction. Recently, a family medicine resident and I left a marital counseling session quite dejected. We had been working with a couple for several months and had until now felt satisfied with their progress within a destructively symbiotic relationship. On this occasion, however, the wife openly talked of her uncertainties about the marriage, her thoughts of separation and possible divorce. The session had been productive, but the atmosphere was one of foreboding and sadness—a sadness that we dealt with in the therapy. After the conclusion of the session, the resident and I discussed the session (as we customarily do). He said, "I feel badly, because today I don't feel that we did anything for them." I replied, " Y o u mean, they didn't do anything for us." He abruptly lifted his head, eyes wide open: "That's it!" he exclaimed. We proceeded to distinguish between our problem and their problem, to identify those fantasies and expectations which we brought to the counseling situation and that affected our goals and attitudes. It was one of the most moving discussions of countertransference I have had—and this with a physician who although deeply caring about his patients insists on keeping a considerable emotional distance from them. Our emotional closeness to them, however, had slipped out in our despair. The question was whether we would analyze it or act on it. I broached the issue of the resident's fantasy of the ideal marriage, the resident's own family situation, our inclination to flee from sadness, to try to gloss it over and patch up things and relationships. This vignette illustrates the blurring of the boundaries between patients and clinicians, clinicians' unconscious use of patients as external defenses against recognizing their own conflicts (in this case, over marriage, separation, and loss). Through countertransference to our patients, we momentarily shore up our own completeness at the expense of theirs, and the reverse is true for their transference to us. By substituting our problems for theirs, we unconsciously attempt to solve our problems through our patients, becoming angry or depressed when they slip through our grasp, when suddenly they mirror our dread rather than our hope. Our own investment in the treatment makes us vulnerable to unspent rage when our benevolence, goodness, and competence are challenged. During one family medicine grand rounds in 1 9 8 1 , in

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which seven residents, several attending physicians, and I participated, a discussion of demanding, manipulative patients elicited considerable group anger and caustic humor. The types of problems under discussion included (1) "patient abuse of the emergency room when they don't need to be seen . . . when the problem is not acute"; (2) "when patients come in with a headache, demanding specific medicines—Darvon and Vistaril . . . " ; (3) "patients don't have to pay at the ER, but must pay at the clinic, so they go to the ER where they know they'll be taken care of no matter w h a t . " In situations such as these, I try to avoid taking sides or advocating either the patient's or the clinician's definition of the situation (such as what is or is not acute) but try to discern how each contributes to the problem, help each understand if not accept the other's perception of the situation, and work toward a resolution that acknowledges both perspectives. It is my experience that family medicine residents and care-givers in general have considerable difficulty in drawing the line between how much they will do for and with patients, in ER, clinic, private practice, and so on. The difficulty stems at least in part from the wish to cure and rescue, which in turn leads them to overdo and overcommit because their self-worth is now bound up in the patient's progress. Residents often feel guilty for not doing even more than they already do, for not devoting themselves more to their mistress Medicine, feel inadequate, and finally resolve the discrepancy between their idealized self and their actual self by ascribing the responsibility for their sense of failure to their patients. If the clinician feels unable to say no to a patient, to set limits rather than continue to feel overwhelmed without protest, to confront the patient with the patient's own feelings of anger or despair (which the clinician must be simultaneously experiencing), or to make room for other needs of the self without feeling unprofessionally selfish (and in turn remorseful and resentful), then the physician will feel virtually compelled to resort to hostile subterfuges to wrest a small, regressive victory from what he or she experiences to be a great defeat. These small retaliations and fleeting catharses certify that the cycle of frustration and vindication will be repeated. By gaining insight into and working through injuries to our self-esteem and sense of competence, by coming to understand the influence of the past upon the present, and by understanding the need to recapitulate painful old experiences, we can halt the vicious cycle.

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Much of the recent self-help literature and audiovisual aids to family practice residents and practitioners that encourage catharsis and the formation of support groups misses the point that most social groups everywhere tend to support one another's acting out, that is, sanction one another's displacements and exteriorizations. In undergraduate medical education and residency training, we can begin to correct this self-defeating situation by providing regular individualized and group forums (such as "Balint groups") at which students and residents are given permission by their faculty to share and make sense of their feelings toward patients. For if projection can boomerang, so likewise can professionalism. T o acknowledge anger toward patients is especially threatening, first, because the expression of anger, like that of other feelings, is often experienced as proof that the physician is acting unprofessionally—is not in control of his or her emotions and is therefore unable to keep an objective distance from the patient—and second, because the feeling of hostility toward a patient conflicts with the physician's ego ideal and self-image as one who is devoted to the health and welfare of his or her patients. The physician who must be omnibenevolent therefore must never be angry. When I have asked physicians what they do with the anger aroused by patients, most often they vehemently deny even having the feeling, or if they acknowledge it, immediately justify it by blaming the patient. La Barre (1978) eloquently writes: The psychiatrist must know himself, through a rigorous and often painful didactic analysis, for he will not be able to see in his patients what he cannot afford to see in terms of his own defenses. (P. 2 6 9 )

This wisdom obtains as much for the family physician as for the practitioner of official psychological medicine—because all medicine is communication and all human communication is open to transference distortions. Because of the human tendency to perceive and experience others as extensions of ourselves (Hall 1 9 7 7 ) , we can readily come to treat the patient with our own dis-ease. Devereux (1980) goes so far as to suggest that diagnosis itself is used to deny that the self is impaired, achieved by differentiating categorically between the person doing the diagnosing and the person diagnosed. Incidentally, this would appear to be the unconscious basis for much of the stigmatization described by labeling

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or attribution theory. Diagnosis shores up the psychological boundary between the (diseased) other and the (normal) self, the diagnostic label being used to disprove the fear that "what is wrong with you is also wrong with me." Clinician and patient alike are part of the clinical data, but physicians often use diagnosis to draw the boundary more distinctly than it actually is.

THE FEELING OF BEING OVERWHELMED: THERAPEUTIC AND COUNTERTHERAPEUTIC RESPONSES Here is a highly typical clinical situation certain to be frustrating, depressing, and anxiety evoking. About to enter the examination room or counseling office, the physician notices several charts clumped together for brief review before meeting the patients. The physician feels overwhelmed even before starting and dreads being engulfed by the family's demands for time—even more, by their neediness. The physician glances at a clock and out into the waiting room and realizes that he/she is already several patients behind. . . . The therapeutic response to the feeling of being overwhelmed by the family is first to acknowledge the presence of that feeling and not try immediately to dislodge it by blaming the family or trying to gain immediate control of them. The physician then might say, "You must be feeling overwhelmed . . . , " which frequently has a positive effect on the patient or family, who feel understood and accepted: "You know what we're going through then." In these situations physicians examine those feelings within themselves that the patient or family is imposing; they do not fear these feelings because they do not fear their own. In a sense, these physicians use a thermometer reading of themselves to assess their patient's fever. They use personal feelings rather than defend against them. The countertherapeutic response is the opposite. It either rejects the patient's or family's feelings (negative countertransference) or indulges them by manipulating (positive countertransference) those feelings. An extreme expression of negative countertransference would be to make an immediate referral to be rid of the "noxious" patient or family; an extreme expression of positive countertransference would be to undertake heroic efforts to take responsibility for family dynamics and to attempt to rescue the family. In either case, the impetus to do something is a flight from feeling and

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memory into action: it is not doing something per se that is the mark of countertherapeutic countertransference but the unconscious motivation, signaled by anxiety, behind taking action. The defensive process can also take the form of affect substitution that results in the release of emotion inappropriate to the situation; for example, feeling overwhelmed, the physician substitutes anger and the struggle for control for the anxiety this produces. The therapeutic response to the feeling of being overwhelmed by what the patient or family is saying (or doing) begins by first internalizing, then testing inside ourselves what the patient or family has introduced, and finally returning an understanding of them based on our self-understanding. We struggle to stay emotionally with the patient or family. The countertherapeutic response to the feeling of being overwhelmed is to engage in feelings and behaviors that are directed toward protecting ourselves against the patient or family.

THE INSULT OF DEATH Death is the great disrupter of life. Often personified as an intruder, death defies human control. Even in our skeptical, largely secularized world, death arouses horror. Much thanotological and frankly antimedical writing notwithstanding (see Aries 1974), ours is hardly the first culture to refuse to accept death: We differ from others only in how we refuse. As Freud (1919) pointed out, to experience the dead is everywhere to experience the uncanny, the antithetically secret and familiar. Encounter with death and near death conflates life and death, raises old doubts about whether the animate is really alive, and conversely, whether what appears lifeless may not in fact be alive. Death confounds fantasy and reality, self and other, animate and inanimate. Death mocks all our certainties and pretensions—in the face of which insult we strive all the harder. In medicine we have succeeded in convincing ourselves that death is ««natural, that it occurs only because we overlooked some test— or because we have not yet found the cure. The more our entire culture becomes medicalized, the more we turn to medicine for a cure—even for the "disease" of mortality. Life itself becomes a condition. Yet the need to outwit death is but one cultural defense

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against accepting the finality of death, the final affront and the limitation to our hard-won intentionality. It makes grim sense that the first "patient" whom most medical students greet is a cadaver: So much is the struggle with death a part of medicine that a defense against the uncanny—the secretly familiar—must be begun in the first initiation rite of medical school. Students learn h o w to deal with animate by first contending with the inanimate. It is their first lesson in depersonalizing the personal—self and object at once. Increasingly, it becomes emotionally safe to act toward patients as though they were inanimate things, reducible to complexes of mechanical or information feedback processes. Clinicians learn in earnest to make the Cartesian split between mind and body, between reason and sentiment, and do their best to keep them from being joined thereafter. Only in this way can they dissect a human corpse with as much impunity and dexterity as others take to repairing automobiles. If life is seen to be a machine, or more recently a computer, then the difference between life and death is reduced to a mechanical function—or malfunction. When such functioning becomes the only criterion for life—or, for that matter, health—we then experience what we call psyche, sentiment, or feeling to be an uninvited and unwelcome guest into the conceptual house we have so painstakingly built. If, however, we allowed those buried uncertainties and feelings about the living and the dead once again to be confirmed by the clinical experience—the emergency room, hospital rounds, the delivery room, the nursing home—we might not have to spend so much time and energy trying to surmount them (cf. Freud 1919). We divulge our obsessive fascination with the emotionally uncanny through its opposite: more or less exclusive interest in the biomedically bizarre and exotic. It is a way of keeping our secret while telling it. Instead of knowing directly (with the full impact of unsettling emotion) the secret that we have been keeping from ourselves (the uncanniness of death), exclusive contemplation of biomedical detail is one way of having constant access and proximity to the secret, experiencing the secret in an acceptable compromise symbol (disease entities, medical diagnosis and technology, and so on) and at the same time distancing ourselves from our own frightening secret: that we stand in the awesome presence of death. N o w focused attention is not necessarily defensive; it is when such specialization is used for the purpose of not looking at certain

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other types of scientifically or clinically pertinent data that it becomes so. In this case, we look in order not to see, for recognition would be too painful; and such recognition is always, at least in part, self-recognition. Physicians often feel compelled to pursue the disease process aggressively down to the bitter end. Medicine's constant refrain is " Y o u have to keep going like the patient's going to make it."

Vignette 2 : Dying and Loss Situations in which actual death occurs or the frailty of life starkly reveals itself evoke massive countertransference responses. Consider the following examples. At a family medicine grand rounds in 1981, a resident physician presented the case of a bedridden, hospitalized ninety-two-year-old woman, who sometimes recognizes and sometimes does not recognize her family. The family say they wish to pursue the idea of a nursing home for her, but they make few efforts to do so. They are seemingly waiting for her to die and at the same time want the hospital to make her well. The woman wants to be allowed to die in peace. Added to the patient's wishes, the family's wishes (ambivalent), and the attending physician's concern for mounting unjustifiable medical costs for this hospitalization is the other physicians' reluctance to allow her to die. One family practice resident said with exasperation, " H o w can you just let her lie there, when you want to pursue it—to make them well. There must be some intervention or further workup. You want to resort to aggressive measures, not just stand there and do nothing." Here, whatever ethical issues might cogently be brought up, the physician's resistance is to death itself. To give in to death is to be vulnerably passive, to resign oneself, to let go of one's need for control. Death is not natural, it is a personal affront. In the face of death, the physician wishes to be active all the more. At a family practice grand rounds shortly thereafter, a resident physician presented the case of an obese, borderline diabetic, thirtyfive-year-old woman whose pregnancy had been quite normal but whose baby was born dead. The baby was called a stillbirth, but those present quickly emphasized that the word only described the birth but did not explain it. The group intensely pursued the need to explain, as one physician said, "to have all the facts in." A senior physician posed a crucial question: "What do we tell the

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mother?"—and looked at me after the rest of the group expressed dissatisfaction with its answers. He continued, "Physicians are supposed to be omniscient and omnipotent." The room was silent. Then he turned to me. "Howard?" Very much put on the spot for the answer, I replied, "I'm not biting on that worm! Because I know what the hook is. 'We did our best,' I think that is all one can say. Our empathy, the fact that we cared, is what counts—not that we tried to be gods. You'd like for me to come up with an omniscience and omnipotence for you. I don't have it—no one does." Later that day the resident physician who had cared for this woman and her family during the pregnancy and who had delivered the dead baby talked with me about what was still unresolved within him: his loss. We talked of his need, as much as the mother's and father's need, to work through the loss and not to replace his own grieving with a frantic search for disembodied facts. He reviewed all that had been done, the backups, and the fact that they just did not know why the baby died. The risk factors (age, obesity, diabetes) might help explain it, but save for an autopsy (and perhaps not even with it), all the facts would never be in. Misty-eyed, he said that he really liked this couple, that they had gone through a model pregnancy, that the woman's mother had really looked forward to a new grandchild—but had died six months ago. As he spoke, the words unfulfilled promise came to my mind, and I referred to the baby as an unfulfilled promise to the parents and the maternal grandmother. With a look of recognition, he said those had been exactly the words that had been going through his mind the past several days. He began to use the feelings released by this tragedy to understand his patient, the patient's husband, and himself. He had felt a great loss—less a blow to illusions of omniscience than an unwelcome expression of life's frailty. He wished to talk with me because he knew that his own work with this case would not be through until he grieved, until he mourned whatever unfulfilled promises the baby represented for him. The third case, not unlike the first, involves a death-in-life situation. Some years ago, during family practice hospital rounds, a troupe of some six residents and attending physicians entered the room of Tillie, a seventy-five-year-old woman with an enlarged heart, congestive heart failure, and poor circulation, who showed confusion and episodes of alertness alternating with long hours of sleep accompanied by loud snoring and coughing. During hospital

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rounds, we were usually quickly in and out of a patient's room, spending at most ten minutes discussing and palpating an "interesting" patient. On this occasion we stood around grimly for thirty minutes. Physicians shouted in her ear, trying unsuccessfully to arouse her. One attending physician said to the resident in charge of the case that he would sign an order for no CPR or resuscitation if a resident would write it. A resident, commenting on Tillie's mucosal cough, said quietly, "She'll probably get some of that in her lungs. I'd suction it myself. Still, they say pneumonia is the old person's best friend. Maybe that will take her." We continued standing, as if immobile. The resident responsible for her care kept looking through the chart, agonizing, "I keep thinking that I've missed something." He told us that all of Tillie's relations were out of state, in contact only by phone. The doctors were her family—which made for a problem of responsibility. Tillie's family did not want to take the reponsibility for her care or death. The resident said that Tillie's heart had expanded so much that there was no more room for it. He spoke of her advanced stage of arteriosclerosis. Someone else said that Tillie had sat up an hour earlier and had been fed—but she rallied less frequently and for shorter periods. Everyone continued standing around, someone mentioning or searching for some particular medical detail. Technical matters of diagnosis, management, and disposition predominated as the group struggled with its own sense of helplessness. Death was never mentioned. It was taboo. We left the room as though emerging from a pall. Later in the day I spoke with the physician responsible for Tillie's care. Never quite detached despite himself, he said that he had known her for three months, ever since her first admission to the ICU for congestive heart failure. At that time, he recalled, he felt, "We're going to lose Tillie. The family gathered around—the only time they came. Then she bounced back and was discharged to a nursing home. Two months later, her second admission, the same thing, and she bounced back again. Then she was out of it—unarousable, just like you saw her today. After each attack she was less with it. Her memory's deteriorating." He spoke with exasperation, not knowing where next to turn, yet wanting to be able to do something. At a joint case conference of family physicians and pastoral counselors some three weeks later, part of the dialogue went as follows:

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Physician A [responsible for Tillie]: I know how bright and friendly Tillie was between these episodes . . . You want to try to get her back to the way she was. Physician B: You felt helpless, frustration at not being able to do a little bit more. Physician A\ Our treatment was a lot of meds to get the fluid off her lungs. It worked in the past. [Discouraged] Such a bad heart, a limp plastic bag. Most people with such bad hearts don't recover between episodes like her. [Voice brightens] She talks of going fishing with John [Tillie's boyfriend]. When she's alert, she even has good recent memory. [Voice darkening again] It's hard to see her lying there sick when you can't do anything. [Brief laugh] John shaves Tillie—you ought to see them together! Reverend A: What to do when there's nothing you could do? Physician B: Frustration . . . the limit of what we can do. Frustration, it's hard not being able to intervene, hard to accept that you can't do anything. Physician A\ At least death's an end point. People with emotional problems live a life worse than death. Reverend A: The word clears the air: "Death," at last someone's said it. Physician C: The patient doesn't want you to be there and hold hands, but expects the physician to do everything up to the last possible moment. . . not to stand aside and let the patient die. [This is said by a physician generous with his support and caring, belying his emphasis on technical prowess.] Reverend A: I think you'll find that Tillie does . . . Physician A [interrupting]: I don't even want to hear the name "Tillie" again . . . I'd feel phony holding hands with a dying patient. Since medical school, I've kept my emotional distance from patients. The trouble is that there's no answers. [He recoils from the possibility of emotional closeness and reintroduces the theme of a search for answers.] Physician B: There you are, there's nothing else to do, but you've got to do something. [A poignant summary of the impossible requirements of the exclusive emphasis on doing.] A week later the physician who wished to banish Tillie from his memory came to my office and announced, " I have some good news

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and some bad news . . . Tillie died. She was back at the nursing home. The nursing home called to tell me." I asked him how he felt about it. He replied, I hate to say it, but I'm glad she died. I knew how alert she could be, and it was just terrible to see her struggling like that for her breath when she'd go into congestive heart failure. You know, that heavy breathing? And she'd stop breathing for fifteen seconds or so, and you'd wonder what would happen next. Then she'd breathe heavy again. She doesn't have to go through that now, and I'm relieved. You try not to get that attached to your patients, 'cause it could really tear you up. Still, she got to you. With a patient like that, it's better off that she died.

I said that I thought it important that he mull over his various feelings about Tillie rather than try to bury them in technical matters, that it sounded as though he felt that Tillie could be a delightful person—a person whose appeal he responded to. His earlier statement about not becoming attached to patients should not be taken at face value but should be recognized as an increasingly feeble defense against accepting his own feelings—that is, acknowledging and putting to use his countertransference. I briefly mentioned my sense of an atmosphere heavy with despair during the hospital rounds some four weeks earlier and recalled his poignant reaching for something which he might have overlooked in the chart. He replied that he did not recall the atmosphere in Tillie's room as being all that emotional. I did not press my interpretation on him. He would work through his feelings at his rate, not mine. I did not see his denials as disconfirmations. After all, he had come to talk with me about Tillie and spoke of how much she had affected him. His isolation of affect from his professional self was gradually giving way to a reintegration of emotion with objectivity, an integration which if present in himself he will also nurture in his patients. He was trying less hard not to feel. Perhaps as death becomes less of a menace to him, life too will be richer. In all three cases, a painfully slow and tentative working through of countertransference toward death and dying led to a less desperate quest for a new medical finding or a last-ditch procedure. This occurred because the recovery of feelings allowed the physicians to experience themselves, patients, and family with a new set of data, releasing them to do differently as well. In the process death became less an alien specter and more a natural part of life.

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COUNTERTRANSFERENCE AND THE OEDIPUS COMPLEX As is well known, the existence and universality of infantile sexuality and of the Oedipus complex (see Spiro 1982) is one of the key discoveries of psychoanalysis. Although the Oedipus complex is widely discussed in interpretations of myth, folklore, religion, and neuroses or other mental disturbance, the disconcerting ordinariness and subtlety of disguise that generational conflicts can assume in everyday life and medicine, for which oedipal is a generic term, are rarely addressed. The physician may unwittingly take the part of the son (Oedipus), the father (Laius), the mother (Jocasta), or the daughter (Electra, sister of Orestes, daughter of Agamemnon and Clytemnestra) in clinical relationships. He or she may unknowingly be enlisted in family dramas that are reenacted safely removed from the family. Doctor-patient, collegial, teacher-student, and attending physician-resident relationships are readily contaminated with unrecognized intergenerational rivalries, fantasies, longings, and dependencies. In other words, things are often not what they seem on the surface. The unconscious has its own rules that overrule objective age differences; it shapes the perception of relationships according to its own logic. Thus one female physician found herself worriedly "mothering" a patient twice her age. An amiable young male physician often found it difficult to issue explicit orders and to make clear demands on his residents. He sought their approval more as a team member and one of the boys rather than as a male authority (father figure). Countertransference may take oedipal or counteroedipal form, the physician taking the part of the child or parent, respectively, in a clinical relationship with a patient of the same gender. The dynamics between the generations, whether members of the same or opposite sex, are often not innocuous in their consequences in medical education and practice. Under their influence a physician can omit crucial clinical data necessary for formulating an accurate assessment and plan of action—as the following case of oedipal countertransference illustrates. Here I relate an incident in which I felt and acted as though I were the son in a father-son relationship with a senior medical colleague.

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Vignette 3: Teaching Moments I have for some years been a friend and colleague of a senior general practitioner who received training and certification in family medicine. He is regarded by the professional medical community and by his immense following of patients as the local doyen of family medicine. Modest, if not self-effacing, he takes compliments with acute embarrassment. He is generous with his time with patients and students alike, making considerable demands of himself but allowing others a latitude in life which he denies to himself. Like most American midwestern, white males, he tends to keep his personal problems to himself—though he is often betrayed by a mournful countenance. On a number of occasions I would say to him something to the effect, "You look tired" or ask, "What's on your mind? You look like you're carrying the weight of the world . . ." We would then talk about the various pressures of work and family, growing older, and so on. He genuinely appreciated these opportunities to unburden himself instead of having to be the steadfast one upon whom everyone laid their problems. On one occasion my physician friend spontaneously began to recite a litany of misfortunes that he felt were starting to overwhelm him. Within a period of several weeks he had unexpectedly lost several patients to cancer. Those whom he had thought stabilized went downhill quickly and died. Then there was a man whom he had treated some ten years ago for hiatal hernia, who seemed otherwise in robust health. Nearly a decade later, having heard nothing from him during the interim, the physician received a call that his former patient was quite ill, with intense pain in the lower abdomen. Following a brief hospitalization and a battery of inconclusive tests, the patient died. Only after an extensive autopsy was the cause of death revealed: a hole in the patient's stomach wall. Hardly a week later, a woman in her fifties whom he had been treating for depression committed suicide by taking an overdose of pills. My friend was especially upset that he had learned about her death when his wife noticed the obituary in the newspaper. He was quietly angry that the people who found her or the physicians who examined her had not gotten his name from the bottle of Tofranil (an antidepressant) she had. He was reasonably certain that thirty Tofranil—the amount he had prescribed—was below the lethal

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dose, but he also wondered what other medications she might have taken. On the one hand, he wanted to believe that he had done all he could, that he had not missed something in her behavior. He said that he refused to comply with her request to hospitalize her, to "knock me out like my psychiatrist did." He had given her the Tofranil to help her get some rest at night and be less depressed during the day. On the other hand, he wondered whether he might have slipped. Then again, "She just didn't seem that depressed." He telephoned the county medical examiner to try to resolve matters once and for all; but the medical examiner could not be certain about all the medication she had ingested. He spoke of his guilt feelings, of the uncertainty, of a certain fear that he just might be losing his touch. Only several months ago he had turned fifty and suddenly was appalled at the specter of growing old, something he said he had not thought about until the birthday was upon him. Last in his chain of associations, he spoke of how difficult it had been several weeks ago to put his aging mother in a nursing home. He and his wife could no longer care for her ever-more-consuming physical needs. He said he felt awful taking her out of her little home where she was in charge and seeing her confined to one room in the nursing home. He now took responsibility for sorting through her some eighty years of memorabilia and found old love letters from the time his parents were courting, their wedding picture, and so on, all of which overwhelmed him with the reality of time's passage and of his aging as well. I pointed out that it must be difficult to have to take over as a parent to your own mother—a situation in which I also currently found myself. Nodding agreement, he continued, saying, "It wouldn't be so bad if it all didn't happen together. I could take it. Everybody's got cancer patients, and you lose one now and then. But not all at once." It was clear to me that he was making coincidence into personal fault, feeling increasingly inadequate and guilty and overwhelmed. I then said to him, " N o w don't you go gettin' depressed." He replied protestingly, "That's what you keep tellin' me. I just got to have a talk with myself, and tell myself I don't need to be depressed." There were a number of interruptions after this, and shortly thereafter he departed for the hospital to make rounds on his patients.

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As our visit ended I felt uneasy but could not explain to myself why. Some seven hours later, while driving home, I found myself thinking about our talk. Clearly, I had some unfinished business. I asked myself, "Why did you tell him not to get depressed? What were you trying to warn him about?" I became angry and embarrassed with myself for admonishing him not to be depressed when it became obvious to me that what I ought to have said was something like "That's enough to get anyone depressed" (or, more neutrally, "down"). It was obvious to me in retrospect that I had resisted making a therapeutic response and instead had come up with a cultural response, saying in effect, "Keep up the good work," "Don't worry about it," "Don't let it get you down," "Keep a stiff upper lip," "Keep your chin up." I realized that the purpose of these cultural slogans is to deny, discount, or try to willfully ward off the feared emotion in the object of the admonition and in the speaker alike. For months I had seen this physician's depression and we had talked of it. But today I could not tolerate it in him. My warning to him was a (countertransferential) warning to myself: I did not want him to be depressed, for if I were to acknowledge the depression in him, I would have to acknowledge its effect on me. I could not be depressed, therefore he dare not be depressed. He became an extension or personification of my fears about myself. I did not want him to say what I could ill afford to think. For the moment I needed him to sustain my own repression. True, I had been supportive; I did give him the opportunity to talk about what was on his mind—up to a point. But at that point at which his problem began to coincide with my own, I missed the opportunity for a therapeutic response. (The timing and timeliness of countertransference responses is as important a technical issue as is the timing and timeliness of interpretations.) In recent months I had become acutely aware of my own aging and physical frailty; I likewise felt increasingly ambivalent about my new role toward my aging and frail parents living some 1,500 miles from what I now call home; I experienced unwelcome terror at the prospect of losing my father; and in my professional life increasing responsibilities and recent affronts had made me question my own adequacy. As I drove into the night, I came to realize that I had been quite depressed recently and had better face my own depression rather than ask father figures to serve as a bulwark

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against it. Only as I could face mine could I permit my physician friend to have his own depression. No longer needing him to help me repress my own depression, I could acknowledge his and help him see it through to the other side. Moreover, my own countertransference reminded me of a common transference reaction on the part of patients toward their physicians. Even though my physician colleague had temporarily reversed his usual professional role, nevertheless as "therapist" I nonetheless experienced my "patient" as a physician whose strength I needed to hold myself together. In part, the social role of physician becomes an externalized structural principle that corresponds to a defective internal structural economy: Outside is used to complete (as internal representation and palpable fact) inside. A dangerous complicity, indeed a circumscribed folie a deux, between physician and patient occurs when the patient who needs the physician to be strong in the patient's behalf evokes in the physician a strength whose exercise in treatment is designed to demonstrate through the patient that the physician is indeed strong. Two incidents further illustrate this oedipal countertransference. The first involved a family practice resident physician in his late twenties. For more than two weeks he had conscientiously responded to the repeated telephone summons of a woman whose husband, a man in his seventies, suffered multiple chronic illnesses (heart disease, stroke, and so on), was confined to a wheelchair, and was blind. The physician would go to their home almost daily, in answer to the wife's fearful uncertainties, such as "I can't tell if he's still breathing. Would you come out and see if he's still alive?" Now the wife was an RN, whose anxiety made her increasingly confused. Moreover, her children, some living locally, others hundreds of miles away, accused her of "wanting to put father in a nursing home and get rid of him" and refused to visit and assist her in caring for their father. She exclaimed that she could not even get away to shop for food since this would mean temporarily leaving her husband. She wanted to care for him but felt overwhelmed caring for him alone. Just as she was the extension or instrument of her children's wishes, so the physician became her extension, to relieve and reassure her. Every member of the family appeared to be accusing all the others of wanting to put their father (or husband) into a nursing home. The resident physician felt caught in the middle, adopted by

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a family he had not intended to join, frustrated by his inability to induce anyone in the family to change, and wearied by such timeand emotion-consuming home visits. I suggested that he present the case at a forthcoming behavioral science conference attended by resident and faculty physicians. He summarized the case material, freely admitting his sense of confusion and paralysis in the management of the case. At one point he said, "I just couldn't see putting my father in a nursing home." Suddenly his flow of speech halted. He had meant to say "their father" but instead came out with "my father." Instead of glossing over this parapraxis by recourse to some culturally acceptable excuse, the group in its surprised silence recognized that it was significant. The resident courageously did not flinch at the unwelcome interruption by his unconscious. He realized that his countertransference reaction to the patient had been the decisive obstacle in his disposition of the case. He had become emotionally adopted by the family and likewise had adopted them, so to speak. In his representation of them, the role of patient had been infused with the role of father; reciprocally, the role of physician had been infused with the role of son. He had been unable to separate the patient's needs in the context of the patient's family from his own needs as realized at the moment of the Freudian slip. Patient management had been in the service of his own familial rescue fantasy and role. The physician's breakthrough in patient management occurred at the point at which he could evaluate the patient's and family's needs and guilts separately from his own. The resident physician then turned to the family's pathological communication and decided to state publicly what had been all along the family's wish but what no one could own up to except by accusing the others of it. He said that he thought it best for his patient and for them that the patient be placed in a nursing home. This way, he reasoned aloud, they would be able to visit him as frequently as they liked and the patient would receive the best medical care possible. The family rejoiced over the decision! The physician used the tactic of violating the family taboo and the family secret himself. He broke the spell by saying what they could not bring themselves to say. Until the moment of the clinician's insight, the family and the clinical relationship were governed by reciprocal projective identification, he with the family and the family with him. He could help

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liberate them from their guilt only as he came to liberate himself from his own. The second example of oedipal countertransference involves another family medicine resident in his late twenties or early thirties. An approach I commonly use to teach about the importance of culture in the physician-patient relationship (such as values, expectations, beliefs, and assumptions) is to discuss with the physician his or her own familial, ethnic, and religious background. I had learned from this physician that his father had come from a wealthy family, had lost everything owing to political and economic circumstances, and had taken a civil service job. With an urgency in his voice, the young man related how his father had placed great pressure on him to succeed in school—perhaps to vindicate his father's life or to reclaim his father's past through his own future. Later, the same day as this discussion, I conducted a behavioral sciences conference with all family practice residents during which I made an assignment to the entire group. This resident seemed particularly concerned about getting the assignment down right. He repeatedly asked me to clarify myself. He wanted to be certain he knew exactly what his instructor expected of him so that he could do his work as "perfectly" (his term) as possible. After the other residents had left the room, he remained behind in his chair, pressing me to clarify the assignment yet once again, persisting with his tense posture and anxious voice. I felt myself becoming increasingly annoyed, even angry, as he seemed to be increasingly desperate. Instead of expressing my anger and telling him to "back down," I found myself thinking that I was starting to react toward him as does an angry father toward a misbehaving son. I felt that no amount of specification or clarification would satisfy my resident, because his wish to satisfy me and his fear that he would fail was overwhelming. Suddenly, our earlier discussion came to mind. Perhaps he had not heard his teacher's voice and message; namely, that process was more important than next week's product. Perhaps he was responding to his instructor's demands with the same urgency and using the same words with which he described his earlier family life and education. Perhaps in his teacher he saw his father's attitudes: an exacting all-or-nothing determination, a world in which a person is given but a single chance, a sense of success defined by perfection and anything less painfully felt to be failure. Sensing his heightened

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anxiety through the instrument of my own anxiety, I paused and said quietly to him, "Doctor, relax. I am not your father. I think that you're hearing me as though I were him." He did relax: His broad smile and eased posture confirmed my hypothesis. I used confrontation to try to force a separation between father and teacher. I then briefly interpreted what I had felt to be taking place between us: that he had acted as though I—his teacher—had the same expectations of him as had his father—and there would be the same dire consequences if he failed to live up to my expectations—and that he could not hear my voice because he was listening to his father's voice in my words. Perhaps for this reason he could not understand the assignment as precisely as he had wished, even though at my request he had repeated the assignment "perfectly." This seemed to me to be a timely opportunity to reintroduce and interpret the concept of transference and countertransference, which we had on a previous occasion discussed intellectually. Once again he beamed: He was ready now to comprehend the meaning of this abstract concept experientially, with conviction. He came to recognize the banality of oedipal politics—in the doctor-patient and the teacher-resident relationship as these actors project their old, unresolved struggles into new relationships. It is interesting that this resident subsequently said to me that he wished to get to know me better "as a person"—that is, as a real object rather than as an erstwhile internal representation and transference target.

MEDICAL STIGMA: THE ATTRIBUTION OF INSIDE TO OUTSIDE Alexander (1981) writes that "case conferences, staff meetings, patient forums and exchanges are all presently characterized by detailed itemizations of persons' proclivities, symptoms and character, rather than by consideration of the interactive structures that occur in clinical environments" (p. 323); and Waxier (1981) concludes that "labeling theory suggests that facts such as diagnosis, length of stay, prognosis, may tell us much more about the social characteristics of selected patients and the workings of the treatment system than about a biomedical process" (p. 302). Diagnostic labels are the product of role negotiation, not simply attributes of the patient him- or herself. Yet the process of attribution that includes the clinician is experienced by the clinician as a search for

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attributes of the patient; and diagnosis is itself the search for objective attributes of the patient. Of all nonpsychoanalytic social scientists with whose work I am familiar, that of symbolic interactionist Erving Goffman comes closest to the theory offered here. In Stigma (1974), Goffman writes that the stigmatized person is "reduced in our minds from a whole and usual person to a tainted, discounted one" (p. 3). Now the universal trick we perform both on ourselves and on the person or group officially discredited is to speak as though the "blemish" or "fault" were exclusively an attribute within the person or group rather than located within a relationship that includes the stigmatizer. We reify stigma as a noun, rather than think of stigma as a transaction, a verb "to stigmatize." We emphasize attributes and downplay the psychology and act of attribution. However, the process of discrediting is an active one between stigmatizer and stigmatized. Goffman points out that "a language of relationships, not attributes, is really needed. . . . A stigma, then is really a special kind of relationship between attribute and stereotype [about] undesired differentness" (pp. 3, 4, 5). What must be explained, however, is why people adamantly protest that stigma is about attributes and persons, not relationships. It is as though humans have some vested interest in not seeing stigma as a problem that involves themselves as well as others. I would further expand Goffman's stagecraft of relationships with a dramaturgy of motivations. A language of relationships, perspectives, and attribution would seem to require a logically and developmentally prior language of and capacity for internalized object relations (Volkan 1976). The language of attributes and the language of attribution are, respectively, the mote and the beam in the unconscious language of externalization, projective identification, and projection. We discredit others so that we might not discredit ourselves; we locate in others the flaws we fear to see in ourselves. Stigma is a special case of the human proclivity for affectively based labels, classifications, and diagnoses. Clinical diagnosis often inadvertently becomes the assignment of stigma. As Devereux (1980) emphasizes, diagnosis means "to tell apart," not simply "to label" or "to identify" (p. 261). Precisely because the self is threatened by the fact or prospect of having mental illness (and, I would add, by somatic and psychosomatic illness as well), clinician and patient often conspire to deny the possibility that the self is

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fundamentally impaired by extrojecting the disturbance outside the self. Devereux incisively writes: The crucial diagnosis "This singularity concerns the healer" is . . . not based on a deviation from the norm but on conformity with some marginal but clearly specified norm. A given individual is not considered "insane" because he does not behave normally, as the majority of his peers allegedly do, but because he does behave the way the "insane" are

known, expected, or supposed to behave. (P. 265) Clinically, we routinely commit the fallacy of misplaced concreteness to avert the danger of feeling narcissistically flawed. We heavily invest in and endlessly (compulsively) refine categories of deviance (disease, insanity, criminality, heresy, and so on) to assure ourselves—the putatively normal diagnosticians and managers of social deviance—that we have nothing in common with the persons so labeled. Now diagnostic thinking, like any form of categorizing, does not necessarily use exteriorizing defenses in part or in whole. Rather, it is when taxonomies bear the burden of unconscious affect and fantasy that they are invested in for the purpose of creating distance between ourselves and the object being distanced. As with other forms of affectively based social labeling, medical diagnosis becomes projective when it is used to allay the diagnostician's (or family's, patient's, or society's) anxiety that he or she shares to some degree the individual's flaw—and imagined fate; for example, do we euphemistically say "tumor" instead of "cancer" for the patient's benefit or our own? In saying to a patient, "You have metatastic disease," we tacitly say, "You are consumed with disease; however, I am not tainted with death." Although medicine strives to be naturalistic, it becomes—despite Pasteur and K o c h — demonological in its magically based fear of contamination by afflicted patients. Medicine's language is arcane in order that the very mundane subject matter of medicine not disturb the practitioner. In this respect, physicians protect themselves by mystifying medicine. At least in part, the science or art of medical diagnosis represents an unconscious (often group) strategy to ward off painful insight by the clinician. Medical stigma is physician autobiography displaced onto the patient. Physicians need to assess their own countertransference even to the medication that they consider prescribing for a patient, since magical expectations and assumptions about drug action will influ-

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ence how appropriately they will prescribe it (Sullivan, 1979). Patients and doctors alike often think of medicine as "magic bullets." Physicians may likewise regard patients who request tranquilizers to be weak, those who seek pain medication to be manipulators, and so forth. Medication can be used by the physician as a powerful symbol with which to stigmatize the patient. Psychiatrist Albert Vogel (1981) writes of the common use of placebos: Unfortunately, recent studies reveal that among house officers in a hospital (and likely among physicians in general) placebos are most commonly used when the physician is frustrated and angry with his patient, i.e., when in an adversarial relationship. Common examples occur when the physician is: trying to prove that the patient is not really sick or is faking; attempting to demonstrate that, contrary to patient's belief, the illness in question is psychological not physical; feeling that the patient does not deserve analgesics or anti-anxiety agents, usually because of some disliked characteristic of the patient such as alcoholism, drug abuse, or noncontribution to society; trying to drive the patient away; punishing the patient; or aware that the patient will be upset, angry, or offended when he discovers that the placebo has been used. (P. 8)

Another factor that encourages the growth of stigma is the patient's personal appearance. Whatever deviates from the bodyimage "self-model" (Devereux 1967) is a ready target for the health professional's discomfort. Distance-creating stigma results in potentially distorted workup (evaluation), diagnosis, prognosis, and treatment. The patient is perceived, not as a distinct person in his or her own right, but as an affront to the physician's self-esteem, which is frequently resolved by putting the patient as much out of sight and out of mind as possible (for example, by turfing). We banish from sight what we fear to have mirrored in ourselves. The grotesque-appearing patient is an uncanny reminder of our own infirmity; in the patient's present we are jarred into contemplating our own future. In a society in which so much of our integrated body image is based on the ability to do things for ourselves and the capacity to keep on the move, the prospect of being paralyzed or being a "cripple" of any kind is abhorrent. Rehabilitation medicine is thus especially vulnerable to the need to solve the clinician's own problems evoked by the patient through the patient (Stein 1979). In a study of postoperative reconstructive surgery patients, Mac-

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gregor (1979) reports the consequences of social stigma toward the deformed and disfigured, which Rubin (1981) summarizes: Macgregor reports that the patients have made surprisingly good adjustments 2 0 years after surgery, despite gloomy psychiatric forecasts about their capacity to cope. She hypothesizes that the psychotherapists who tended to view emotional disturbances as a basic "neurosis" were projecting their own discomfort with severe disfigurement, tended to overestimate the subjects' weaknesses and underestimate their potential strengths, and using the then available personality protocols, failed adequately to measure patient's courage and resiliency. (P. 16)

It is insufficient to study by themselves the coping strategies and defense mechanisms of chronically ill or handicapped patients since the situation with which they are coping and against which they are defending themselves is in part governed by health professionals' own aversion, or countertransference.

COUNTERTRANSFERENCE BY OMISSION This chapter has thus far considered examples of family physician countertransference derived from several contexts: observation of physician-patient/family encounters, participation in case conferences and grand rounds, and individual case consultations and counseling with resident physicians. A different type is what might be called countertransference by omission, that is, where the evidence of countertransference lies not in what the physician does but in what he or she refrains from doing. Countertransference is revealed as much in what is left unsaid and undone (scotomatization) as in what is said and done. Obviously, an inhibition against performing an act can only be inferred and confirmed by discussion afterward, whereas acting-out behavior can usually be directly observed. In my work with family physicians, there are certain predictable topics that residents have tended not to discuss with their patients or to bring to me as an issue for consultations. Only after I have brought them up myself, and after considerable discussion, can I conclude that these are bona fide countertransference issues for the physicians and not idiosyncratic preoccupations of my own. Among the most recurrent issues not dealt with are the following. 1. Psychosexuality: Although taking a sexual history has become an official part of the overall medical history, the physician's interest

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tends to be limited to the patient's sexual behavior; that is, medicine tends to confuse copulation with genitality, just as Western society tends to downplay the sexual relationship (intimacy, tenderness, fantasy, aggression, playfulness, commitment) and emphasize the more mechanical or performance side of human sexuality. Devereux (1967) contrasts the "impersonal superficiality of sexual relations in our time" with the "obsessive asceticism preceding it" (p. 110). Intimacy—not alone sexual intimacy—is a taboo subject. Sexual behavior and sexual dysfunctions are comfortable, acceptable subjects; sexual feelings are felt to be a private matter and a source of embarrassment as a public topic (whether within the physician-patient dyad or resident group). 2. Homosexuality and other life-style variants: In my experience, although family practice resident physicians attempt to be intellectually open-minded toward a wide spectrum of life-styles, such as single-parent families, homosexuality, various ethnicities and religious practices, they nevertheless tend to feel threatened by them and incompetent to deal with them. In one case, for instance, a woman in her late teens had been admitted to the emergency room and hospitalized following a suicide attempt that occurred after she had received a long-distance telephone call from a woman whom she referred to as her "roommate." According to a female friend with whom she was currently living, the roommate was the patient's former lover and had telephoned to declare an end to their relationship. During the patient's week of hospitalization, everyone involved in her care suspected her of being a homosexual, acted toward her as though she were, but never mentioned the issue to her. This included family physicians, pastoral counselors, social workers, and so on. On the final day of her hospitalization, when she was scheduled to depart with a bus ticket in hand for her roommate's city, the family physician in charge of the case asked me to visit with her in the hospital room. The physician and I talked with her for perhaps an hour. I was pleasantly surprised to learn a wealth of detail that had been obtained about the patient's complicated past family situation. But although I knew a great deal about her childhood, I knew virtually nothing about the woman's present life situation, which had led to the suicide attempt. Here, as so frequently occurs in the interpretation of any kind of history, the conspicuous lacuna in historical data is an artifact of the historian rather than the subject matter.

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Later I discussed the case with the family physician, wondering whether everyone's interest in the patient's past was being used as a defense against knowledge of the patient's present. Exclusive attention to psychogenetic antecedents (of what?) seemed to represent a resistance against knowledge of the patient's contemporary relationships and their meanings—to the providers of health care as much as to the patient. In the hospital room I elected not to pursue a line of questions that would culminate in questions about the patient's sexual preference. The timing was poor. She was about to board a bus for a distant city; her continuity of care would abruptly end shortly. I refused to single out for—in my opinion—prurient factual or ethnographic interest material that could not be followed up clinically. At the time I simply did not think it essential in terms of the patient's welfare that I find out on the spot whether she was gay. The resident concurred. He confided that he had not known how to bring up the matter of her sexual preference and feared lest Pandora's box be opened. His fears about how he might feel if the patient admitted to a lesbian relationship, amplified by a fear of being overwhelmed by her (imagined) response, resulted in his avoiding the topic of sexuality in her presence while treating her with pleasant but circumspect distance as though she were a confirmed homosexual. The remainder of the consultation was spent dealing with the resident's own feeling at having been at a loss to do differently. He knew something was amiss. I emphasized that there was no formula to elicit the patient's sexual preference but that during the history taking, he might have asked her about the breakup with her roommate, about their relationship prior to it, and the like. I had no idea how safe she felt talking about it, but I did know that his feeling of vulnerability had compelled him and his colleagues to avoid it. He came to realize that all along they had been alternately repelled and fascinated by her alleged homosexuality and that they had all assumed more about her than they knew. The need to sustain a fantasy about the patient, to keep the patient at arm's length emotionally, interfered with inquiring whether that fantasy had anything whatsoever to do with the patient. Here externalization largely governed the hospital course and discharge procedure. 3. The emotional component of chronic, serious, or terminal organic disease (cardiovascular disease, duodenal ulcer, diabetes mellitus, cancer, and so on): Physicians tend to treat seriously ill

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patients by splitting off the emotional component of the illness (whether etiological or aroused by illness itself) from the illness proper. The physician's denial and repression system frequently coincides with that in the patient, with the result that physician and patient collude and talk only of the "repair work" that can or cannot be performed. Today even the word cancer is spurned for the more euphemistic abbreviation CA. When uttered, "cancer" is often said in a hush. In our day the word cancer carries with it the quality of a supernatural curse, like the word cholera in past centuries. Likewise, the emotion-laden word death is infrequently spoken; in its place appear numerous euphemisms like "terminal" or "end stage," whose anesthetic psychic function is to make it less familiar and less personal. Noticing some years ago that I had rarely been consulted on such disorders as cardiovascular disease, hypertension, duodenal ulcer, ulcerative colitis, and the like, I asked a number of family medicine residents to describe their treatment approach to patients with these diseases. They replied that they treat the organic lesion (with surgery, medication, or diet) and may make some suggestions for life-style change but try to steer clear of anything too emotional for fear of "getting in too deep over our heads." They tend to see behavioral sciences as useful in conceptualizing and treating neuroses, depression, marital discord, culturally different patients, family problems associated with deviant behavior—but not "real disease." Somewhat more in practice than in theory, they compartmentalize organic or real disease and behavioral problems— despite the lectures, seminars, and readings to which they are now routinely exposed in their preclinical academic medical education. Some residents vehemently disavow the notion that real pathology could be emotionally overdetermined. Others say remorsefully that although they know they should pay more attention to the emotional component of the illness, somehow they do not think of it at the time or cannot find or make the time in their busy schedule to deal with it. I have found over time that by insinuating myself into cases such as these—rather than waiting to be invited to participate in them—I can offer these family physicians the opportunity to deal with their own feelings about uncertainty, frailty, death, loss, and decline. As a result, they have less need to engage in a conspiracy of silence, so to speak, with respect to emotion-laden medical conditions. This

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obtains as well for the (closely related) final issue summarized briefly as follows. 4. Meeting with the family for an evaluative-therapeutic session: A meeting with the family (from nuclear to extended, whether in the family medicine clinic or at the patient's home) can provide a wealth of information within a short period of time about the relationship between the identified patient or symptom bearer and his or her family. Seating arrangement, sequence of speakers and gestures, inflection, and the like offer a perspective on the illness that history taking with the patient alone simply cannot provide. At first family practice residents with whom I have worked are reluctant to sit down in a closed room with a family—if not terrified at the prospect. What they will or will not see is secondary to their worry about what might happen to them. I have heard seasoned family therapists and apprentice family physicians alike express a common fantasy of being devoured alive and spit out by the family. In this context, the insistence on seeing individual patients, the sanctity of the private physician-patient relationship, and the evocation of confidentiality are all offered as a defense against the feeling of being overwhelmed in the presence of the family (the clinician's own family situation reactivated in the present). We may selfprotectively meet alone with the patient to avoid meeting with the family. By meeting with individual patients, we feel at least some sense of control, whereas the prospect of sitting together with the family conjures fantasies of personal annihilation. We can minimize the importance of the family for the patient (as representation and reality) only if we first minimize its effect on ourselves—and then transfer that conclusion onto the patient. The converse is likewise true: Only as we recognize the importance of our own family in shaping life patterns can we come to recognize the importance of the family in the patient's life.

CULTURAL AND CLINICAL AVOIDANCE OF COUNTERTRANSFERENCE ISSUES In medical education today, from undergraduate through residency, considerable emphasis is being placed on the doctor-patient relationship. This offers an important corrective to previous exclusive consideration of the anatomical, biochemical, physiological, and pathological aspects of medicine. Nevertheless, my experience in

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medical education since the early 1970s has been that the social and behavioral sciences that were expected to help transform medicine have themselves largely become acculturated to the models and metaphors of human beings as machine and computer, which dominate medicine and the wider culture alike. Clinical interviewing and communication have been heavily influenced by a pedagogy that prepares the future practitioner for an assembly line in which human bodies and lives are mechanically repaired. A thoroughly predetermined set of "behavioral objectives" processes students inexorably toward "terminal outcomes," allowing no room for the novel, the unexpected, the feared subjective (Gardner 1977). Packaging often seems to take precedence over content and process. The person of the student or resident often gets short shrift in medical education; he or she is expected to be an accepting conduit of medical philosophy rather than an active participant in the search for meaning. An exclusive emphasis on skills and techniques has the consequence of making impersonal the personal—even while students are taught to exhibit a personal demeanor. They learn cognitively to define, and behaviorally to perform, the establishment of rapport; the opening and closing of an interview; the negotiation of a therapeutic contract; the posturing of the attentive position; the essential skills of reflection, empathy, support, confrontation, summation, interpretation, and the like. Communication understood in this way facilitates the unimpeded movement toward diagnosis, treatment, compliance, management—and the patient next in line. The behavioral sciences too come to betray their subject—the human being in sickness and health—by reducing him or her to easy formulas and stereotypes (whether ethnic, sexual, or the like). Historically, however, the introduction of patient interviewing, therapeutic communication, family and cultural context, and so on into the strictly focused biomedical interview in the 1960s was itself part of an attempt, through the introduction of the behavioral sciences into medical education, to humanize and personalize the educational process by conceptualizing and treating the whole person, not merely a disease entity or faulty organ system. This idealism, the good intention, must not be denied. But it also should not be denied that this widened contextual outlook was rapidly adapted to the prevailing pedagogic style not only of medical edu-

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cation but also of American education of which medicine is but one expression: lineal, programmed, mechanical, impersonal. Initially lauded as the harbinger of reform in medical education, the behavioral sciences soon tailored themselves to suit the prevailing medical and national cultural ethos with the result that their application to medical education became forbiddingly mechanistic. Currently, in family medicine's courtship of a streamlined family therapy, and in psychiatry's renewed interest in a biopsychiatric model of mental disorder, we can see how the behavioral sciences come to serve and in many respects rationalize the clinical and cultural norm. Beyond the medical specialties themselves, we can discern in the recent proliferation of corporate-industrial models for medicine (HMOs, DRGs, and so on) a revitalization of the mechanical model throughout American medicine. The metaphor of the machine has dominated the Western world view since the eighteenth century (since the publication in 1748 of La Mettrie's book, L'Homme machine, or "man the machine"), and has been succeeded in the past two decades by the metaphor of man the information-processing computer, a metaphor that is continuous with the earlier one. Accordingly, errors in relationships are seen as the results of faulty encoding, decoding, and transmission. We are admonished by cultural proponents of high technology that we had all better learn the language of the computer lest we become obsolete. Identified with machines, we become extensions of the apparatuses we design and build to extend ourselves. In this world view, subjectivity is isolated from objectivity, sentiment is disparaged, and detachment is valued. Medically, we pay close attention to the soma and either ignore the psyche or reduce its manifestations to somatic causes. Along with the split between reason and sentiment, and body and soul, is a split between public and private, the result of which is generations of scientists and politicians (from Newton to Bismarck, let us say) whose public self was empirical and practical but whose private self was mystical and sentimental. However, the consequence of the repression of the psyche or soul in this empirical world of Realpolitik and "hard ball medicine" is the return of the repressed through countertransference. Our cultural obsession with machines and computers is a defensive maneuver to distance ourselves from the frightening frailties of

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the human condition in sickness—not only the frailty of the patient as we confront him or her but also our own as we encounter ourselves in the patient. The emotionally sanitized language of the computer defensively substitutes for the language of the heart. In many respects, by providing cultural strengthening of such defenses as splitting, repression, and isolation, medical education alienates the medical student and resident physician from the patient whom it purports to serve—and from parts of the student or resident physician him- or herself. More formally stated, exclusive disease orientation implements the personal, professional, and cultural defense of affect alienation.

THE EDUCATIONAL ISSUE: TO COLLUDE OR NOT TO COLLUDE My ethnographic and psychodynamic approach to medical education and clinical research is that of an agent of culture change. Through case consultation and counseling, I encourage medical students and residents to inquire into the tenets of their culture and into what they themselves use it for. In many instances, they learn to use cultural material less defensively and thereby gain greater access to the patient because they rely less on the biomedical model to protect themselves from the patient (more accurately, from what the patient represents within themselves). Virtually all medical examinations are directed toward the physician's examination of the patient and/or the patient's family— through the physical examination, laboratory tests, mental status and psychiatric examinations, family assessment protocols, and so on. Whereas these may be necessary to evaluate the patient, they are insufficient for they omit the self-examination of the physician (or other health care practitioner). In clinical teaching, research, and the design of intervention strategies, I encourage that research into the self take place in constant dialogue with research into the patient (or other formal clinical subject). Such research strategy or curriculum design becomes an ongoing aspect of therapy with therapist, researcher, and educator alike. Psychohistorian Lloyd deMause (1982) writes recently that " a l l claims to represent what others feel have the same logical status— we only know directly what we ourselves feel" (p. 247). We mis-

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takenly believe that we have direct insight into others, unmediated by the self. It is only through the unsettling process of gaining access to our own psychopathology of everyday life in medicine that we indirectly gain access to an understanding of pathology within patients and families (Devereux 1967). In this way, we help to diminish acting out and enhance insight within patients; we become less part of the problem and more part of the solution. The most recent Diagnostic and Statistical Manual (III) of the American Psychiatric Association (1980) illustrates the cultural trend toward ever-finer refinements of behaviorally or phenomenologically based categories of diagnosis. The purpose is to make psychiatry more scientific, since the criteria of verifiability come closer to the model of the physical sciences (at least the nineteenthcentury pre-Einstein and prequantum physics model). Increasingly, the overdetermined subtleties of internal dynamics are not only lost but also their clinical status is repudiated (see Schmidt 1979). Many psychotherapists and family therapists take the position that keeping out of the transference will save time, money, and energy. Yet such strategies as keeping outside the transference, ignoring it when it occurs, or consciously manipulating the transference themselves constitute countertransference maneuvers (Stein 1983). These clinicians say, in effect, "I will not become personally involved" or "I will decide precisely how I will become actively involved" in the therapeutic process. Increasingly, psychiatry or family counseling practitioners are called "coach," "consultant," or "engineer." It would seem that the issues raised during the 1927 debate on medical versus nonmedical (lay) analysis are still current (Symposium 1927). The early solution proposed by Freud and lay analysts was to create a new group of curers who would be equally distant from the "doctors" as from the "priests" (see Freud 1963), thereby preventing psychoanalysis from becoming handmaiden to medicine or religion. During the same debate, Franz Alexander argued that psychoanalysis needs medicine less than medicine needs psychoanalysis; Herman Nunberg proposed that all physicians should undergo analytic training before they so much as approach the sick; and the Hungarian Psychoanalytic Society advanced the idea that the personal analysis is the center of psychoanalytic training. The reason that this debate is of contemporary as well as historic interest is because it poses the central question which all

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medicine, indeed all healing-caring-curing professions, addresses: What does a physician need to know in order to practice good medicine? Today, amidst increasing medical specialization, medical departments and disciplines vie for every hour of instruction, laboratory, and clinical experience they can get. Anyone who knows the political scene nationally in medical education knows that the behavioral sciences, psychiatry, family medicine, and community medicine are far from integrated into the academic curriculum or the family of academic departments as siblings with equal status and privilege. A rigid distinction continues to be made by students, residents, and faculty between the hard and the soft sciences, between real disease and psychiatric, family, or social problems. Furthermore, in medicine high status has increasingly come to be associated with high technology. Schools of public health remain separate administrative units from schools of medicine—and stepsibling medical institutions at that. This all attests to the massive splitting of affect from the rest of medicine and the defensive labeling of the latter as real. Nonetheless, to use the language of business science, "accountability" that does not take account of the role of unconscious factors in the etiology and response to disease and that discounts the importance of these factors in the clinician and in the clinical relationship cannot be cost effective in the long run. The relegation of affect to its current low-status position has had clear results. We think immediately of the increasing medicalization of psychiatry and of psychiatric treatments; the equation of chemotherapy in, for example, schizophrenic and depressive illnesses with therapy itself to the exclusion of psychotherapy; the tailoring of individual therapy into brief, task-oriented counseling or coaching sessions devoted to problem solving in which the transference and unconscious meanings are intentionally ignored; the growing emphasis on therapeutic contracts between clinician and patient, narrowly limiting the topic of clinical interest; the increasing popularity of hypnotic-suggestive and cathartic therapies; and the equally widening popularity of family therapies (for example, use of the genogram in Bowen family theory, of paradoxical injunction in the Palo Alto group, and of the structural therapy of Minuchin). The current educational and clinical scene can accurately be described as a flight from insight into action. Some years ago I had the following discussion with a senior

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educator in medical behavioral science after I had administered and graded a major exam. I told him of my pleasure that the medical students had logically and clinically advanced plausible answers that I had not anticipated. He coolly insisted that we could only credit the "right" answers. Although he acknowledged that in life there are mostly grays rather than black or white, right or wrong still we must teach and test as though there were clear right and wrong. The students were to have chosen the best possible answer. They were to be rewarded (by a grade) not for creative, original thinking but for learning how to anticipate the expectations of often arbitrary authority. We were to teach them what to think (and therefore not to think) and, in the process, how not to feel. He firmly reprimanded me for allowing myself to be seduced by the students into indulging their and my philosophic proclivities for analyzing everything. Clearly, medical behavioral science as a critical method was out of place here. He insisted, "In the emergency room I don't want these students to be creative, I want them to act. I don't want them to stop and think, I want them to know instinctively what to do." It was as though thought and action are opponents rather than allies. It is imperative that all practitioners think about what they are doing and not simply ply their trade based upon the known and the (often dangerously) presumed. The critical and creative and integrative faculties are as important to have at our disposal in the emergency room as elsewhere. Only by allowing creative thinking can we encourage consideration of alternate ways of acting. The significant can only be discovered fortuitously; and the serendipitous discovery by definition cannot be controlled, programmed, or foreseen. What we often do, however, is exclude the possibility of the fortuitous and deny its educational or clinical importance when it does arise. My colleague's defense of the inviolability of our testing methods can be understood as anticipatory in nature, an attempt to subsume all eventualities in the service of preserving our established understanding and authority. If we half admitted it, we really do not know all the kinds of things we need to know. This is not cause for despair and paralysis; it is instead an opportunity. In the behavioral sciences as in medical education, we spend far too much time teaching what to think and what to observe and far too little time teaching how to think and

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how to observe. Ebel (1978) pithily writes, "All behavior is subject to scrutiny. All acts are fair game" (p. 170). A methodology worthy of the name "scientific" wears its mantle lightly and harbors a healthy skepticism. An attitude of free-floating attention acting in concert with focused emphasis would enhance any scientific research and clinical endeavor. As philosopher Alfred N o r t h Whitehead (1925) admonished: Seek simplicity and mistrust it. By following the unexpected, the novel, the surprising, and even the unsettling in medicine, we often arrive at something clinically significant. We thereby know how to intervene better or recognize the limits of intervention. A number of communication theories thoroughly describe the role played by strategies, alliances, coalitions, schisms, fictions, triangles, boundary conflicts, and scapegoating in families and clinical relationships. Yet these same theories and the intervention strategies based on them deal with rules and patterns of interaction without inquiring into what communication is about, what it is for. Despite the valuable contribution of family and communication theorists to the description of interaction patterns and sequences (see Stein 1983), we need an approach that encompasses both the mechanics or pragmatics (behavior) of communication and the purpose for which these particular modes of interaction are used. In a sense, the biomedical model of organ systems and the family or interactional model of interpersonal systems both run aground on the same shoals: the failure to include unconscious influences on the functioning of those systems. Although ideologically very different, both systems approaches tend to avoid looking too closely at inner meaning as part of behavior. T o advance conceptually and clinically, we need to become more inclusive rather than more exclusive. Ross (1982) writes that psychoanalytic developmentalists have not surrendered the centrality of unconscious fantasy and intrapsychic conflict to the emphasis on external reality and simple interactionism proposed by the interpersonal school or the family systems advocates. . . . Some analysts have come to view psychic reality and external transactions between people as repositories for each other. (P. 193)

From an analytic viewpoint, much of interpersonal communication and institutional structure is created and maintained for the purpose

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of managing anxiety and ambivalence. The influence of unconscious forces in medicine and science remains an elusive and persistent frontier in any systems thinking. Within American medicine the reluctance to incorporate psychodynamic principles into medical pedagogy and practice is unique neither to psychiatry nor to the various behavioral sciences which psychiatry, family medicine, and other specialties have included in their curricula (such as medical anthropology, family studies, and family therapy). I have considered psychiatry and the behavioral sciences as something of a case example in this section for two reasons: (1) I have worked as a behavioral scientist in psychiatry and family medicine settings and have been able to follow their methodological and ideological developments at first hand. (2) These internal developments can be seen as something of a microcosm and as diagnostic for more widely prevalent directions in American medicine, medical education, and American culture. As an exception to this trend, Devereux's From Anxiety to Method . . . (1967) remains the best comprehensive treatment of countertransference in clinicians and behavioral scientists. In it Devereux offers generous examples of how the patient's sex, age, body characteristics, race, culture, and the like become screens onto which the physician's attributions become perceived attributes of the patient.

CONCLUSIONS In this chapter I have considered the physician role from within, so to speak, through an analysis of countertransference. Through vignettes from a number of clinical situations and topics, transference and countertransference are shown to be as common in the practice of primary care medicine as they are prevalent in those clinical professions with which they are officially identified (psychiatry, psychoanalysis, clinical psychology, and social work). Acted on without awareness, they are a source of distortion and unhappiness in human relationships—and of error in clinical assessment and management. Yet transference/countertransference phenomena may be an inexhaustible source of insight into the patient by way of insight into the self. Furthermore, the analysis of countertransference fosters the diminution of exteriorization and the integration of personality in the student and physician. This chapter can be summarized as follows. Biomedicine as a

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professional subculture (with its many internal subdivisions) within American society is governed by a number of implicit premises or unconsciously motivated basic assumptions, all of which appear in idiosyncratic or institutionalized physician countertransference: 1. I am in charge; I am in control, or I expect to have control. 2. I know—or there is or will be a way to know for certain. 3. I can cure, or a cure will be found. Therefore, I can conquer disease with the compliance of the patient or despite the patient (if I cannot win, it may be the patient's fault or perhaps I overlooked something). 4. I can and must make a difference, in a brief time, in my patient's life through my intervention. 5. Death is a complex process, which—if we only knew all the biological elements—could be controlled. If a patient dies, I must have missed something. 6. Emotion only interferes with clinical objectivity. Expressing emotion is unprofessional. 7. The different or difficult patient is the flawed patient. Thinking about the subject of this chapter, I have come to understand in part how the physician experiences the doctor-patient relationship and how my reflection and interpretation of that experience in collaboration with the physician can improve the clinical relationship and enhance patient care. A truly therapeutic communication between physician and patient would seem to be based on a single question: "Am I saying or doing this to help the patient or to better defend myself?" This is the same question that I was compelled to ask myself whenever I met with family medicine residents to observe, consult on, and supervise their cases. What psychoanalysts call resistance is an unconscious barrier to learning about our patients and ourselves. Such resistance is not obstinacy. Its effects are far more subtle than the many vignettes in this chapter can attest. Faced with a difficult patient, we can begin to recognize and unravel our own resistance by asking such questions as " W h a t is it about the patient and about myself that I find difficult to face?" "Why can't I understand this patient?" "What is it that I wish not to understand about the patient and about myself?" and " W h a t must I first ask about myself before I can answer it about the patient?" Beyond individual resistance, we

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can identify what might be called institutionally or culturally shared resistance. An example of institutionally shared resistance is the conventional use of the biomedical model (assessment, diagnosis, treatment) for collectively defensive purposes against the intrusion of unconscious ideas, fantasies, conflicts, and feelings. This professionally shared resistance might also be identified as a "culturally constituted defense mechanism" (Spiro 1965:100). Finally, I wish to address an admittedly nettlesome methodological issue: How was it possible to observe the physician's countertransference? The answer is simply that I had to be disturbed by the physicians to assist them, just as the physicians had to be disturbed by their patients to assist them. There is no way around this uncomfortable fact. Devereux (1967) comments: Psychoanalysts sometimes speak of the "revelation" of the patient's unconscious in analysis. This statement is carelessly worded. The unconscious is no more directly observable than is the heat of the bowl of water in the experiment analyzed by J. von Neumann. What is directly observable, and therefore constitutes a datum, is the reverberation—the disturbance—that the patient's utterance sets up in the unconscious of the analyst. It is the inspection of these internal disturbances which yields data "at the observer" and, naively speaking, even "within" the observer. . . . In interpreting their reverberations within himself, the analyst professes to interpret also the unconscious of the patient. This is, clearly, a hypothesis and, moreover, one which involves the subsidiary assumption that the unconscious of the analyst is much the same as that of his patient, chiefly because one's unconscious is a relatively undifferentiated function or portion of the psyche and can therefore resemble that of another individual more than can one's highly differentiated conscious. Any analyst who believes that he perceives directly his patient's unconscious, rather than his own, is deluding himself. (Pp. 3 0 3 - 3 0 4 )

By extension, then, ethnographers of the human condition who aspire to get at meanings and relationships beyond superficialities also do not directly observe the other. Rather, they learn to observe the other by learning to observe themselves. This is the meaning of becoming an "observing ego": not (as we mistakenly believe) learning to become a detached, Aristotelian unmoved mover, but to become the most moved mover. Everything we do as humans reveals the imprint of our autobiographies; what distinguishes each

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of us is how that imprint is made, with or without our conscious awareness. As physicians, anthropologists, or patients, we gain our objectivity through disciplining our subjectivity. What makes for a psychoanalyst's understanding of an analysand is also the essential ingredient of a clinical understanding of a patient or of an ethnographic understanding of a culture. Our unwritten autobiographies stalk our therapies, case studies, and cultural interpretations. Countertransference reveals a type or level of knowledge about ourselves and others to which we normally have little access. It signals to us that some area of meaning, counter to our intention, is making itself known. Knowledge of this unknown region is indispensable for understanding the inner world of ourselves and other persons irrespective of context. In clinical teaching and supervision at least, the ethnographic method seems inseparable from the clinical task. By following family medicine residents' (relatively) free associations and interpreting to them their professionally sanctioned resistances, I help them to observe themselves as they observe their patients, to observe themselves to better observe their patients. The metacultural goal and lifelong task of this endeavor, for physician, patient, and ethnographer, is, to slightly modify Freud's famous dictum: Where id and punitive superego was, there shall ego be.

REFERENCES Adler, Gerald. 1 9 8 1 . The Physician and the Hypochondriacal Patient. New England Journal of Medicine 3 0 4 ( 2 3 ) : 1 3 9 4 - 1 3 9 6 . Alexander, Linda. 1 9 8 1 . The Double-Bind Between Dialysis Patients and Their Health Practitioners. In The Relevance of Social Science for Medicine, edited by L. Eisenberg and A. Kleinman. Boston: D. Reidel. Pp. 3 0 7 - 3 2 9 . Aries, Philip. 1 9 7 4 . Western Attitudes Toward Death. Baltimore: Johns Hopkins University Press. DeMause, Lloyd. 1 9 8 2 . Reply to Commentary by D. O. Wesner in Symposium on the Fetal Origins of History. Journal of Psychohistory 10(2):246-248. Devereux, George. 1 9 6 7 . From Anxiety ences. The Hague: Mouton.

to Method

. 1 9 8 0 . Basic Problems of Ethno-Psychiatry. Chicago Press.

in the Behavioral

Sci-

Chicago: University of

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Diagnostic and Statistical Manual of Mental Disorders (DSM-III). 1980. Washington, D.C.: American Psychiatric Association. Ebel, Henry. 1978. Leaves from a Notebook in Progress. New York: Argonaut Books. Freud, S. 1919. The Uncanny. Standard Edition of the Complete Psychological Works of Sigmund Freud (SE). London: Hogarth Press. . 1963. Psychoanalysis and Faith: Letters of Freud and Pfister. New York: Basic Books. Gardner, Leonard. 1977. Humanistic Education and Behavioral Objectives: Opposing Theories of Educational Science. School Review 85(3):376-394. Goffman, Erving. 1974. Stigma: Notes on the Management of Spoiled Identity. New York: Jason Aronson (orig. 1963). Hall, Edward. 1977. Beyond Culture. Garden City, N.Y.: Doubleday/ Anchor. Kohut, Heinz. 1971. The Analysis of the Self. New York: International Universities Press. . 1972. Thoughts on Narcissism and Narcissistic Rage. The Psychoanalytic Study of the Child 27:360—400. La Barre, Weston. 1978. The Clinic and the Field. In The Making of Psychological Anthropology, edited by G. D. Spindler. Berkeley, Los Angeles, London: University of California Press. Pp. 259-299. Lawton, Henry W. 1982. The Myth of Altruism: A Psychohistory of Public Agency Social Work. Journal of Psychohistory 9(3):265-308. Macgregor, Frances M. Cooke. 1979. After Plastic Surgery. New York: Praeger. Rochlin, Gregory. 1973. Man's Aggression: The Defense of the Self. Boston: Gambit. Ross, John Munder. 1982. Oedipus Revisited: Laius and the "Laius Complex." In The Psychoanalytic Study of the Child, edited by A. J. Solnit, R. S. Eissler, A. Freud, P. Greenacre, and P. B. Neubauer, vol. 37. New Haven, Conn.: Yale University Press. Pp. 169-200. Rubin, Vera. 1981. Review of After Plastic Surgery (by Frances M. Cooke Macgregor, New York: Praeger, 1979). Medical Anthropology Newsletter 12(3):16. Schatzman, Rochelle I. 1983. Comment on The Myth of Altruism (by Henry Lawton, Journal of Psychohistory 9 [1982]:3). Journal of Psychohistory 10(3):381-387. Scheingold, Lee. 1981. Dreams of Family Practice Residents. Family Medicine 13(6):14-16. Schmidt, Casper G. 1979. The New Diagnostic and Statistical Manual (DSM-III) in Perspective. Paper presented at the Second Annual Convention of the International Psychohistorical Association, New York City, June.

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Searles, H. F. 1979. Countertransference and Related Subjects. New York: International Universities Press. Spiro, Melford. 1965. Religious Systems as Culturally Constituted Defense Mechanism. In Context and Meaning in Cultural Anthropology, edited by M. E. Spiro. New York: Free Press. Pp. 100-113. . 1982. Oedipus in the Trobriands. Chicago: University of Chicago Press. Stein, Howard F. 1979. Rehabilitation and Chronic Illness in American Culture: The Cultural Psychodynamics of a Medical and Social Problem. Journal of Psychological Anthropology 2(2):153-176. . 1983. An Anthropological View of Family Therapy. In New Perspectives in Marriage and Family Therapy: Issues in Theory, Research and Practice, edited by Dennis Bagarozzi, Anthony Jurich, and Robert Jackson. New York: Human Sciences Press. Pp. 262-294. Sullivan, Jerry. 1979. Personal communication. 5 November. Symposium. 1983. Comments on The Myth of Altruism (by Henry Lawton, "Journal of Psychohistory 9 [1982]:3) and response by the author. Journal of Psychohistory 10(3):378-401. Symposium on Lay Analysis. 1927. International Journal of Psychoanalysis 8:174-283. Time. 1981. MD Suicides. 16 February. P. 57. Vogel, Albert V. 1981. Placebo and the Physician-Patient Relationship. Colloquy (October):4-8. Volkan, Vamik D. 1976. Primitive Internalized Object Relations. New York: International Universities Press. Waxier, Nancy E. 1981. Learning to be a Leper: A Case Study in the Social Construction of Illness. In Social Contexts of Health, Illness, and Patient Care, edited by E. G. Mishler, L. R. Amarasingham, S. T. Hauser, R. Liem, S. D. Osherson, and N. E. Waxier. New York: Cambridge University Press. Pp. 169-194. Whitehead, Alfred North. 1925. Science and the Modern World. New York: Macmillan.

The Contest for Control: A Case of Diabetes Mellitus in Multiple Contexts

This chapter presents a complex vision of the extensive, interlocking unconscious system that maintains a patient's illness behavior. It unfolds around a case study that identifies the multiple contexts of meaning within which the patient's life-threatening disease, diabetes mellitus, takes place: intrapsychic, familial, medical, and cultural (see Minuchin 1974:709; Segal 1978). Clinician countertransference is seen as part of the boundary of the symptom and as a cue to its meaning. The case study interprets the unconscious communication of many participants in the case (the patient, his family, the clinical staff) who are unwittingly involved in the perpetuation of the disease process. Unconscious themes shared by the participants are replayed by the patient who serves as the focus of their attention. The patient successfully engages society's collusion in his reenactment of inner and familial dramas. Consider the following brief vignette sent to me by a colleague whose family history of diabetes is woven into a family identity in which the disease has become a vehicle for expressing a family's way of life: What we seem to be moving toward, with our new understanding of family and group dynamics, is a truly horrific vision that I have reason to understand from the vantage point of my o w n family history. My 113

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father was a man who ate nothing but meat, potatoes, refined starches, and sugar for most of his life; who was chronically and very severely overweight; who added to this "diet" enormous amounts of salt. His eating habits were the subject for a standard "set-piece" involving my mother's "despair" at his not eating a few vegetables or an occasional piece of fruit—on the other hand, his resistance to her complaining seemed stably connected with the fact that the food she put on the table was the food that was so "bad" for him. His diabetes, as well as his brother's diabetes, was not diagnosed until he was in his fifties, though he had probably had it for a good part of his life—stuporous depression being the state he alternated with apoplectic rage. Then, of course, I was diagnosed—following my 1971 divorce—as also diabetic (though I got the condition under almost complete control via my home-cooked primal-therapy regimen; which also, of course predisposed me to make my own diet a less regressive one). My wife's family also has a history of diabetes; so in terms of standard medical thinking, my four-and-ahalf-year-old son is doubly predisposed to the condition. But I don't have to tell you, hardly, that a typical "gift" from his grandmother—who is aware of all of these facts—is a big box full up with packages of chocolate and cookies: her way of suggesting that she would like both him and his father to crap out the way her husband did when his ruined body finally gave out on him. (From notes 1980) In this vignette we meet once again the homeostatic principle of unconscious complementarity. W h a t certain members of the system cannot accept in themselves they assign or "delegate" (Stierlin 1 9 7 2 ) to a member or group subsystem who then feels compelled to accept their unconscious assignment. Ebel ( 1 9 8 0 ) writes: In unhappy families, the pain of complementarity is the pain of not having the "others" acknowledge what one is doing inside one's own life, because one is in fact having to act out the psychological material they will not admit to. Such a situation is intensely tormenting because it combines close physical proximity with psychological exclusion. (P. 284) W h a t members of families or groups cannot acknowledge in themselves they require of their scapegoat, who willingly mirrors and complies with their disavowed antisocial, destructive wishes by risking self-destruction in antisocial acts. These systems are based on an unconscious division of labor: The officially symptomatic member dramatizes what the normal members only fantasize. The

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sacrificial rite of the scapegoat (pharmakos in the Greek epic [Murray 1911]) embodies their badness and purges them of it (cf. Stanton 1977). The case presented in this chapter compelled me to rethink everything I had thought I knew about deviance, for behavior that at one level was an intolerable violation was at another not only tolerated but also provoked because it was necessary for others in the patient's wider emotional system. Disobedience thus became obedience—and safeguarded the emotional tie among all participants. In this case, diabetes is the official disease that everyone agrees to talk about and treat; however, it is the wider unstated intrapsychic and interpersonal process that keeps the patient's diabetes brittle and maintains the stability of the system in which the patient functions. In portraying the social uses of disease, this case intimates how any disease can be adopted or maintained by any network or group for the management of its own emotional economy. The answer to the biomedical question "What is the disease?"— or "What label shall we assign to the matter under consideration—disease, sin, crime, social problem, psychopathology, family dysfunction?"—reveals our explanatory model (EM) (Kleinman 1980; Kleinman, Eisenberg, and Good 1978). As noted earlier, all participants to an illness episode—including those who are never present in the official clinical encounter—bring perceptions about what is wrong and expectations about what ought to be done. These may be systematized, inconsistent, loosely organized, or even barely articulated. They are often affectively charged ways of navigating through illnesses. People often wield their EMs with considerable tenacity and convey them with the conviction of necessity. Physicians are as committed to their EMs as patients and families are to theirs. Witness, for instance, the common impasse between internists recommending conservative care and surgeons recommending surgery, between orthopedists and neurologists interpreting the same X-ray, between psychiatrists and family therapists, and between doctors of various specialties reading the identical EEG or EKG. Much discord between clinician and family and among clinicians themselves occurs over a corollary question to "What is the disease?" namely, "Where is the disease located?" (tissue versus bone, patient versus family, and so on). Moreover, under some circumstances,

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perception of the disease may also reveal what we need the problem to be to avoid interfering with repression. How we explain disease etiology, illness perpetuation, and treatment may betray our unconsciously determined illness ideology, one that compels us to view a sickness in a particular if not exclusive way. Many pioneering studies of malignant family symbioses tend to focus too narrowly on the family itself. The present study takes a naturalistic approach to identifying the boundary of the symptommaintaining behavior and finds that it encompasses the health care system and the participants in the patient's wider cultural ethos.

DIABETES AND CONTEXT After nearly forty years of psychiatric and, more recently, family dynamic research, diabetes mellitus has clearly been established as more than a metabolic disorder caused by the dysfunctional regulation of glycogen deposit in the liver, the mobilization of fats, the uncontrollable rise of blood sugar concentration, and the decreased or total absence of production of insulin by the pancreas (as in much juvenile-onset diabetes) (see Alexander 1950; Minuchin 1974; Segal 1978). Still, the biomedical explanatory model (Good 1977; Kleinman, Eisenberg, and Good 1978) remains the accepted one—an accurate but narrow part model in which the diseased person is seen, in Alexander's (1950) wry words, as a "caloric apparatus" (p. 200) and the disease is defined strictly as one of insulin deficiency and dietary dysfunction. In the nondiabetic the pancreas automatically regulates the amount of insulin in the bloodstream, functioning as a metabolic homeostat. With the diabetic it is otherwise, for metabolic monitoring and adjustment must be a conscious and persistent effort. What the normal person silently accomplishes by part of his or her body system can be accomplished in the diabetic only by the discipline of the whole personality—together with the assistance of others within his or her environment who are themselves capable of selfdiscipline. What is from the physician's viewpoint a compliance problem (that is, a struggle for control) is from the diabetic's a struggle for self-discipline. In the treatment of diabetes, the goal is (after Freud) to replace the pancreas with the ego. From an evolutionary viewpoint, anthropologist James V. Neel (1982) argues, diabetes was originally of selective advantage. Under

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the harsh environmental condition of large and irregular meals that prevailed for human hunting populations, diabetes offered better storage and a more protracted process of metabolism than occurs in those without the trait: The lowered amount of insulin produced from the pancreas delayed the breakdown of sugar constituents, and therefore blood sugar was used more slowly. Only as food supplies became plentiful and regular did diabetes become a disease. Thus what can be seen from the cellular level as maladaptive starvation can be seen from the organism-population-environment relationship as adaptive food use. This frame of reference, however, even if correct, is only one part of the story. The conventional biomedical flowchart of the sequelae of insulin deficiency in diabetes mellitus (see fig. 1), although technically accurate, is incomplete. For it is devoid of context apart from internal pathophysiology and biochemistry. The biological organization is not only adaptive or maladaptive from the point of view of population genetics and the environment but it also becomes available for use by the emotional, familial, and social organization as well. This perspective suggests that we further inquire into precisely what the emotional, familial, and social organization might use the biological process for, an approach that promises to shed additional light on the dynamics of adaptation. I have observed that as a rule, physicians patiently, thoroughly, and devotedly explain procedures, doses, and times of insulin administration to their patients. Likewise, they carefully advise their patients of diabetic diet regimens and regular urine monitoring, which the patient should follow to minimize the likelihood of glycosuria, increased blood sugar, and ketoacidosis, not to mention complications like stroke. Still, the rate of compliance is far from encouraging. Patients return to the clinic with elevated blood sugar or, worse, require hospitalization for ketoacidosis. The round of patient education and self-monitoring then proceeds once again. I quickly noted a "more of the same" quality (Watzlawick, Weakland, and Fisch 1974) to the interaction, which can be summarized in the following exchange: "You must . . . I'll try, but . . . " The disease experience is frequently overdetermined by the core conflict between infantile oral aggressive and receptive wishes, on the one hand, and the need to give, to meet the voracious demands of others, on the other hand. The result of this ambivalence is a monumental internal struggle over self-control (see Alexander

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HYPERGLYCEMIA

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Glycosuria

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OUTCOMES AND COMPLICATIONS

Ketoacidosis—Coma—Death Nephrosclerosis—Death Recurrent Infection—Death Heart Attack—Death Stroke—Death F I G U R E 1. Progressive Sequelae of Insulin Deficiency in Diabetes

1 9 5 0 ) . In the d i f f i c u l t clinical s i t u a t i o n d e s c r i b e d h e r e , the p h y s i c i a n a n d p a t i e n t f o u n d t h e m s e l v e s in a " g a m e w i t h o u t e n d " ( W a t z l a w i c k et al. 1 9 7 4 ) — b a s e d o n c o n d e n s a t i o n s o f " e x t e r i o r i z a t i o n w i t h o u t e n d " — o v e r w h o w a s to control and w h o w a s to be controlled (and resist c o n t r o l ) . In B a t e s o n ' s ( 1 9 7 2 ) t e r m s , a r e l a t i o n s h i p w h i c h t h e p h y s i c i a n

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would have liked to be complementary (succorance/dependency or instruction/compliance) was used by the patient to be symmetrical (a mutual struggle for control that often takes the form: "You must . . . I won't"). Not only did the patient remain persistently dissatisfied (part of his unconscious agenda being to defeat any attempts to satisfy him) and recurrently ill but also the physician's needs to cure and to control were thwarted. As a result, the patient was quickly stigmatized as a management problem. The patient ultimately became a target for the physician's feelings of inadequacy. The physician defended himself by saying, in essence, "There is nothing wrong with me or my medicine; it is you who fail to comply and because of it, remain sick." Unconscious resistance to examining the clinical relationship is often far greater than we imagine (Anstett 1980). Yet realistically, beyond the drain on the clinician's emotions and time the patient was also a drain on the hospital's technology and space resources and not least on society's economic resources. All this is prefatory to a case presentation whose point of departure is the disease of diabetes mellitus. Let me brace the reader not to expect a typical American success story. Indeed, the tale might better be accepted as an American tragedy built on the interlinking of psychosomatic, characterological, familial, medical, and cultural loops. On several occasions I have presented this case to medical students, family practice residents, and physicians' associate students. The unanimous response has been silence and frustration or anger—an anger often directed at me for pointing out the absence of an instant solution that could magically set things right by doing something. The case amply illustrates how the boundaries of a disease entity of a specified organ system (here the metabolic-endocrine system) can be extended to those of the culture itself. Moreover, the unfolding of the case can be understood operationally as our cultural answer to the question "What is diabetes?"— and as the consequences of that definition. In the discussion that follows the case, I address several major conceptual and clinical issues that it raises (Stein 1980; Stein and Kayzakian-Rowe 1978). The names I have chosen for the principal characters are not accidental: Mr. Wozzeck and his wife Marie are drawn from the opera Wozzeck by Alban Berg, based on an early nineteenth-century play by Georg Büchner. In the opera the central pathological character becomes the plaything of others whose pathology is that

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they are captivated and sickened by him. They goad him into destroying himself, just as he provokes their hate. He not only becomes worse because of them but also, in a more unconscious, sinister sense, for them.

CASE STUDY When he first became the patient of a family physician with whom I was working in 1978, Mr. Wozzeck was a twenty-two-year-old white male diabetic. According to a very sketchy family-social history, his juvenile-onset diabetes was diagnosed at age five. Since that time his diabetes has frequently raged out of control, requiring many hospitalizations. His case had become a file that was by 1 9 8 0 perhaps one foot in thickness. The presenting symptom of diabetic acidosis was a familiar one in Mr. Wozzeck's medical history. On the several occasions I saw him during family practice rounds in the hospital, he lay lethargically in bed, wearing a refractory scowl, saying few words, but demanding and complaining when he did speak. In 1 9 7 6 alone Mr. Wozzeck was hospitalized more than twenty times for ketoacidosis, often with impending diabetic coma. He was a regular visitor to the emergency room and a well-known although unwelcome guest to every medical facility in his town of 1 0 0 , 0 0 0 as well as to ERs in at least six surrounding counties. His blood glucose was invariably found to be between 4 0 0 and 8 0 0 on admission. The best that hospital staff hoped for was to get him to feel better, to remove the acetone from his urine, and to lower his blood glucose to about 2 0 0 and send him home. However, no sooner did he get home than he mixed large doses of insulin with beer and other carbohydrates like hamburgers, which he consumed steadily. Mr. Wozzeck's presenting himself to the emergency room and for admission to the hospital seemed to be the only way in which he attempted to bring himself and his diabetes under control—only to go out of control as soon as he left. His medical record read like a broken record. A person could begin reading anywhere and discern the same theme over and over again. For instance, at one point Mr. Wozzeck was admitted to the hospital with uncontrolled diabetes and severe tonsilitis. His chief complaint was that he had been sick for a week with a severe sore throat. The family physician had given him penicillin, but

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he improved little. The physician then examined Mr. Wozzeck in the emergency room and discovered his blood sugar to be 800. He decided to admit him to the hospital for emergency treatment of his sore throat and uncontrolled diabetes. Two days later Mr. Wozzeck had responded to the penicillin, his acidosis had disappeared, he was eating well, his throat looked better, and his lab work was not unusual except for his normally elevated blood sugar. He was discharged—and the cycle began anew. Mr. Wozzeck was described as manipulative, demanding, bad tempered to the nurses in the hospital, obedient—temporarily—to the physician, refusing to comply with a prescribed diet or following it only for a while, never paying his bills on time, and litigious. During one hospitalization in 1 9 7 9 in which his blood, urine, and food intake were carefully monitored, his wife, Marie, smuggled in an immense cake for him—which made havoc of the medical team's attempt to bring his diabetes under control. Apparently, no one either noticed the cake or did anything about it. The family physician informed me of the event later, describing it as a mere fact that the nursing staff (which reported it) could do nothing about. Only several weeks earlier, Mr. Wozzeck, working irregularly as an oil rigger, had experienced one of his many frequent accidents. A pair of tongs fell on his right hand, causing some minor abrasions on his third and fourth fingers. Shortly after, Mr. Wozzeck experienced yet another episode of ketoacidosis and associated his hand injury with the new flare-up in his diabetes. He attempted to file for compensation, claiming that the diabetic episode was caused by the accident. However, his family physician wrote to the insurance company that no causal relationship existed. The physician, as with his many earlier experiences with Mr. Wozzeck, was in a quandary about how to help. He wondered whether it might be best to transfer the patient to yet another physician. Mr. Wozzeck was frequently labeled a problem patient. It quickly became clear, however, that his problem was not only inside but also outside—a response to problems that others brought to their relationship with him. Early in Mr. Wozzeck's treatment with one thorough and conscientious resident, the resident remarked to me, "I don't blame him for doing what he pleases. He knows that his chances for living a long life are pretty slim. If I were him I'd live it up too. I can understand that he goes and eats what he wants, that he doesn't obey anybody but himself" (broad smile). Here the

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physician, otherwise a meticulous and introspective man, so closely identified with the young patient that he temporarily lost sight of what the patient needed. The physician was looking at his patient through his own fantasies, reliving youth vicariously through his patient. Over several months' time, we discussed his identification with his patient's acting out. Over time as well, his fascination gave way first to anger at Mr. Wozzeck's manipulations and mistrustfulness then to a jaded indifference. When M r . Wozzeck was brought to the emergency room the physician would only do the minimum to "dry him o u t " (that is, bring the blood glucose level of 800 down to 150 or 200) and summarily discharge him. W e discussed his aversion to Mr. Wozzeck, how he attempted to disguise his anger but revealed what he would conceal—in a way matching his patient's behavior, even spurring it on. M y limited work on this case consisted primarily in helping the resident gain insight into his own response to the patient, to help him separate himself emotionally from the patient so that he could respond to the patient as someone distinct from himself. During a hospitalization in 1979, part of Mr. Wozzeck's intensive treatment included a heavy dose of preventive medicine. He was lectured to, admonished, and given demonstrations in how to manage his diabetes. The dietician talked to him. The psychiatrist talked to him. His stepfather talked to him. The hospital clergyman talked to him. His family physician talked to him. It was reported that he did not seem to understand anyone, let alone obey them. He did, however, seem capable enough to navigate the eternally stormy seas of the health care system. Because of the limitations of the disease model, his many clinicians did not recognize that there was more to treat than the disease. Their response was thus limited to more of the same, symptomatic treatment and discharge. Care was episodic, not comprehensive. They did not inquire into the meaning of the illness as a way of life. In a sense, the health care community was part of his disease maintenance. Mr. Wozzeck's out-of-control behavior pervaded many areas of his life. N o t only did he disobey those official care-givers w h o would help him to feel better but while an inpatient he also disturbed patients in the other rooms and often had to be moved. His out-of-control behavior was also reflected in his accident proneness. In 1976 he fell from an oil rig and began to complain of back pain

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(an orthopedic exam was negative). Later in 1978, he was involved in a car accident and suffered three compressed vertebrae. Since then he felt that his back pain had been getting worse and worse. The pain did not radiate and no current neurological damage could be found to account for its persistence. At home Mr. Wozzeck did not check his urine regularly and came to the clinic for a blood glucose test only sporadically. Chronic back pain, frequent nausea and vomiting, tender abdomen, and frequent infection were a part of his way of life. He would rush to the emergency room to be taken care of, then while hospitalized he would impulsively become angry with a physician or with a nurse, sign a release AMA (against medical advice), and leave for home. As much as everyone conscientiously and patiently tried to help him, he thwarted their every effort to bring his disease under control. There seemed to be a suicidal tinge to his gambling with fate (cf. Mirsky 1948; Rosen and Lidz 1949). He demanded that the medical world be responsible for the consequences of his impulsive selfdestructiveness. He demanded that they rescue him, yet he often would bring himself to extremes of danger as if he hoped that one day they would not be able to fulfill the role that he expected of them. Projectively, the world would then be proved no good. His "accidental" death would not be his suicide, it would be their fault. Mr. Wozzeck's family and social history are as chaotic as his medical history. In 1978 he underwent a psychiatric exam as part of his successful attempt to claim disability from Social Security. Apparently, he had been through such examinations before. The following data, summarized from the psychiatric record, are presented from the time perspective of 1978. Mr. Wozzeck's mother is forty-two years old, and his stepfather is forty-four. He has two living siblings, one brother and one sister (both asymptomatic). It is unclear whether these are natural siblings or halfsiblings. His wife, Marie, is twenty years old and they have two daughters, one two years old and the other nine months old. His past religious affiliation is Methodist; no information was elicited about Mr. Wozzeck's current religious beliefs and practices. He stated that he had been diagnosed as having diabetes mellitus around the age of five. H e had been in the hospital many times when he was small, and before the age of six had been hospitalized for an eleven-month period during which they were attempting to control his diabetes. He states that be-

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cause of his illness, his mother considered that he was too nervous to go to school and consequently he dropped out following the second grade. He has never known his father, who left his mother when Mr. Wozzeck was still an infant. He describes his mother as being an alcoholic. He was never able to get along with his mother's second husband and feels that his stepfather does not like him either. At the age of thirteen his mother, who had indulged him, told him to leave home. He then began working on his own and has tried working off and on ever since. The longest that he has held a job was for a couple of months; this was a night security job at which he worked three evenings a week. During this two-month period, he was hospitalized twice; following his second hospitalization he lost his job. (A vicious circle can be noted: He cannot work because he is sick and he is sick because he cannot work.) Mr. Wozzeck has had no formal education and can neither read nor write. The only thing that he can do well, he says, is drive a truck and do mechanical or day labor work, but he cannot do these for more than a few days at a time without winding up in the hospital. He also states that he gets very frustrated sitting around the house so much so he works in the garden or around the house—but this too results in his having trouble with his blood glucose and ending up in the hospital. Mr. Wozzeck says that he recently (1978) tried to go to night classes for people like himself who lack formal education, but discovered that people in these classes were very young and were doing and learning things that he felt he should have known when he was seven or eight years old. This embarrassed and frustrated him. He dropped out shortly thereafter. The psychiatric evaluation concludes that Mr. Wozzeck appears to be a very anxious young man with strong feelings of inadequacy and impotence. He is quite excitable, impulsive, and has rapid shifts in mood. To compensate for feelings of inadequacy, he tends to be verbally aggressive and abusive and defies authority. He has very low ego strength, which makes it virtually impossible for him to cope with outside pressures of any kind. Mr. Wozzeck is unable to handle ordinary stresses of life, resulting in internal emotional turmoil and contributing to his unstable diabetes. He cannot be expected to learn to manage his diabetes and live within any set limitations. The psychiatrist regards Mr. Wozzeck as permanently disabled and concludes that whether or not Mr. Wozzeck receives disability payment, he will never be able to cope with reality or to function well enough to support himself or his family. The consulting psychiatrist evaluated M r . Wozzeck from the point of view of the latter's individual personality, as though his

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pathology were self-contained and uninfluenced by the behavior and motivations of others. Yet the patient did not sustain his pathology exclusively on his own. He was essentially told, " Y o u must learn to control yourself. You will never be able to control yourself. We will even help you to be out of control or look the other way and then resent you and finally reject you—just as did your mother." The psychiatrist's dynamic formulation was plausible, except that it was devoid of context other than the patient's internal state. It is useful to expand the intrapsychic frame of reference to include the interpersonal both in Mr. Wozzeck's past and in his present—with particular reference to his then current relationship to his wife and to health care-givers who got caught in his and their own cycles, respectively, of the need to receive and the need to give. Clearly, the self-esteem needs of health care-givers clashed head on with the self-esteem needs of Mr. Wozzeck. The psychopathic tendency in Mr. Wozzeck's personality would have to be dealt with by a clinician who is quite sure of him- or herself and has resolved the issues of initiative, impulse control, and identity. This is not to invert the psychiatrist's pessimism into fruitless optimism. Rather, it is to make explicit just where all the disease is and more precisely to specify what all the disease is. For instance, consider the episode discussed earlier in which Mrs. Wozzeck brought in a cake for her husband or later occasions in which she similarly smuggled in hamburgers, carbonated beverages, potato chips, and the like. Now both she and her husband had been told innumerable times that he was not to eat such foods— anywhere. They seemed to understand the medical advice but ignored it. Whom, then, should we label as psychopathic—only the identified patient?—or is this rather a Bonnie and Clyde situation where Mr. Wozzeck could not say no to his indulgent wife nor could she say no to him. They both seemed to be in collusion against medical—perhaps any—authority. Moreover, the physician had been unable to induce her to come to his clinic office to pick up a brochure that would help her care for her diabetic husband. Yet the coalition was not limited to two. Hospital staff seemed powerless to limit those who could not limit themselves, thereby becoming part of the disease process. Nurses (female) passiveaggressively expressed their resentment over their patient's apparent though inconstant deference to physicians (male) and his cavalier

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defiance of their slightest request. Many wished he would go away—or die. My starting point, with a paucity of data, was to recognize Mr. Wozzeck's illness as a way of life. A wider perspective on the health care system suggests that because of the "supermarket" style of medical care available, there was no way to limit his abuse of the health care system or for it to limit its "abuse" of him. If and when Mr. Wozzeck became dissatisfied, he simply left the hospital or did not show up for appointments. Acting out was his style of free enterprise. In mid-1979, during one of his relatively diabetic-controlled periods (he was driving a truck as employment), he was caught by the police both smoking and trafficking marijuana and was subsequently put in jail. During the pretrial period, his mother frequently telephoned the family physician he had been regularly seeing, petitioning him to try to do something to get her son out of prison, to write some medical excuse that would exempt him from punishment. The physician refused to comply. Later Mr. Wozzeck himself asked his family physician and a psychiatrist if they could come up with a psychiatric diagnosis that would declare him (a) unfit to stand trial and (b) in need of psychiatric treatment as opposed to imprisonment. They also refused, recognizing his use of the request for therapy as yet another attempt at manipulation. Following his sentencing and immediately preceding his transfer to a federal prison in early 1 9 8 0 , both Mr. Wozzeck and his mother telephoned the family physician to obtain pain medication, which he desperately wanted to take with him. Their demands were turned down. On another occasion Mr. Wozzeck began to refuse to take his insulin. The warden phoned the physician, reporting the new development. As had often occurred before, Mr. Wozzeck threatened an acute diabetic episode as admission ticket to several days' hospitalization. The physician asked to speak with the patient. He told Mr. Wozzeck that he was definitely not going to admit him and that Mr. Wozzeck was sensitive enough to his body to know by now how much insulin he needed to administer to himself. Mr. Wozzeck's test of limits was in vain: The physician remained steadfast in placing responsibility in the patient's hands. Mr. Wozzeck reluctantly backed down—this time. On this occasion the physician truly helped the patient by not helping him (that is, not

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attempting to gratify his aggressive orality). Instead, he addressed the patient's capacity for maturity and responsibility. Taken together, these episodes show how Mr. Wozzeck's family viewed responsibility, how others participated in his lack of selfcontrol, and how he tried to co-opt health care personnel into his private and family pathology by manipulating their good will into giving him license to be again out of control. In late 1 9 7 9 and early 1980, his wife said to the physician that she was considering divorcing Mr. Wozzeck; he was too erratic, too unpredictable, too moody. Once again, in Mr. Wozzeck's view, the world had proved itself to be "no damned good," "out to get me," "leaving me to rot in jail." His insight was projective. Inside was outside—whereas feedback given him was primarily projective identification by others. He was a confirmed gambler in a dangerous game with all-too-willing partners. As Dalmau (1961) notes, in the psychopath there is a relative dissociation of the superego with projection of its role onto society in terms of getting caught and punished. Projection is an ego defense closely related to paranoid defenses and those defenses predominate in the psychopath. I've heard a psychopath rage against the police officer who caught him, but never at himself. There may be several ways of explaining the apparent lack of superego in the psychopath. Whether the mechanisms of projection, denial, undoing, dissociation and reaction formation are all responsible or one more than the other is not as relevant as the fact that the superego is functionally detached from the personality and projected onto society. In order to understand more clearly the behavior of the psychopath, let us keep in mind that the core of the superego is formed by the parents and what the child believes the parents expect. Later on society extends the role of the parents. The functional elimination of the superego then becomes equated with a symbolic murder of father and mother; the persistent attack against society also carries the same symbolism beyond the intrapsychic structure . . . The instinctual behavior of the psychopath is quite possibly a reaction formation against a massive, repressive superego. It is the threat of this overwhelming superego that forces the psychopath to deny its existence and project it symbolically onto society and even then he is not free from it [hence] . . . the need for expiation through external agencies such as hospitalization, jailings, accidents and victimization through acts of fate . . . The psychopath, perhaps more than any other patient, uses reality as a vehicle for symbolic behavior, and transference

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conflicts are acted out in stage-like representation . . . The psychopath uses the death drives as a boomerang without awareness that what he throws out will hit him in the back of the head . . . His violations are frequently so flagrant that he seems to be begging to get caught. Once caught there is a denial of any personal responsibility for being caught, even blatant proclamations of himself as a victim of persecution by the police in a beautiful paranoidal shift. Then of course he is "forced by circumstance" into a dependent repressed position to justify further his rage and the next opportunity to ventilate it against society. (Pp. 444—447, 4 5 2 - 4 5 3 )

The unwelcome truth of the matter is that we need to hate our psychopaths (see Brown 1981). Through them, at least in fantasy, we can disinhibit ourselves—and then punish ourselves through them. Americans admire the crafty and unscrupulous oil wheeler and dealer J. R. Ewing in the television series "Dallas" for the same reasons that they admire the robber baron industrialists and gangsters who flout social norms (cf. Devereux 1 9 8 0 : 1 0 0 - 1 0 1 ) . Often official condemnation is combined with secret approbation. Is it any wonder, then, that psychopaths are so refractory to treatment when we are so ambivalent about what we want from them? A considerable part of their reputed incurability lies in the fact that they play an important unconscious part for us, one which we would lose were they resocialized. Ostensibly seeking love, psychopaths seem only to incur our hate—and their self-hate and rage is then safely projected outward. Mr. Wozzeck appointed family, medicine, and society to serve as his "hidden executioner" (Asch 1980). They—not he—will resolve his ambivalence once and for all by implementing his suicidal fantasy. Though he despises them, he desperately needs them as his restitution. Having provoked their wish for his death, he will be a victim of their hate and will only in that way succeed in killing off the evil, polluted part of himself. Only in death will the purified part of him be once again lovable.

PROBLEM IDENTIFICATION, ITS MEANING AND CONSEQUENCES This case suggests that the diagnosed problem cannot be heuristically isolated or even spatially localized in the patient with diabetes without taking account of the larger maladaptation for which the

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diabetes is symptom and metaphor. The expanded problem consists in a social division of labor, in which only some become debilitated in an organically, psychologically, socially, or familially official way. When we consider the expressive division of labor by affect, we discover that asymptomatic or undiagnosed members of the system purchase their stability and well-being at the price of the sick members of the system, who in turn stabilize the system (cf. Bowen 1 9 7 8 ; Minuchin 1 9 7 4 ; Watzlawick, Beavin, and Jackson 1968). In Mr. Wozzeck's case, the interests of the "health culture" (Weidman and Egeland 1973) models of mainstream American culture, the health care system, family, and patient so overlap that all participants tacitly agree not only to focus exclusively on somatic episodes but also not to explore psychological and interpersonal influences on the illness. This agreement corresponds to what Ferreira (1963) termed a "family myth": The term "family myth" refers to a series of fairly well-integrated beliefs shared by all family members, concerning each other and their mutual position in the family life, beliefs that go unchallenged by everyone involved in spite of the reality distortions which they may conspicuously imply. . . . the family myth is much a part of the way the family appears

to its members, that is, a part of the inner image of the group . . . [It is] accepted by everyone in the family as something sacred and taboo . . . The individual family member may know, and often does, that much of that image is false and represents no more than a sort of official party line. But such knowledge, when it exists, is kept so private and concealed that the individual will actually fight against its public revelation, and, by refusing to acknowledge its existence, will do his utmost to keep the family myth intact. For the family myth "explains" the behavior of the individuals in the family while it hides its motives. . . . to maintain the myth is part of the struggle to maintain the relationship . . . (Pp. 5 5 - 5 6 ,

60) With Mr. Wozzeck the family myth is in reality an extended family myth, which is rigidly adhered to by all participants in the system. For instance, this system includes, and its consensus is further confirmed by, the consulting psychiatrist whose diagnostic impression officially validates the conviction held by all others that the problem is contained within the patient and that nothing can really be done to change the patient. Although much continues to

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be done to help him, that is, to restabilize his metabolic system, such help has so far assured that he will remain sick. Whereas Mr. Wozzeck's demands for ever more regressively infantile status have been met by his ever-widening network of caretakers, those demands reflect unconscious rule setting by those around him to which he is conscientiously adhering. Stated differently, noncompliance is a tacit form of compliance, for caretakers and patient are in fact complying with one another. Patient and cadre of healers, of course, profoundly resent each other, a resentment that surfaces in mutual deviousness as each escalates the passive-aggressive warfare from which they cannot extricate themselves. Health care personnel, at the end of their patience, will resort to triage and turfing. For his part, Mr. Wozzeck becomes frustrated with his treatment and abandons it, only to find rejection and disappointment anew. What is ostensibly a caretaking relationship becomes mutually punitive or sado-masochistic. Issues of cost effectiveness, hospital use, and reality testing all become shipwrecked by unconscious issues that lurk beneath the surface. In the present case, "out-of-control diabetes" is simultaneously a specifiable organic condition and a metaphor for and symptom of a character disorder, a family dysfunction, and social deviance. The entire interpersonal, intrapsychic, and somatic system is simultaneously out of control, yet only one member is labeled— and stigmatized. Numerous studies of illness experience tend to reduce this experience to perception of symptoms, cognitive categories of causation, role behavior, and decision-making processes. There is almost an elegantly mathematical quality to such reports. Yet such accounts possess an unreality that comes from their omission of affective reality, which colors the entire experience. The result of such analytic depersonalization is that description of illness experience often reads like a machine operation or data processing manual. How we answer the question "What is Mr. Wozzeck's problem?" determines how and for what he is treated. Our conceptual model does not merely influence us; it coerces us into transforming the unknown and uncertain into the familiar and manageable—or excluding it from relevance. Our models are Janus-faced; they point to solutions and risk the perpetuation of problems engendered by these solutions. The model determines what kind of data is admissible as evidence. In more technical terms, the case of Mr. Wozzeck

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illustrates how the medical system is a subsystem of the culture whose ethos pervades all structural units. As Benedict (1934) long ago observed, "The significant sociological unit is not the institution but the cultural configuration" (p. 224). From what might be called a metacultural or metamedical point of view, I find that to answer fully the question "What is diabetes?" we must formulate questions that place the disease in the context that accounts for its aggravation. The case suggests at least several questions: "What role does the disease play in M r . Wozzeck's total life?" We could say that for this patient diabetes mellitus is a condition that is exacerbated, though not strictly caused, by his unconscious perception that he is emotionally starving, a dimension rarely addressed in health care. " W h o is diseased?" " W h o needs the identified patient to be diseased?" "What would they do without Mr. Wozzeck's disease?" Finally, "What prevents members of the system pathology from posing these questions?" The latter question pointedly suggests that models of illness are not merely cognitiveperceptual apparatuses that organize data and direct behavior. They are this, of course; but people invest their deepest commitment and affections to particular models. Traditional medicine, with its conceptual model and division of labor, draws its boundary precisely where only one part of its work ends and by doing so involves itself in the family and individual patient myth (cf. Ferreira 1963) that only the blood sugar and glycosuria are out of control and in need of adjustment. It is here that the psychiatrist and family dynamics analyst can demonstrate how the disease is genuinely systemic and psychofamilial—not so much by reading the official clinical record as by listening to the unrecorded hearsay and circumstantial evidence of clinicians' impressions. These impressions give the following picture. Quite apart from the diabetes, but exacerbating it, M r . Wozzeck's mother has always vacillated between overprotection and neglect, clinging and rejection, overfeeding while emotionally starving him, encouraging his grandiose, out-of-control behavior by setting no limits, while later protesting her helplessness to constrain him. Inconsistently caring for him, she failed to teach him to care for himself. From her point of view, the disease justifies her heightened concern for her son. In reality, she uses the disease to intensify her overinvolvement (to the exclusion of her husband). We rightly discern in M r . Wozzeck's acting out, manipulativeness,

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and seeming hysteric naïveté, an oedipal tempting of fate in the never-ending series of near-miss ketoacidosis and emergency room visits in insulin coma. He complies, then rebels, then must atone. He makes the rounds of emergency rooms, family physicians, and clinics, which tightly regiment his life to lower his blood glucose level and enlist a host of specialists to instruct him how to take care of himself. All this is designed to help him keep himself under control—whereas his premise and theirs is that he cannot control himself or be controlled. What is the personal and familial meaning of this premise—a meaning that sustains the relationship? Behind the psychopathic impulsiveness and devil-may-care attitude is a self-destructiveness that has always managed to escape the final climax. But should he not be rescued, it will not be his fault, for he feels responsible for nothing: The world is responsible for him, not the reverse. The oedipal drama is transparent: the wish and fear to possess the forbidden mother, the fact that he does possess her (just as she invests her life in him), his need to undo the successful competition with an ineffectual father, the collusion of a family system that refuses to protect him from the consequences of his fantasies but that instead openly indulges them. His oedipal fate comes from the oracle that is the family itself: the self-indulgent, cold yet rescuing alcoholic mother; the distant, repelling and repelled husband who can effect no change; and siblings who see in their errant brother the chosen one whom they are enjoined not to be like. In the patient the price of Dionysian enjoyment is punishment. In adolescent and adult life the patient finds, in spouse and medical staff, those who will give him succor, but never enough, those whom he can frustrate but who must take care of him—until by accident his disease, dissociated from his self, kills him (cf. La Barre 1969). As ethnographer I stand outside the cultural model on which this case is based. From this vantage point, very little data has been elicited on Mr. Wozzeck's early psychological development, the effect of family dynamics on illness episodes, the effect of character structure on disease process, an identification of precipitating events for acute diabetic episodes, his day-to-day life routine at home and work, and the like. We find it difficult to know Mr. Wozzeck as a person distinct from the stereotype that enshrouds him. Mr. Wozzeck, the identified patient and scapegoat for the system,

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is only the official casualty; all those who participate in the system are casualties as well. We are diminished to the degree that we must diminish him. Just as his defenses cut both ways (protection and further vulnerability), so do ours. The clinicians' determined insistence that Mr. Wozzeck control himself while they likewise insist that he cannot control himself, attests to their own problem of control, to what his seeming uninhibitedness represents to them. His myriad caretakers are as fascinated with him as they are disgusted with him, perhaps so repelled because so attracted. He is a frequent topic of lively conversation and humor, as though those talking about him are vicariously participating in his exploits. We often relish what we contemn, which is why Wozzeck's psychopathy can be likened to the trickster figure in primitive folklore (Radin 1956). He is a kind of modern Till Eulenspiegel whose merry—and deadly—pranks violate what we strive to uphold and indulge what we struggle to repress. His psychopathy speaks to us, because it is our own rebellious wish beneath our acceptance of responsibility. Unofficially admired and feared, envied and applauded, he acts out all reversals of civility. He is everyone's badness. He is the universal cultural antihero. His violations and excesses are everyone's release. How can we set unambiguous limits for one whom we appoint to violate those very limits? Are not his excesses our silent revolt against moderation? It is of the essence of the trickster figure to be highly skilled in the art of social negativism and to conduct this defiance publicly. He or she knows the rules well enough to manipulate them and spurn those who defend them. In many patients we recognize the trickster by the feelings they elicit in us—we rue their next appointment but secretly admire their rebellion against norms that we have incompletely internalized. Trickster patient and responsive doctor are obverse sides of the same psychodynamic coin—which is why the two cannot help but irritate each other. If control is the hallmark of the responsive doctor, out of control is the preserve of the trickster. The emotional meaning of illness can be culturally decoded if only we will listen to what the patient is saying about him- or herself and what others are saying in response to the patient's recurrent symptoms. Consider that if the psychophysiology of Mr. Wozzeck's history of diabetes is emotional starvation (craving for the mother's affection transformed into obsession with nourishment

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or food; see Gadpaille 1952; Meyer, Bollmeier, and Alexander 1945), then is not his passive suicidal style, reinforced by the passive homicidal style of his familial and medical network, that of poisoning? To atone for his largely externalized rage and guilt, he must turn nourishment into self-inflicted punishment. The wider American cultural context should also be discerned: a nation founded by rebels against a parental monarchy that would control it from afar; the motto proclaiming the right to "life, liberty, and the pursuit of happiness"; the fascination with ruthless outlaws and men of action on the side of the law; the contemporary insistence on "doing my own thing" and that others "get off my back"; and so forth. What Mr. Wozzeck is getting away with is far from idiosyncratic: He is in a sense an extreme living out of that portion of the cultural ethos. To flaunt doctor's orders, to leave the hospital AMA, is to violate the cultural law. Self-control is firmly built into medical education. Physicians are admonished to maintain self-discipline and a professional habit of objectivity at all times. They are enjoined never to give in to emotion but to control themselves so that they can always be in control. Their control requires compliance from the patient. In this context, such a patient as Mr. Wozzeck is an affront to all that medicine represents and to its assumptions about how people are supposed to behave as patients. At the same time, since he serves as something of a cultural safety valve for unacceptable wishes and actions of those who are expected to maintain their self-control at all times, he is invariably sent the double message of "control yourself—here's how" and "act out—we'll watch." By so doing, his care-givers collude in the cycle that assures he will go out of control. The emphasis on control in this case led to clinical failure. Failures are instructive, for they take us to the heart of cultural values, premises, expectations, decision making, and the like. In a limited sense, Mr. Wozzeck's treatment was a success since each hospitalization lowered his blood glucose level. However, culturally real success is synonymous with cure, and diabetes cannot be cured, only at best controlled. Over the long run, Mr. Wozzeck's recurrently elevated blood sugar—not to mention his accident proneness, his litigiousness, his manipulation, his psychopathy—points to clinical failure.

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BEYOND CONTROL The psychopathic Mr. Wozzeck craves to be hated, his projected self-hate boomeranging back upon him (though beneath it he hopes against hope that someone will find something to love, something redeemable, in him). Health care providers willingly comply with his wish through exteriorizations of their own. The struggle between them centers around the cycle of acting out and control. Acting out is one of Mr. Wozzeck's few channels for delineating a personal boundary between himself and those who would control him, for their attempts to induce him to control himself are experienced as coercive. Yet, as we have seen, his out-of-control behavior is not his private property either. On the one hand, his deviancy is an act he performs on the stage of others' fantasies; on the other hand, his tempting of Fate is a call for attention and an act of revenge against those whom he hates and whom he knows hate him. Even his desperate drawing of a personal boundary does not separate him from those whom he needs and needs to hate. The best chance Mr. Wozzeck has for being helped would be for those in the health care system not to try so hard to help him. It is crucial to know what help has come to mean to him and them: help = coercive control = punishment. By relinquishing the need to control him, health care-givers would not set themselves up again and again as the old adversary whom he must defeat even as he demands rescue. His care-givers try too hard, insist too diligently, and spend too much time talking to or at him—and hardly any time listening. From our biomedical viewpoint we redundantly ask, " W h y doesn't he do X or Y ? " when what we need to know is " W h a t does he do?" not just in relation to his diabetes but also to the rest of his life. Clinicians could profitably listen to his understanding of his illness, his categories of experience, and his worldview and use these as "bridges" (Weidman 1979:86) toward helping him in terms that are meaningful in the context of his life. There certainly would be ample time for this during his lengthy hospitalizations! Should his multiple clinicians not wish to be part of his repetition compulsion, they could best learn how to treat the disease by defocusing on the disease (cf. Watzlawick, Weakland, and Fisch 1974), which in fact has become a symptom, and refocusing on the

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person—on M r . Wozzeck's way of life into which the disease fits so perfectly. Mr. Wozzeck might improve, have fewer and less calamitous diabetic episodes, were a more inclusive explanatory model adopted, one in which the biomedical model is seen as a subsystem. As with the explanatory model, so for the treatment as well: The technical procedures administered to the patient would be less likely to lead to a battle of wills if they were contained in a relationship in which health care providers—who genuinely cared—participated with the patient as partners in his treatment. Caring, though tangible in a different sense from insulin, is the ingredient absent from his life for which he most deeply hungers. At a more abstract level, what I am suggesting is transcultural communication, which facilitates the transition to biomedical treatment by refusing to impose unicultural assumptions and procedures on a member from a different culture (Weidman 1979). As Weidman forcefully argues: Very little encouragement and reward can be built into clinical interactions with patients from different cultural backgrounds as long as unconscious but profound disregard for their views permeates every clinical transaction within an orthodox facility. (P. 86)

By extension, people do not have to be grossly different in their cultures for us to consider how best to use their cultural understandings and practices toward their improved health. The fact that distinctions are subtle does not make them less important; they become more of a challenge to recognize. Moreover, the therapeutic effect of a clinical encounter is precipitously diminished by the unconscious disregard for the patient's meaning and relationship system, which is itself unconsciously motivated by a fascination with and aversion to what the patient's behavior represents to the clinician—as we have seen in this case. N o t only does Mr. Wozzeck have profound problems over delineating his personal boundary and identity but also these problems are immeasurably confounded by health care practitioners whose own boundary and identity problems are reciprocally dissociated and displaced onto the patient. This leads me to a further observation on the persistence of such chronic diseases as diabetes mellitus. Medical teaching facilities regularly use teaching patients or teaching families to illustrate

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pathology through formal interviews and even by having the patients themselves lecture on their infirmities. Certain patients and families can be counted on to appear and demonstrate their disease, so to speak. Many of them look forward to the opportunity of telling their tale, of displaying the incurable affliction. Being a perpetually active patient is not only their personal and family identity but it is also an identity in which the medical setting maintains an active interest, even as it treats the same patient or family for the disease. A patient's boast, " W h a t would they do without us?" gets to the heart of why the patients never get better or become less dependent on the medical facility. After all, they are appreciated for their pathology. The patient and family adopts the clinic or medical institution into their extended family, which in turn needs them to remain sick. Perpetual care comes to require perpetual illness.

CONCLUSION In recent years a conceptual distinction between disease and illness advanced by Eisenberg (1977) and Kleinman (1980) has been widely adopted in the medical and medical behavioral science literature. According to this framework, disease refers to "abnormalities in the structure and function of body organs and systems," whereas illness denotes "experiences of disvalued changes in states of being and in social function; the human experience of sickness" (Kleinman, Eisenberg, and Good 1 9 7 8 : 2 5 1 ) . Illness is the experiential response to disease. Following the lead of M r . Wozzeck's case, I would propose that disease and illness need not be two distinct processes, one biomedical and the other sociosymbolic, the latter a response to the former. Instead, in some cases the intrapsychic and interpersonal experiences may figure prominently in the etiology and maintenance of a disease state (cf. Watzlawick, Weakland, and Fisch 1 9 7 4 ) . The formulation I have offered in this chapter for the relationship between a psychodynamically informed contextual view of the patient's diabetes mellitus and the biomedical approach to the disease is related to a recent formulation advanced by Kleinman ( 1 9 8 2 , 1 9 8 3 ) and Kleinman and Hahn ( 1 9 8 1 ) . Kleinman ( 1 9 8 3 ) draws our attention to "the social construction of all sickness in-

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terpretations" (p. 98). In this case I have attempted to identify unconscious contributions to sickness episodes and to their interpretation by doctor, patient, family, and so on. Kleinman makes the salient points that illness and disease are commonly different labels, imposed by different persons or groups of persons and applied at different times during a sickness episode. Although Kleinman initially had proposed that disease constituted the biomedical definition of a sickness episode and that illness constituted the patient's and family's labeling and experience of that episode (that is, response to disease), Kleinman (1983) subsequently reversed the sequence based on his work with Hahn. According to this new view, illness is defined prior to disease, and with good reason. When we fall sick we (including physicians themselves) first experience illness. This is the culturally constituted, socially learned response to symptoms that includes the way we perceive, think about, express and cope with sickness. . . . When the sick person first visits a practitioner, the two initially communicate in terms of culturally shared illness idioms. But soon thereafter the practitioner begins to further construct the sickness in the technical terms of his theoretical system, be it biomedicine, psychoanalysis, chiropractic, or traditional Chinese medicine, for example. This technical reconstruction constitutes disease. Disease, in this formulation, is not simply the biomedical interpretation of illness, but the interpretation by any practitioner, be he professional or folk healer. (Pp. 9 7 - 9 8 )

Now I would not wish to insist with Kleinman that the sequence invariably progresses from illness to disease, for a person may not feel sick, yet during a routine checkup the physician may diagnose a heart murmur or cancer and the patient subsequently may feel sick; likewise, a patient or family may acknowledge the presence (even life-threatening nature) of disease that has been medically diagnosed yet not assume the sick role (see Stein 1982). The importance of Kleinman's formulations lies elsewhere, namely, in the fact that he compels us to inquire how the patient and family think, feel, and act with respect to the disorder before diagnosis by a physician and following subsequent medical labeling, presentation, and treatment. It is essential to know how diabetes mellitus is diagnosed and treated in the family and by the patient, with specific attention paid to possible unconscious meanings of the symptom

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in the patient, family, and lay network. Such attention might help us to detect when physician, patient, and family may be obtaining primary and secondary gain from the complementary illness of which the explicit focus is the biomedical disease in the patient. In the preceding case, I have not only identified the physician's disease model and the patient's and family's illness models but also I have attempted to advance a psychoanalytically informed interpretive model that can help us to understand the motivation underlying their use. The psychoanalytic model may also help us to identify etiological pathways in the patient's personality, family, and wider social field that partly determine (or overdetermine), prolong, and exacerbate his biomedically defined disease. Kleinman's model helps us to understand the pathway to treatment; the approach I have presented may likewise help us to understand the pathway to the development of disease. This case of diabetes mellitus compels us to rethink the question of the site of disease (see Stein 1979). Intrapsychic process, interpersonal relationships and meanings, and organ system functions can be construed as the communication system that overdetermines the site of pathogenesis and pathology (Stein 1983). In diabetes, the lower secretion of insulin or its absence would be a necessary, though not sufficient, condition for the exacerbation of the disease. In a masterful analysis of Greek mythology and drama, Devereux (1953) uncovered the culturally scotomatized Laius complex where pathology of paternal homosexual and filicidal aggressiveness toward the son was necessary to precipitate the complementary Oedipus complex in the excessively father-fearing son. Indeed, Devereux demonstrates that it is the pathology of the house of Atreus and beyond that culminates over generations in the oedipal tragedy. Likewise, Sander (1978) proposes that "the presence of a chronically unhappy marriage of blame and recriminations is often a curtain 'superseding' individual and usually complementary neuroses" (p. 169, my emphasis). In this discussion of diabetes mellitus, I have suggested that a complementarity exists in the somatic, intrapsychic, familial, and interpersonal division of labor that includes members of the health care system. The cycle of pathology includes the identified patient but is not exclusively contained in him. In short, his biology, his disease process, is inseparable from and responsive to those internal and external meanings and relationships that function as a system.

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M y goal in this chapter has been to discover ethnographically the kind of system in which the patient's recurrently out-of-control diabetes makes sense.

NOTE This chapter is dedicated to the memory of Alban Berg (1885—1935), composer of Wozzeck. An abbreviated version of this chapter was published in journal of Psychoanalytic Anthropology 5 (Spring 1 9 8 2 ) : 1 7 3 - 1 9 6 . © 1982 by the Association for Psychohistory, Inc.

REFERENCES Alexander, Franz. 1950. Psychosomatic Medicine: Its Principles and Applications. New York: W. W. Norton. Anstett, Richard. 1980. The Difficult Patient and the Physician-Patient Relationship. Journal of Family Practice l l ( 2 ) : 2 8 1 - 2 8 6 . Asch, Stuart S. 1980. Suicide and the Hidden Executioner. International Review of Psychoanalysis 7:51—60. Bateson, Gregory. 1972. Steps to an Ecology of Mind. San Francisco: Chandler. Benedict, Ruth. 1934. Patterns of Culture. Boston: Houghton Mifflin. Bowen, Murray. 1978. Family Therapy in Clinical Practice. New York: Jason Aronson. Brown, Peter H. 1981. The New Super Villians. Parade Magazine 12 April:20—22. Dalmau, Carlos J. 1961. Psychopathy and Psychopathic Behavior: A Psychoanalytic Approach. Archives of Criminal Psychodynamics (Special Psychopathy Issue): 443—455. Devereux, George. 1953. Why Oedipus Killed Laius. International Journal of Psychoanalysis 34:132-141. . 1980. Neurotic Crime vs. Criminal Behavior. In Basic Problems of Ethno-Psychiatry, translated by Basia Miller Gulati and G. Devereux. Chicago: University of Chicago Press. Pp. 1 4 8 - 1 5 4 . Ebel, Henry. 1980. How Nations "Use" Each Other Psychologically. Journal of Psychoanalytic Anthropology 3(3):283-294. Eisenberg, Leon. 1977. Disease and Illness. Culture, Medicine and Psychiatry 1(1):9—23. Ferreira, Antonio J. 1963. Family Myth and Homeostasis. Archives of General Psychiatry 9 : 5 6 - 6 1 .

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Gadpaille, W. J. 1952. Psychic Factors in the Etiology, Course, and Management of Diabetes Mellitus. Senior medical thesis, manuscript. Good, Byron. 1977. The Heart of What's the Matter: Semantics and Illness in Iran. Culture, Medicine and Psychiatry 1(1):108—138. Kleinman, Arthur. 1980. Patients and Healers in the Context of Culture. Berkeley, Los Angeles, London: University of California Press. . 1982. Neurasthenia and Depression. Culture, Medicine and Psychiatry 6(2):117—190. . 1983. Editor's Note. Culture, Medicine and Psychiatry 7:97-99. , Leon Eisenberg, and Byron Good. 1978. Culture, Illness, and Care: Clinical Lessons from Anthropologic and Cross-Cultural Research. Annals of Internal Medicine 88:251-258. , and Robert Hahn. 1981. The Sociocultural Model of Illness and Healing: Review and Policy Implications. New York: Rockefeller Foundation Working Papers. La Barre, Weston. 1969. They Shall Take Up Serpents: Psychology of the Southern Snake-Handling Cult. New York: Schocken. Meyer, A., L. N. Bollmeier, and F. Alexander. 1945. Correlation Between Emotion and Carbohydrate Metabolism in Two Cases of Diabetes Mellitus. Psychosomatic Medicine 7:335-341. Minuchin, S. 1974. Families and Family Therapy. Cambridge, Mass.: Harvard University Press. Mirsky, I. Arthur. 1948. Emotional Factors in the Patient with Diabetes Mellitus. Bulletin of the Menninger Clinic 12:187-194. Murray, G. 1911. The Rise of the Greek Epic, 2d ed. Oxford: Clarendon Press. Neel, James V. 1982. The Thrifty Genotype Revisited. In The Genetics of Diabetes Mellitus, Serono Symposium No. 47, edited by J. Kobberling and R. Tattersall. New York: Academic Press. Pp. 283-293. Radin, P. 1956. The Trickster: A Study in American Indian Mythology. New York: Bell. Rosen, H., and T. Lidz. 1949. Emotional Factors in the Precipitation of Recurrent Diabetes Acidosis. Psychosomatic Medicine 11:211—215. Sander, Fred M . 1978. Marriage and the Family in Freud's Writings. Journal of the American Academy of Psychoanalysis 6(2):157—174. Segal, Julius. 1978. "Psychosomatic" Diabetic Children and Their Families. National Institute of Mental Health, Research Grant: M H 21336, U.S. Government Printing Office, DHEW Publication No. (ADM) 7 8 ^ 7 7 . Stanton, M. Duncan. 1977. The Addict as Savior: Heroin, Death, and the Family. Family Process 16(2):191-197. Stein, Howard F. 1979. Rehabilitation and Chronic Illness in American Culture: The Cultural Psychodynamics of a Medical and Social Problem. Journal of Psychological Anthropology 2(2):153—176.

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. 1980. Illness as Metaphor: Review Essay. Journal of Psychological Anthropology 3(1):33—38. . 1982. The Annual Cycle and the Cultural Nexus of Health Care Behavior Among Oklahoma Wheat Farming Families." Culture, Medicine and Psychiatry 6 ( l ) : 8 1 - 9 9 . . 1983. An Anthropological View of Family Therapy. In New Perspectives in Marriage and Family Therapy: Issues in Theory, Research and Practice, edited by Dennis A. Bagarozzi, Anthony Jurich, and Robert Jackson. New York: Human Sciences Press. , and Soughik Kayzakian-Rowe. 1978. Hypertension, Biofeedback, and the Myth of the Machine: A Psychoanalytic-Cultural Exploration. Psychoanalysis and Contemporary Thought 1(1):119—156. Stierlin, Helm. 1972. Family Dynamics and Separation Patterns of Potential Schizophrenics. In Proceedings of the Fourth International Symposium on Psychotherapy of Schizophrenia, edited by D. Rubinstein and Y. O. Alanen. Amsterdam: Excerpta Medica. Pp. 169—179. Watzlawick, Paul, Janet Beavin, and Don Jackson. 1968. Pragmatics of Human Communication. New York: W. W. Norton. , John Weakland, and Richard Fisch. 1974. Change: Principles of Problem Formation and Problem Resolution. New York: Norton. Weidman, Hazel H. 1979. The Transcultural View: Prerequisite to Interethnic (Intercultural) Communication in Medicine. Social Science and Medicine 1 3 B : 8 5 - 8 7 . , and Janice A. Egeland. 1973. A Behavioral Science Perspective in the Comparative Approach to the Delivery of Health Care. Social Science and Medicine 7 ( l l ) : 8 4 5 - 8 6 0 .

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4

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"How Could I Eat Uncaring Food?": From Identified Patient to Family Pathology

This chapter explores the interplay of clinical observation, assessment, and intervention in the case of a malnourished woman. It interweaves two stories: the official clinical story about the patient, her family circumstance, and what happened; and the unofficial story within a story. This second report narrates the unfolding of the observers' deepening awareness of types of clinically salient data, which added new dimensions to clinical observation, interpretation, and intervention. If, as Alexander (1979) writes, "participation in a circumstance is always a form of observation" (p. 64), then even assessment is a form of intervention. The chapter, then, should be read as a story about the identified patient, the patient's family, and the clinical assessors/intervenors alike. It is not only an interesting case in its own right but is also a parable of the relationship between clinical observer and the clinically observed in any encounter. What we can do is constrained by what we can know—and what we cannot allow ourselves to know. If I assert that the following report is a species of clinical ethnography, then I must immediately say that it is not only about the malnourished woman and her family but also about how I and my physician colleague, Timothy A. Wilson, went about observing. In our writing we locate ourselves in the narrative; that is, we make explicit our point of 143

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view, identify the clinical shortcomings that initially derived from adherence to that point of view, describe how we came to adopt more encompassing frameworks—and rediscover the fact that behind all data lies a point of view. Despite our fond wish that our preferred map be the territory, it is not. At best, our final map will be a provisionally better one than the original. The earliest version of this chapter consisted of a clinical case report for a behavioral science conference on a "difficult patient" seen at a family medicine clinic. When I first wrote it with family physician Timothy A. Wilson in early 1 9 7 9 , 1 was still several years away from formulating a model of complementary interlocking unconscious systems in medicine. What in this case urged me in that direction was the vague feeling from the outset that somehow this patient's symptoms were not quite all her own, that perhaps someone else needed her to be sick for them for unconscious reasons of their own (see Chapter 3, "The Contest for Control," which arrives at the same conclusion). This feeling led me to a psychoanalytic family systems viewpoint on her inability to separate from her family. It then gradually became evident that this nascent framework of reciprocal psychodynamics that had helped to account for interpersonal relations within the family was not limited to the patient's family and that the boundary of the symptom had come to encompass the health care system and the community itself.

WHAT YOU SEE IS HOW (WHERE, W H Y . . . ) Y O U LOOK This study discloses how closely intertwined are conceptualization, observation, diagnosis, and treatment (Fabrega 1974; Foster 1976; Stein and Kayzakian-Rowe 1978; Von Mering 1961). It demonstrates how an initial medical diagnosis, although technically correct, was misleading because it was limited to one context that was in fact part of a wider system of contexts. The diagnosis inadvertently distorted our assessment of the condition and its etiology and initially misdirected the treatment plan. The disease in question was initially labeled "malnutrition," more specifically, an "eating disturbance." Only gradually did we come to understand the patient's eating problems as part of a system of shared meanings and conflicts within the family relation-

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ship structure, the basis of which is the problem of separation. T o do this, however, it was necessary to redefine the biological membrane to encompass the social membrane of the family "organ system." This redefinition in turn required that we be prepared to observe what we ordinarily would neither look for nor notice, since it is at variance with the dominant cultural model underlying medicine, which directs our attention to certain types of data and away from others. Thus this chapter discusses not only the specific illness process but also how it was discovered, an ethnographic approach which the clinician might adopt in patient care. In recent years medical anthropologists have stressed the decisiveness of the illness context in the illness experience (Kleinman et al. 1 9 7 5 ; Kleinman, Eisenberg, and Good 1 9 7 8 ; Stein 1976). The question now is how to integrate content and context. If medicine is to encompass a holistic human biology, then it is necessary to adopt the perspective of a relational biology; that is, a biology that encompasses relationships and meanings, intrapersonal and interpersonal, that profoundly affect the somatic and psychological processes of human beings. Language, symbolism, unconscious meaning, and family dynamics are not extrabiological but are speciesspecific attributes of a distinctly human biology (La Barre 1968, 1972). Humans are as specialized in prolonged dependency and in the inexpugnably universal trinity of the nuclear family structure as they are in their chromosomal structure and hormonal distinction by sex. It is only because of our medical blinders that we select for attention only what occurs beneath the skin and then define it as legitimately (and tautologously) biological. The family is one context that has been poorly conceptualized in medicine. Traditional Western medicine has viewed the family as an assortment of discrete potential patients, as a unit of patient recruitment sharing only a genetic history, and as the background to clinical assessment and management, which occupies the foreground. Yet a family consists of a relationship structure and a relationship history (Bowen 1978), which affects the development, onset, maintenance, management, and remission of illness. It is quite legitimate, then, to turn to the family as an ethnographic unit of health and illness. The clinical anthropological focus does not have to be the traditionally studied tribe or ethnic group but can just as legitimately be the family, for ultimately the clinical issue is

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how cultural material is used by people in their conscious and unconsciously influenced health care decision-making strategies (Devereux 1 9 5 6 ; Stein 1979). There is the danger, however, that the family can be falsely perceived as a closed system, just as anthropologists have often treated a given culture as a closed system. A similar problem pervades medicine, as we can see by the reductionism of medical specialties. Frequently, psychiatrists will attempt to demonstrate that the problem is all in the psyche; internists will assert that it is all in a diseased organ; family therapists will claim that it is all in the family; and so forth. As a consequence of the medical division of labor that falsifies the systemic nature of human biology, clinical correlation conferences are held in which members from the different disciplines often can barely understand one another's language. Each medical specialty manifests the characteristics of a culture with its distinct worldview, language, epistemology, rituals (clinical procedures), and the like. Clearly, any attempt to understand the multiple "semantic networks" (Good 1977) of an illness, that is, the meanings assigned to the nature of the illness, must include not only those of the family but also those of the clinicians who interact with the family and the identified patient. Retrospectively, we recognize that the major source of resistance to the redefinition of our patient's eating disturbance was the collusion between (a) our own culturally embedded biomedically derived model of disease (Kleinman 1973) and (b) the patient's family's insistence that the patient had always been "different." W e all concurred upon the same metadiagnosis: that whatever is wrong with the patient is contained exclusively within her. From cross-cultural studies we know that the formulation of an etiology determines what we know, what facts we gather (and omit), and what we then do therapeutically (Eisenberg 1 9 7 7 ; Kleinman, Eisenberg, and Good 1 9 7 8 ; Stein and Kayzakian-Rowe 1 9 7 8 ; Von Mering 1961). What had initially prevented our redefinition of the problem was the congruence between the "family myth" (Ferreira 1 9 6 3 ; Stierlin 1973) and the medical-cultural model of disease. The way medicine in Western culture treats the patient can unwittingly become part of the patient's problem precisely because medicine shares the cultural myth with the patient's family and enters into an unconscious collusion with them. How, then, did we extricate ourselves from the culture-bound

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and family-bound conceptualization of etiology, diagnosis, and treatment? We did this essentially by adopting a holistic, as opposed to a reductionistic, point of view (Stein 1978). As we listened to the patient's interpretation of her illness and as we encountered a different perspective through a home visit with her mother, it became clear that we were dealing with a systemic pathology, one that was not simply organic or that was exclusively a problem of the patient.

CASE PRESENTATION: MALNUTRITIONDISEASE, SYMPTOM, AND FAMILY SYMBOLISM Joan Berlin, the identified patient, is a divorced woman in her mid-thirties. She is the eldest of three siblings, having one younger brother and sister. She has one son. Joan, her widowed mother, and married siblings all live in the same southern city. Joan came to the emergency room with problems relating to food. She was not eating and had weight loss, diarrhea, nausea, and abdominal pains. She emphasized that she had long ago rejected materialistic society, as represented by her rich mother, Mrs. Berlin, and preferred a life-style built around mysticism, astrology, and health foods. She was a set of contradictions. She said she ate only white (clean) but not red (blood) meat. She smoked organic cigarettes, not commercial ones—but still smoked constantly. She preferred natural medicines but readily accepted synthetic medicines she felt would work (such as Tylenol for pain). She hated materialism but refused to stay in the house without an air conditioner and consistently chose lobster and steak (in spite of the latter being red meat) over less expensive natural or organic foods. She also claimed to be a vegetarian. She was admitted to the hospital for malnutrition, previous office visits having failed to increase her weight from eighty-two pounds. She complained that she had no money of her own and that her mother gave her food only as a means of selfishly holding on to her. Upon admittance to the hospital, following the malnutrition workup, she did accept food. She gained three pounds the first day. Then her mother visited her, entering the room with an angry "What the hell are you doing here!" They argued, Joan was "unable

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to eat," and was subsequently observed to give her food to her friends. Thereafter, she only smoked and drank coffee. It was at this point that more appeared to be involved in the patient's illness than was seen at first. From daily talks with the patient in the hospital and from a home visit to the mother, it became impossible to decide who was telling the "true" story or whether either story was indeed true. Both mother and daughter appeared to need to distort the truth with their own bias. In talking about the other, each appeared to be talking about emotionally charged aspects of herself. We discovered that their history needed to be viewed not as facts but as perspectives—as personal and family myths, that is, as shared defensive distortions (BoszormenyiNagy 1966; Ferreira 1963; Stierlin 1973). Food became an important clue to understanding Joan's personal pathology and how this was embedded in family pathology. Food served as a powerful mechanism of control and dependency. Joan sought hospitalization because she felt she was being starved by "poverty," that is, by the failure of her wealthy mother to support her. Mrs. Berlin felt that Joan was negligent—even destructive— with all she had been given. "I gave my daughter an expensive house, carpeting, furniture, everything. She misused it and didn't keep it up. So I took it back." Joan described as one of the happier periods of her life when she and several of her friends had set up a communal living situation in this home hundreds of miles from her mother, a living arrangement in which Joan ruled the household. The mother described how Joan had "always been different." Even as a child Joan would extravagantly choose lobster rather than hamburger at restaurants. She complained that her deceased husband always sided with Joan against the mother, who wanted to order more moderately priced food. But the daughter got her way—with the food and the husband. Apparently, there had always been a special relationship, a collusion, between Mr. Berlin and Joan, which Mrs. Berlin seemed helpless to balance. Not only Mrs. Berlin but her two other children as well deeply resented this favoritism. Mrs. Berlin bitterly complained that on many family trips she would want to stop at an inexpensive motel or restaurant but that Mr. Berlin would insist on "only the best," oblivious to their then more modest financial status. Both he and Joan were characterized as unrealistic, yet we got the impression that

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Mrs. Berlin never put her foot down and said a decisive no, thus contributing to subsequent excesses. Joan described a recent incident in which her mother took her to the store to buy food for her: M y mother constantly complained about the high price of things as we went down the aisles. That did not prevent her from taking them, though. When we stood in the checkout line, she embarrassed me. She threw down the money which was short of the amount needed and left me to pay the rest and carry the groceries to the car. As though I was responsible for the huge bill. I found that I was short of money and had to borrow it from the person in the line, although it was a small amount.

Joan could have returned some items to the shelves and taken only what the mother's money would cover. She did not. She took the groceries to the car, told her mother about the scene in the line, and refused to comply with her mother's demand that she return with her mother's money to repay the person who had made the loan. Joan said, "Both of us were upset. We left arguing. I did not want to eat the food under those circumstances." During Joan's hospitalization, Dr. Wilson and I made a home visit to the mother. Her house, located in an upper-middle-class neighborhood, was huge. Joan's mother greeted us at the door, dressed in what appeared to be a formal gown. The entire decor of the house was elegant and opulent. As soon as we were seated, she brought us coffee in delicate china cups. Our interview lasted perhaps one hour. Immediately after we left, Mrs. Berlin phoned her daughter in the hospital. The phone call upset Joan very much. Joan said to Dr. Wilson that she was afraid we were siding with her mother against her and that we now probably thought Joan was worthless and bad because her mother so selflessly gave her so much, whereas Joan was an ungrateful daughter. She now wanted to present her case: What my mother gives is not free. She attaches strings to everything. She makes it look like I'm a freeloader. Well, I'm not! She has probably led you to think that I don't have to pay rent for the house that I'm living in. It's true she owns the house, but I pay rent to her!

Joan then related the grocery store episode and concluded with a poignant accusation: " H o w could I eat uncaring food?"

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It was initially tempting to identify the patient as victim and mother as persecutor. But such a distorted scenario would have failed to recognize that both mother and daughter keep the pattern going. Pathology had to be seen as systemic, not simplistically located in the patient—whom the mother too is eager to identify as the sick one. The linear cause-and-effect model does not work here. What better describes the relationship is a patterned sequence that is cyclical, one that can be said to begin at any point. For instance, the mother insists that if she does not feed her daughter, Joan will starve. So Joan is a poor victim in need of maternal rescue. At the same time, the mother resents while needing Joan's parasitic dependency, overgives yet begrudges the very expensive food or furniture she insists they cannot afford, and demands that Joan be thankful for her reluctant bounty. On the grocery shopping trip described earlier, Joan herself chose expensive items; Joan did not tell her mother that she felt her mother was herself shopping extravagantly; when abandoned at the checkout counter, she did not correct their joint error by taking only as much as the mother's money could purchase and did not allow the mother to repay (through her) the debt. Joan blames her mother for attaching strings to everything, yet Joan neither untangles nor cuts the strings when an opportunity arises. Joan, as victim, becomes persecutor and the mother becomes the victim. The mother as persecutor then punishes Joan for being extravagant, ungrateful, and destructive, rescinding a gift (such as the house), withdrawing support, and creating a scene—all of which place Joan in the position of victim, a position from which she now needs (and waits) to be rescued by mother. The mother protests to us, " D o you want me to let her starve? Where else would she live? How could she take care of herself? . . . " The cycle is complete. During the home visit, a seemingly trivial incident confirmed for us beyond doubt the family pattern and became the pivotal point at which we switched from thinking exclusively about Joan as patient to family as problem. Joan's mother was seated in the middle of a luxurious couch. We, the two writers, were seated in chairs in front of her, each with a small coffee table for his cup. Suddenly, a cat walked into the living room from the hallway behind us, leapt onto the expensive couch, and began clawing at the luxuriously soft material on the wide ledge of the couch behind

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the mother. The mother scowled but did not move. She ordered the cat to stop clawing but did nothing to stop it. She explained: This is Joan's cat. I'm keeping it for her. I just hate it. It takes over the whole house, jumps on anything it wants. Joan's been saying for weeks that she'd come over one day and take him back to her house, but she's never done it. So meanwhile, I'm stuck with him. He gets into everything, won't listen to anything you tell him. But I can't leave it outside—something might happen to it. So I'm the one who has to look after him, feed him. Joan just won't take the responsibility for him. W h a t am I to do?

For us, this episode distilled the essence of Mrs. Berlin's relationship with Joan, not merely Joan's cat. Through it, we were able to connect into a single pattern dozens of episodes that were identically structured. This event compelled us to defocus on Joan, the identified patient, and refocus on the enigmatic system of symbols, meanings, and conflicts that characterized the relationship between Joan and Mrs. Berlin. It was no longer accurate to look at Joan as a person separate from her mother, for the two were in fact inseparably, symbiotically fused. Mother and daughter were part of each other in virtually every thought, word, and deed. Just as the mother was unable to set limits for the cat, she was also helpless in the face of her daughter's needs and unceasing demands. Mrs. Berlin complained that Joan and the cat were out of control, but seemingly she needed them to be out of control and then to blame them for their misdeeds. Joan's acting out met some of Mrs. Berlin's unconscious needs. Following Freud, we might say that Joan's character disorder results in a public enactment of Mrs. Berlin's anxiety neurosis. Her private fantasy is repressed and delegated to Joan to act out vicariously for her—and to have that acting out duly punished (La Barre 1969). If Mrs. Berlin did not have Joan to act out for her, then Mrs. Berlin would perforce become her own problem. As frequently happens in families with symptomatic members (either psychiatric or psychosomatic), when the sick member begins to improve, a previously well member suddenly becomes sick. The price of Mrs. Berlin's apparent health is Joan's illness; the price of Mrs. Berlin's normality is Joan's deviance; the price of Mrs. Berlin's compulsive control is Joan's acting out. Joan's bizarre behavior complies with

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her mother's order that Joan be "crazy." In disobeying her mother, Joan obeys her. Is there, however, any way in which Joan might disobey her mother and not obey a tacit injunction? That is, might there be a way that Joan could attempt self-control that was not already preempted or controlled by her mother—that was not more of the same pattern (Watzlawick, Weakland, and Fisch 1974)? Yes, by differentiating her body from that of her mother, making the first steps toward a distinct self through a refusal to eat "uncaring food." Joan's body symbolized her autonomy; her use of her body (first vomiting, then refusing to eat) dramatized her separation and her vigilant defense against maternal intrusion. The woman who refuses to eat is voraciously hungry emotionally and discriminates on the basis of emotional need between "bad food" associated with her mother and "good food" associated with the hospital. In her earlier ideological rebellion against—flight from—her mother, Joan had associated the image of the persecutory, force-feeding mother with all the accoutrements of her mother's life-style (for example, red meat). The only way to eat nutritious food that was not poisoned by overlays of meaning from the mother was to find a form of food that symbolically represented the opposite of her mother. Joan found this in natural, organic foods or, more accurately, in the identity the health food movement was able to provide her, if only temporarily. Over the years mother and daughter have said to each other, in essence, "The problem with me is you; if only you were to change, then everything would improve" (Hall 1977) and at the same time, "I don't want you to change; I need you as you are so that I can remain as I am." Both have been bound by the injunction, "Don't grow up." Each has said to the other, "It is you who keep holding on to me," which means dissociatively, "I can't let go of you." Each has sabotaged the other's—and her own—slightest venture toward independence. Money has played a crucial role in maintaining the symbiosis. Mrs. Berlin has protested that "Joan doesn't know how to do anything. She would be destitute without me." Joan has protested reciprocally that "I don't have a job. I wouldn't know what to do." Both mother and daughter have drawn the other's bank account of guilt, each unable to help the other assess realistic financial needs and possibilities.

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Conflict over Joan's enormous telephone bills (which her mother always, but protestingly, paid) further symbolizes the destructive symbiosis, that is, their inability to establish limits for themselves or each other. During the home visit, these bills were among chronic problems Mrs. Berlin enumerated. "I've always paid for her calls. She calls her friends all over the country. I gave her a phone so that I could call her if I wanted to talk with her. But this is unreasonable. And there's no way I can stop it." Advice giving, although often therapeutically futile, may be diagnostically revealing. When we suggested that perhaps she might remove the phone, hence be rid of the problem, the mother replied, "I can't, what if she needs to talk to me?" We then suggested a compromise, that Mrs. Berlin insist that Joan pay for the long distance calls whereas she would pay for local calls. This time the mother retorted, "Joan wouldn't agree to it. And I must have a phone to reach her. What do you want me to do, leave her out in the cold? She doesn't have any money of her own. How would she pay for it?" Here the mother complains of how much an emotional and financial burden Joan is, yet holds on to this burden. Likewise, Joan complains that her mother exercises so much control over her life, yet she resists doing anything to help her own separation. Joan insists: I cannot live in a house [the one she rents] without air conditioning. Only my mother can afford the air conditioning . . . I am forced to stay here [with her mother] so my dyslexic son can attend special classes . . . I can't get away from my mother because she can reach me anywhere [on the telephone, which Joan needs her mother to subsidize] . . . I absolutely have to let my mother know where I am. She needs me too much for me to disappear.

Each protests that the other person is utterly dependent on her. In practice, the family myth needs to be inverted to become psychological truth (Boszormenyi-Nagy 1966). "She needs m e " means "I need her." Food, cat, telephone, and the like are all content issues through which the conflictual relationship is played. Mother and daughter sabotage both their own and each other's attempts to set limits. Each defeats herself and the other. The mother, in essence, says, (1) " Y o u are out of control"; (2) "Control yourself"; (3) " Y o u can have anything you want"—which leads to

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Joan again becoming out of control. The mother's tacit injunction in fact is "Be out of control." The relationship can be expressed by a formula: The mother says, "I need to take care of you," which translates into the family myth, " Y o u need me to take care of y o u " ; Joan says, "I need you to take care of me," which translates into Joan's personal myth, " Y o u won't let go of me." These myths confirm Joan's function as a person dependent on a mother who is dependent on her dependency. The mother needs Joan to be a dependent child, and Joan in turn needs her mother to take care of her as a needy, helpless child. Yet these needs are ridden with resentment. The mother resents spending a lifetime of giving, so she disqualifies the intent of the gift through attaching strings. Joan, resenting her unending dependency, either destroys or despoils her mother's gifts or ideologically repudiates her mother's life-style while demanding from her mother all the luxuries of the materialistic life she despises. Rejecting her earlier devotion to her Baptist religion, she now commits herself to astrology, mysticism, the occult, and to a God who works through her, whose boundaries are her own, and who gives her everything she needs (with no strings attached). Rejecting the conventional marriage of her parents (and her own two earlier marriages), she chooses communal living and unmarried sex. Abjuring artificial and synthetic foods, she preaches a Spartan life of natural, organic foods, and medicines—although she is not above eating lobster and steak, and requesting Tylenol to relieve pain and Dalmane to induce sleep. What at first glance is a bundle of contradictions is in fact symptomatic of a pervasive ambivalence in every domain of life. Although it was not possible to obtain, a complete psychiatric history, it was possible to discern in this present relationship a repetitive pattern that reflects a relationship history. Moreover, the incident involving Joan's cat told us much about the mother-child relationship in Joan's earlier experience: giving the cat the run of the house, seeing the cat's destructiveness, resenting the cat's freedom and its destruction of everything she gives, feeling helpless to limit the cat's activities, and so on. Another incident with Joan's ten-year-old son augments this pattern. For his birthday, Mrs. Berlin gave him a motor bike, but with the strict stipulations that he could not take the bike home with him and that he could play with

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it only while he was at his grandmother's home. The gift, then, was another way of keeping her grandson around. How does all this help explain Joan's symptom choice, malnutrition? All Joan's previous symbolic and ideologic attempts to separate herself from her mother had failed: Neither privatistic religion, group living, astrology, or geographic distance could affect a genuine separation. Malnutrition can be understood as an attempt to stop her mother's force feeding and begin to establish, however bizarre it may appear, her own boundaries and her own identity. The abdominal cramps, nausea, and vomiting were a somatic rejection of her mother's indigestible food. Joan could no longer "stomach" her mother's intrusive presence or remain dependent on a relationship that did not nourish her. Food, then, must be understood as a metaphor for the mother-daughter relationship. Once in the hospital, safe from the control of her mother and under the control of Dr. Wilson, Joan readily accepted food. She wished to be fed the "good food" of a nuturant relationship—to begin all over again with a good, mothering person. Here the value of the hospital environment as an asylum cannot be underestimated (Wilmer 1962). In the hospital the physician, Dr. Wilson, was able to make the orders and set the limits—and on one occasion, though unintentionally, kept the mother waiting outside Joan's room until he was finished with his medical rounds. After the mother's visit, Joan again refused food. Nonetheless, when Joan left the hospital she felt in decidedly good spirits. The hospitalization served a personal function that was not part of the medical rationale: to separate the mother from the daughter, to help the daughter do what she alone could not do (at least for now). It was midway through the hospitalization, following our home visit, that we discovered the disease behind the symptom (malnutrition) and discovered further the psychological and interpersonal function of Joan's hospital stay and presenting symptoms: the wish for a mother-ectomy! From the mother's point of view, the home visit may have been the start of a daughter-ectomy, although this attempt was less dramatic than Joan's. Frequently in psychotherapy, a patient may respond to the therapist's interpretations with a string of affirmations followed by negations: "Yet, doctor . . . but." In subsequent sessions, however, the patient may come up with these same insights

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or suggestions as his or her own idea or may report new activities based on these insights without being aware of their origin. What is dynamically important here is that an initial resistance is followed by subsequent (unconscious) acceptance and internalization. During the home visit, we acted toward the mother not as if she were the cause of Joan's problem but as a human being who was herself trapped in a web she did not understand. By talking with her as a separate person with her own needs, we facilitated the start of her own separation. Our intention was not to attempt to have them sever their relation but to enable it to be less mutually consuming and destructive. By working with the mother (who was not the identified patient) and helping to strengthen her autonomy even slightly, we were indirectly helping her to be able to partly let go of her daughter (Bowen 1978). One suggestion we made to Joan's mother was that after Joan's discharge from the hospital, they meet for lunch or dinner at a hamburger restaurant, that is, a place of the mother's choosing that was inexpensive. This was not merely a matter of relationship engineering. Its success depended upon whether the mother felt autonomous enough to show congruence between word and deed. W e learned that they did not meet at a hamburger shop but rather at a yogurt parlor! Mother and daughter ate an inexpensive lunch at a health food restaurant—quite a compromise. Only two weeks after Joan's discharge, Joan proposed that she and her mother go into business together. The business?—a health food store. Mrs. Berlin would invest the initial capital, Joan would run the store, and a friend of Joan's would provide the business know-how. Although this proposed venture had much in common with Joan's previous grandiose and unrealistic schemes, it demonstrated considerably more integrated organizational and realitybased thinking. Life would need to be rationally planned and coordinated, not lived for the moment with utter disregard for the future (on the premise that mother would always be around to rescue her). Certainly, food remained a dominant theme, except that here Joan would be the motherly one whose business would be to feed good food to her community! In concept, the venture would combine both the materialistic and spiritual worlds in a realistic way. There remained the danger that if the enterprise collapsed, Mrs. Berlin would have still further evidence of her daughter's incompetence— and need for her, that is, if Mrs. Berlin were not supported in her

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own separation process. As events turned out, Joan's friend declined her offer for a more lucrative opportunity elsewhere. Shortly after, Joan began to look around the city for a job—something she had never before done. She found a satisfying and adequately paying job as instructor in a shop that deals with growing natural foods, handcrafting clothes and home ornamentations, and the like. For Joan, the job she chose allowed her to integrate two previously mutually exclusive worlds; it also allowed her to be in the relational position of the one who teaches, who gives—who has something to give. It is at this point that we last saw Joan and Mrs. Berlin, some five months after Joan's hospitalization. If the movement from illness to health can be characterized by a progression from a static, closed system to a more open, flexible one, then we would be inclined to say that the family's, not merely the patient's, health had decidedly improved (Beavers 1976; Speer 1970). Clinical science is not prescience. Nevertheless, if our argument is correct, we know the ingredients of continued recovery and of recurrent symptoms because we know now the meaning of malnutrition to Joan and her family. Only by deciphering malnutrition as a symptom of repetitive family patterns could we reorient our treatment plan from an exclusively biomedical perspective to a more comprehensively psychodynamic and relational perspective.

DIAGNOSIS, INTERVENTION, AND CONTEXT: THE STORY WITHIN A STORY The case study began as a clinical consultation requested by Dr. Wilson, who had admitted the patient to the hospital. Joan Berlin had presented a constellation of symptoms that were difficult for him to pinpoint diagnostically. His preliminary diagnosis was the most concrete available: malnutrition. Still, that only described the fact that she was undernourished, not why or why now or in what contexts that malnutrition made sense. Over time, Dr. Wilson obtained a clearer picture of her symptoms, intrapsychic defenses, and conflicts. However, since symptoms, defenses, and conflicts are simultaneously intrapsychic and interpersonal, we wondered about the environment that originally nourished and now helped to sustain them. For a while we considered diagnosing Joan as having anorexia nervosa, but we soon realized that this would hardly help

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our ignorance, though it would have assigned a more culturally respectable label to her symptoms. We needed better perspectives, not simply more acceptable labels. We had the further problem of distinguishing the patient's accusatory fantasies about her family from their reality, for the interpersonal reality of the patient's family was part of the "symbiotic orbit" (Mahler, Pine, and Bergman 1975) from which she could launch herself. Despite her flight from her family over hundreds of miles and many years, she was emotionally inseparable from them. Indeed, they even financed her rebellion! If she had difficulties in separating from them, perhaps they also had difficulties in separating from her. As the case demonstrates, this is the shared unconscious conflict that gave rise to bizarre communication in the family. Pathological communication requires reciprocal externalization of disavowed intrapsychic contents to keep it going; without the latter, there would be no need for the former. Thus it was a matter of learning the pattern of the former and the underlying meaning of the latter. Admittedly, this emphasis on the interpersonal system is a departure from the orthodox psychoanalytic focus on the intrapsychic system of the patient. Yet, as Devereux (1980) pithily remarks, one should discard the untenable pseudo-analytic shibboleth "Reality is not analyzable" and then, precisely because of a legitimate preoccupation with infantile fantasies, pay attention to actual adult behavior that reveal the basic nature of unconscious parental destructiveness and seductiveness. (P. 160)

The complementarity between the Oedipus (son) and Laius (father) complexes that Devereux argues for also characterizes the intergenerational problem of separation anxiety discussed in this chapter. We wanted to find out the intrapsychic story contained in Joan but acted out in behalf of her entire family. This required that we shift our original focus. The daughter's protracted delinquency, her foredoomed bid at separation, makes no sense except as a revolt against her family's— especially her mother's—ambivalence toward her. Not unexpectedly, in her rebellion she was even more conforming than her parents could ever be. The patient's symptom choice makes sense only if we know the familial and cultural context that made it a

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mutually acceptable way of dealing with her anxiety. As Devereux (1980) writes, " T h e child or adolescent acts out the illness of its parents—that it has the symptoms appropriate to the latent immaturity and psychic illness of its parents" (p. 168). Although excessively harsh on the parents who, because of their own unconscious anxiety, project their conflicts into their offspring, Devereux cuts through to the essence of the complementarity between pathology of parents and offspring: We have the so-called female juvenile sex delinquents whom we have made and therefore deserve. A society that discourages maturity, degrades love, cheapens valor, sneers at ideals, and pursues shoddy objectives can expect nothing better than sons who are either hoodlums or else timid conformists and daughters who are either sluts or else champion church-social pie-bakers. The sickness is ours—they only have our symptoms. We carry the germs—though they have the fever. It is we who are disoriented and anxiety-ridden; they are but our "deputy lunatics"—the scapegoats of our sins of omission and commission. (P. 168) The daughter complex, that is, the identified patient's strange life-style, was common gossip all over town. The mother complex, or more accurately the family complex, eluded us at first because of the fact that the family appeared to the outside world to be model citizens—productive, respectable, and the like—and the fact that the family diagnosis of their deviant-sick daughter was labeled and confirmed both by the official medical system and public consensus. During our home visit, the mother's accusing plaint— though always in the service of wanting to "understand" and "help" her daughter—perfectly mirrored that of the daughter who was not present. If the daughter, the identified patient, was "socially negativistic" (Devereux 1980) toward her mother, against whom the daughter defined herself, the mother was with equal force socially negativistic toward the daughter, defining herself as everything the daughter is not. This mutual recrimination and digging in was fueled by what Wynne (1965) calls a "traded dissociation" whose defensive function is to prevent "painful self-awareness" (Sander 1979), which would awaken the threat of separation anxiety. In this family projection system, mother and daughter (and sibling subsystems as well) use each other as an obstacle to change—all the while blaming

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the other for failing to change first. ("If you make the first move, then I'll feel safe enough to let down my defenses slightly"—which guarantees that no change will take place, a gambit used from family relations to international diplomacy). On a final theoretical note, this case illustrates Melanie Klein's (1955) concept of identification by projection: "Identification by projection implies a combination of splitting off parts of the self and projecting them on to (or rather into) another person. These processes have many ramifications and fundamentally influence object relations" (pp. 311—312). For both mother and patientdaughter, the split off, devalued part of the self is perceived to exist inside the other person. Each feels herself to be an extension of the other. With respect to diagnostic issues, the history of this chapter's reception in manuscript form over the past several years is as fascinating as it has been demoralizing (to the writers!): It has been a veritable projective test that discloses what readers want the diagnosis to be, what data they select to make their case, and what data they omit. The common denominator is the wish to label and simplify the case—to make it manageable—rather than accept its complexity. Nowhere in this report do we advance a diagnosis. Our concern is the pattern, the psychodynamics, the fit among symptoms, unconscious conflicts, and family and community relationships. The result is that the case is, as one commentator remarked, "neither fish nor fowl." We have refused to commit to a single label—and in medicine that makes everyone nervous. T o say that the patient is a malnourished woman with anorexia nervosa and borderline personality is helpful but still insufficiently comprehensive of her situation. As though this were not enough, since the focus of the report is primarily ethnographic rather than strictly psychoanalytic, family dynamic, or anthropological, the case falls through the cracks in professional turf as well. What the problem is (diagnosis, label) and to whom it belongs (discipline, methodology) seem to be more important than exploring the problem and seeing what it has to offer (see also Stein and Pontious in press). Several commentators chided us for missing the obvious diagnosis—anorexia nervosa—since the material clearly pointed to a disturbance in eating (see Bruch 1973a, 1 9 7 3 b ; Minuchin, Rosman, and Baker 1978). They wish that we had discussed the case by

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building on the appropriate literature, which presumably would strengthen our case. However, over her long career as a patient, Joan had frequently been diagnosed as schizophrenic, although she has not been known to manifest the primary symptoms of the disease. We do not insist that Joan is not anorexic; we will acknowledge that she is also anorexic, but we would not limit our assessment or intervention to this way of viewing her problem. The diagnosis perhaps tells us more about those diagnosing than about her. She makes her way in the world rather deftly! She epitomizes every physician's (including psychiatrist's) "problem patient," " c r o c k , " "turkey," and manipulator. She is the nadir of every physician's and hospital ward's day. Health care-givers are relieved when she leaves and would rather she never return. The response which she elicits from them is identical with that of her mother's response to her. Yet if only they would have used their awareness of their own frustration, their wish to reject her, as tools to help her understand herself—instead of defending themselves against her and abandoning her (which is her fear and wish combined)—she would long ago have been treatable. The behavior of health care professionals in her experience confirms her conviction that a world filled with bad mothers is poised to attack her. Dr. Wilson is the first physician in her impressive medical curriculum vita who took time to listen to her and not leap to a diagnosis with which to distance himself from her. The achievement of anthropology is the ethnographic method of free-floating attention in which the observer truly does not know what to look for and does not feel the compulsion to look for anything in particular (La Barre 1978). Such a method that permits playful exploration is also the one that permits the discovery of the significant, which might differ from the expected. It is the spirit of inquiry that made research an essential part of the treatment in this case. As we noted earlier, how we identify the patient's problem is influenced by how we as clinicians and investigators think about the problem. " H o w Can I Eat Uncaring Food?" unfolded as a case within a case, which documents our change in thinking during the course of our contact with the patient and thereby our greater access to data which we had not earlier recognized as valid. The changes in the management and outcome of the case came about only as a result of changes in our perception of the case.

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The symbolic meaning of the patient's malnutrition to all participants in the patient's network had first to be admitted to our consciousness before we could modify our strategy in the case proper. This in turn reminds us that one context (among many) in which the symptom can be embedded and that can thereby impede healing is the physician or health care team. This lesson in learning not to solve the wrong case and the importance of the clinician's growing awareness is hardly unique to this case. Let us briefly examine some additional case material that urges us toward the same conclusion.

VIGNETTE 1 Some years ago a black female family practice resident sought consultation with me on a patient of hers who had recently attempted suicide. Initially, the case was presented by the resident as concerning only the patient; soon we discovered the case within the case, namely, her countertransference to the patient and eventually her transference to the consultant, which altered her perception and action in the case itself. The story can be pieced together as follows: One night the physician, a woman in her thirties, was awakened in the hospital resident's quarters by a call from the emergency room. A young black male in his twenties had made a suicide gesture by lightly cutting his wrists. She hurried to the ER, admitted the patient, and supervised his care during his hospitalization. On subsequent days she found herself feeling increasingly annoyed with the young man and made hostile, ridiculing remarks to him. She resented him but could not understand why. She sought a consultation with me. Among her first words were "Couldn't he at least have made a real suicide attempt? This one was so paltry. If you're going to get me out of bed, you'd better do yourself in good!" My first thoughts were about the externally induced stress on an on-call resident, moonlighting to make ends meet, sleeplessness, responsibility, and so on. As the resident made further associations about the patient, it became apparent that more than these current situational pressures had made her edgy. The young man's suicide attempt had reactivated her anger toward her husband who had killed himself with a gun some years earlier. Moreover, her skin was of deep, almost blue-black, pigmentation, whereas both her

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husband and the patient were quite light-brown complected. As she continued to talk, she realized that she was seeing her husband in many attributes of the patient: keen intelligence, manipulativeness, depressiveness, and now the parallel of tragic circumstances. It was as though in this countertransference she was reliving her husband's death. She temporarily had dealt with her separation panic by resenting the patient rather than directing anger toward her husband. Over the course of several consultations, she was able to gradually differentiate between the husband representation and the patient representation and was likewise able to discover something which she liked about the patient. However, as the consultations progressed, a transference toward me, a white Jewish male, appeared. Her idealization of me rapidly alternated with vilification. She gradually came to realize that she especially resented the high status that light pigmentation was given within the black community (as well as the white) and she associated high status and specialness in general with whiteness, Jewishness, and maleness and with myself in particular. She also wanted to possess those putative ethnic-linked characteristics that she disparaged and envied in her dead husband, the patient, and me. At least in part, ethnicity for her had become an outer stage upon which she enacted—and now tried to understand—an inner drama. Her transference to me clarified her countertransference to the patient. (It should be added that the official focus of all these consultations remained that of patient care, since that approach permitted the resident to deal with personal issues without feeling vulnerable—that is, an intolerable passivity which she associated with being a patient.) Gradually, she began to deal with her husband's death, which she had been unable to mourn because of her anger. By the end of several weeks of discussion, she had begun talking—and feeling—more about her husband and less about either the patient or myself. Her work with the patient also improved.

VIGNETTE 2 At a family medicine grand rounds, a sixty-five-year-old female patient with her first "seizure" was presented. The history, physical exam, and laboratory results all seemed equivocal. N o one present

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could even confidently label the episode as a seizure. We knew only that it was associated with her single episode of nausea and vomiting. One resident, feeling thwarted by our uncertainty, whimsically suggested inducing her to vomit so we could determine whether she seized again. W e wondered aloud whether the mysterious seizure had been caused by virus or stress. One veteran faculty physician admonished the group, " Y o u might as well learn now that there's a lot in medicine that we can't explain." He ventured the plausible explanation that "some elderly respond to stress with seizures." Imperceptibly, the patient's problem had been superseded by a group problem: frustration over a lack of clear-cut explanation, diagnosis, and decisive course of action. An eloquent faculty physician then succinctly revealed our case within a case: " W e feel incumbent to treat things, even though we don't know what they are. The common wisdom is 'Let's put her on something [medication], then we can call it something [said sarcastically] with a diagnosis'" (from notes 1 June 1984). The patient's still unknown problem did not evaporate after this, nor did the fear of legal reprisal for physician errors ("We're looking down the gun barrel," as one physician put it). Nevertheless, the group had articulated and at least partly worked through its countertransference to the case. Despite the group's initial inclination to take flight into action, patient management proceeded cautiously.

VIGNETTE 3 This third and final supplementary example begins with a family medicine resident consulting with me about an alcoholic patient. He was treating a thirty-one-year-old alcoholic (the patient's and physician's label alike) who had requested referral to a distant alcohol treatment facility where he could be assured of anonymity. The resident then asked me, "Where can we send the patient for treatment far from here where he's not known? He's sensitive about being found out." I mentioned a number of facilities but asked to hear more about the case to be certain that in honoring the patient's request (part of the manifest explanatory model) we would not simply be colluding with the problem. We subsequently learned that the patient's solution to intense anxiety had always been to take flight to distant cities, including remote treatment centers for

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alcoholism. Since physician-patient rapport was excellent, I encouraged the resident to help his patient "sit still" with the anxiety rather than simply assist the patient's wish to flee. Patient and resident worked together for several months during which the following history was pieced together. The patient had been treated by his family physician for various minor medical problems and had previously admitted to moderate alcohol intake. He now anxiously reported his recent alcohol intake of approximately a fifth of Scotch every three or four days. He stated that for the past several weeks he had been drinking nightly, at least two mixed drinks per night, and that almost each weekend he became intoxicated to the point of not remembering many of his activities of the night before. In addition, the patient stated that he had been recently arrested for driving under the influence of alcohol and had an upcoming court date for resolution of that charge. He initially spoke of himself as self-employed and able to maintain his normal work schedule despite his heavy daily drinking. Additional information clarified that he and an older brother currently manage a family business. There is constant competition between the two of them and with their father for ultimate control of the business In his family history, the patient reported alcoholism in his father and at least two of his eight brothers and heavy drinking in most of his other brothers. The patient is the third oldest of eleven children. They are of Irish Catholic heritage. The patient describes his family as very close knit. This patient had been married for approximately two years and was now divorced. In his family there is constant competition among the male siblings for one another's girlfriends or potential wives—to the point of sexual involvement if that can be accomplished. It is noteworthy that of all the symptoms present in this family, only the patient's alcoholism is discussed by the family as a focus for needed treatment. The behavior of everyone else is accepted as normal. The patient's family has frequently encouraged him to seek alcohol detoxification. The patient stated that when things became intolerable he would take several short trips to several cities simply to get away. He would stay alone in a hotel for three or four days and remain intoxicated. In the past when he attempted to limit his alcohol

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intake, family members would deride him for not drinking at family gatherings. He recalled a recent incident at his mother's birthday party. During a time when he had been trying to stop drinking and had made that fact widely known, his mother approached him and seductively asked, "Aren't you going to have a drink?" In a related incident, he had just discarded all the alcohol in his old apartment and moved to make a fresh start when one of his brothers came for a visit, bringing him a substantial supply of liquor as a housewarming gift. Over time, the patient's bouts of withdrawal, flight, and drunkenness diminished in intensity and frequency. The resident sought to reassure him that although he might have relapses, his abstinence was not a prerequisite for admittance to counseling. As the patient better came to understand his family pattern and its profound meaning for him, he felt less compelled to comply with it. As we might expect, he experienced increased family pressure to return to the fold, to be the " g o o d " bad boy. Although his drinking remained an issue in treatment, the resident did not treat it as the only or the most crucial issue. Whatever modest success we can claim for this case we attribute at least in part to three factors: (1) our initial refusal to comply hastily with the patient's explicit explanatory model ("I am an alcoholic; send me to a treatment center far away") and our subsequent inquiry into the meaning of the request; (2) our ability to tolerate our own anxiety in not complying with the patient's attempt to place us in the role of rescuer (which would have merely confirmed him as utterly incompetent to handle his anxiety and would also have colluded with his definition of the family as " b a d " ) ; and (3) our interest in eliciting the patient's implicit explanatory model (including his emotional role in his family), which we believe helped the patient to understand the meaning of alcohol in his own mental functioning and family integration and enabled him to consider alternatives to his management of anxiety. What Boyer (1983) writes of the insight-oriented psychotherapist is an attitude that might well be adopted by all physicians, for at bottom the clinical issue is everywhere the same: For the insight-oriented psychotherapist, belief is no substitute for evidence; his hypotheses are to be tested against emerging data and the therapeutic alliance is vitally important. He invites his patient to retain

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an observing part of the ego and interprets regression as defense and/or resistance. He sees the patient's wish to view him as omnipotent as part of transference phenomena and his aim is to free the patient both of transference distortions and of his relationship with the therapist. He knows that abrupt symptom removal frequently disguises underlying psychopathology. He views suggestion therapy to be not infrequently a manifestation of countertransference problems. (Pp. 239—240)

CONCLUSION This chapter has documented how a medical problem came to be redefined and the consequences of that redefinition. From the medical point of view, the patient's malnutrition was unambiguously a disease process. Joan's eating disturbance, however, proved to be symptomatic of what had become simultaneously a somatic, intrapsychic, and familial disturbance. In the context of her familial emotional structure, Joan's refusal to eat represented a symbolic attempt to separate herself from her mother—a move toward health, however misplaced—whereas from the viewpoint of the family, the patient's effort to break away from the family was defined as pathological. Food played an important role in this case, not only literally as nutrient or its lack, but also as a metaphor of relationship, selfhood, control, and personal boundaries. To our emaciated patient, food was indigestible. Abdominal pain, nausea, and vomiting are certainly real. However, what made the food indigestible is what food represented: Joan's relationship with her mother (both real and internalized). " H o w could I eat uncaring food?" told us that not only food but also the relationship that contained it was disgusting. Joan's gastrointestinal system dramatized somatically her intense interpersonal struggle with her mother. O u r observations led us to redefine the illness process so that the disease and diseased patient were seen as symptoms of a personality and relationship dysfunction not confined to the gastrointestinal organ system. This does not magically eliminate the need to understand the event from the point of view of the organ system—an extreme position often taken by cybernetically inclined family therapists for whom the relationship alone is often seen as the disease. Instead, we are led to introduce other organ systems beyond the somatic, domains of medically salient facts that place the event in a wider context—indeed, that redefine the nature of the event

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(Eisenberg 1 9 7 7 ; Stein and Kayzakian-Rowe 1 9 7 8 ; Watzlawick, Weakland, and Fisch 1974). This case is not intended to document a success story; its purpose is to suggest a direction that medicine would benefit from both conceptually and clinically. The case study is more important in how it taught us to improve any clinical investigation by observation than in specific conclusions reached. We propose that the method of clinical ethnography can help clinicians learn how to know, assisting them to expand (not replace) the traditional biomedical criteria of what to know. The principal lesson of this clinical study is that the most salient clinical data were acquired serendipitously, that is, through the inductive accidents afforded by observation unencumbered by the dictates of what to look for.

NOTE Portions of this chapter were written with Timothy A. Wilson, M.D., a family physician now practicing in Kansas City and Smithville, Missouri.

REFERENCES Alexander, Linda. 1979. Clinical Anthropology: Morals and Methods. Medical Anthropology 3:61-107. Beavers, W. R. 1976. A Theoretical Basis for Family Evaluation. In No Single Thread: Psychological Health in Family Systems, edited by J. M. Lewis, W. R. Beavers, J. T. Gossett, and V. A. Phillips. New York: Brunner/Mazel. Pp. 4 6 - 8 2 . Boszormenyi-Nagy, I. 1966. From Family Therapy to a Psychology of Relationships: Fictions of the Individual and Fictions of the Family. Comprehensive Psychiatry 7:408—423. Bowen, M. 1978. Family Therapy in Clinical Practice. New York: Jason Aronson. Boyer, L. Bryce. 1983. Approaching Cross-Cultural Psychotherapy. Journal of Psychoanalytic Anthropology 6(3):237—245. Bruch, H. 1973a. Eating Disorders: Obesity and Anorexia Nervosa and the Person Within. New York: Basic Books. . 1973b. Anorexia Nervosa. In Emotional Factors in Gastrointestinal Illness, edited by A. E. Lindner. Amsterdam: Excerpta Medica Amsterdam. Pp. 1—15. Devereux, G. 1956. Normal and Abnormal: The Key Problem of Psychiatric Anthropology. In Some Uses of Anthropology: Theoretical and

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Applied, edited by J. B. Casagrande and T. Gladwin. Washington, D.C.: The Anthropological Society of Washington. Pp. 23—48. . 1980. Female Juvenile Sex Delinquency in a Puritanical Society. In Basic Problems of Ethnopsychiatry, translated by B. M. Gulati and G. Devereux. Chicago: University of Chicago Press. Eisenberg, L. 1977. Disease and Illness: Distinctions between Professional and Popular Ideas of Sickness. Culture, Medicine and Psychiatry 1:9—23. Fabrega, H., Jr. 1974. Disease and Social Behavior. Cambridge, Mass.: MIT Press. Ferreira, A. J. 1963. Family Myths and Homeostasis. Archives of General Psychiatry 9 : 4 5 7 - 4 6 3 . Foster, G. 1976. Disease Etiologies in Non-Western Medical Systems. American Anthropologist 78:773-782. Good, B. 1977. The Heart of What's the Matter: Semantics and Illness in Iran. Culture, Medicine and Psychiatry 1 : 1 0 8 - 1 3 8 . Hall, E. T. 1977. Beyond Culture. Garden City, N.Y.: Doubleday/Anchor. Klein, Melanie. 1955. On Identification. In New Directions in Psychoanalysis, edited by Melanie Klein, Paula Heimann, and Roger Money-Kyrle. New York: Basic Books. Pp. 3 0 9 - 3 4 5 . Kleinman, A. M. 1973. Toward a Comparative Study of Medical Systems. Science, Medicine and Man 1 : 5 5 - 6 5 . , L. Eisenberg, and B. Good. 1978. Culture, Illness, and Care: Clinical Lessons from Anthropologic and Cross-Cultural Research. Annals of Internal Medicine 8 8 : 2 5 1 - 2 5 8 . , P. Kunstadter, E. R. Alexander, and J. L. Gale, eds. 1975. Medicine in Chinese Cultures. Washington, D.C.: U.S. Government Printing Office for Fogarty International Center, NIH. DHEW Publication No. (NIH)

75-653.

La Barre, W. 1968. The Human Animal. Chicago: University of Chicago Press. . 1969. They Shall Take Up Serpents: Psychology of the Southern Snake-Handling Cult. New York: Schocken Books. . 1972. The Ghost Dance: The Origins of Religion. New York: Dell. . 1978. The Clinic and the Field. In The Making of Psychological Anthropology, edited by George D. Spindler. Berkeley, Los Angeles, London: University of California Press. Mahler, Margaret, Fred Pine, and Anni Bergman. 1975. The Psychological Birth of the Human Infant. New York: Basic Books. Minuchin, S., B. L. Rosman, and L. Baker. 1978. Psychosomatic Families: Anorexia Nervosa in Context. Cambridge, Mass. Harvard University Press. Sander, Fred. 1979. Individual and Family Therapy: Toward an Integration. New York: Jason Aronson.

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Speer, D. C. 1970. Family Systems: Morphostasis and Morphogenesis, or Is Homeostasis Enough? Family Process 9 : 2 5 9 - 2 7 8 . Stein, H. F. 1976. A Dialectical Model of Health and Illness Attitudes and Behavior among Slovak-Americans. International Journal of Mental Health 5 : 1 1 7 - 1 3 7 . . 1978. The Slovak-American "Swaddling Ethos": Homeostat for Family Dynamics and Cultural Continuity. Family Process 17:31—45. . 1979. The Salience of Ethno-Psychology for Medical Education and Practice. Social Science and Medicine 13B: 1 9 9 - 2 1 0 . , and S. Kayzakian-Rowe. 1978. Hypertension, Biofeedback, and the Myth of the Machine: A Psychoanalytic-Cultural Exploration. Psychoanalysis and Contemporary Thought 1:119—156. , and J . M . Pontious. In press. Family and Beyond: The Larger Context of Noncompliance. Family Systems Medicine. Stierlin, H. 1973. Group Fantasies and Family Myths, Some Theoretical and Practical Aspects. Family Process 12:111—125. Von Mering, O. 1961. Healing Experience and Disease Causation. In Family-Centered Social Work in Illness and Disability: A Preventive Approach. Monograph 6. Pp. 51—67. Social Work Practice in Medical Care and Rehabilitation Settings, Medical Social Section, National Association of Social Workers. Watzlawick, P., J . Weakland, and R. Fisch. 1974. Change: Principles of Problem Formation and Problem Resolution. New York: W. W. Norton. Wilmer, H. 1962. Transference to a Medical Center. California Medicine 96:173-180. Wynne, Lyman. 1965. Some Indications and Contraindications for Exploratory Family Therapy. In Intensive Family Therapy: Theoretical and Practical Aspects, edited by Ivan Boszormenyi-Nagy and James L. Framo. New York: Harper and Row. Pp. 297—300.

Conclusion We know more than can be formulated in one finite systematized scheme of abstractions, however important that scheme may be in elucidation of some aspect of the order of things. —Alfred North Whitehead ( 1 9 2 6 : 1 3 7 )

In this book I have explored the role of countertransference in medicine. A number of case studies and vignettes were used to illustrate the wide spectrum of common clinical situations in which countertransference is manifested. The approach taken to countertransference has been to address the process whereby the medical student, resident physician, or seasoned practitioner might better recognize, understand, and use unconsciously motivated feelings that are activated during the course of patient care. The material has been presented with the hope of triggering the recollection of kindred situations and issues in the reader. However, in medical education and clinical practice, countertransference is by no means the whole story, any more than a single thread is the entire weave. In addition to the experiential, somewhat intuitive and aesthetic approach to countertransference taken here, there exists a substantial body of knowledge on the topic of countertransference, some of which has been cited in this book. T o complete our understanding of the scope of countertransference, we must accompany our self-analysis with further disciplined study. Reading enriches and grounds experience, just as experience constantly tests and receives confirmation in the literature. I can remember quietly exclaiming to myself many times while reading some passage from Erik Erikson or Freud, "Yes, now I 171

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understand what I was feeling when I was with this patient" or family or physician. The very best literature often seems like a dialogue with the reader. When the literature on countertransference is well used in physician training, it not only supplements what can be learned through process but also helps give outer form and, even more important, internal structure to that process. The intrapsychic story of doctor and patient alike (as well as other health care personnel) exerts an influence on the unfolding of the clinical process and is part of the case material itself (Stein 1984). Reading and experience together illumine that inner story. The meaning of the clinical interaction to all participants merits attention in clinical teaching and practice, for it is an inescapable variable that exerts a silent but insistent influence on assessment, diagnosis, treatment, outcome, and prognosis. Clinician countertransference and patient transference introduce mutual distortions that undermine clinical efficacy. From the physician's side, a contributing factor to the introduction of unconscious distortion is the fact that medical education offers little preparation that would give the physician access to understanding countertransference reactions and the ability to employ them therapeutically. Self-knowledge is an underused clinical tool, one that greatly contributes to the proper identification of what the clinical problem is and where it is located. Countertransference is a topic that should be introduced early in the education of medical students and continued throughout medical education. In lectures, seminars, readings, and continuing education as well as in the hands-on experience of patient care, the future practitioner should be given access to the influence of selfinvolvement in medicine and to a structured means of analyzing the psychodynamics of medical care. If the interpretive issue of physician countertransference is important enough to be treated in medical education at all, it is important enough to be treated comprehensively. In my experience as a medical behavioral scientist, what the patient or family transfers onto the resident physician, the resident physician in turn may transfer onto the attending physician or the behavioral science consultant. How clinical teachers respond to this transference from medical students and residents teaches through the latter's identification with the teacher's style. By helping the resident to understand what he or she is feeling in response to the patient, the clinical teacher who has become relatively comfortable

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in discussing such feelings indirectly helps the resident to comprehend what the patient is saying through the transference. The resident physician who feels understood is one who is capable of understanding his or her patient. The resident physician who feels that his or her feelings are accepted by a faculty supervisor is also one who is capable of accepting feelings expressed by the patient. In clinical teaching it is simply not enough to be a patient advocate without being simultaneously a student or resident advocate. In his still revolutionary essay, "The Golden Rule in the Light of New Insight," Erik Erikson (1964) defines mutuality as "a relationship in which partners depend on each other for the development of their respective strengths" (p. 231). He then proceeds to reformulate the Golden Rule in the light of a psychoanalytic understanding of human development: Truly worthwhile acts enhance a mutuality between the doer and the other—a mutuality which strengthens the doer even as it strengthens the other. Thus the "doer" and "the other" are partners in one deed. Seen in the light of human development, this means that the doer is activated in whatever strength is appropriate to his age, stage, and condition, even as he activates in the other the strength appropriate to his age, stage, and condition. Understood this way, the Rule would say that it is best to do to another what will strengthen you even as it will strengthen him—that is, what will develop his best potentials even as it develops your own. (P. 233)

Erikson then specifies "a mutuality of divided function," "a professional, and yet relatively intimate, one: that between healer and patient" (p. 236), which "permits the medical man to develop as a practitioner, and as a person, even as the patient is cured as a patient, and as a person" (p. 236). We are thus most capable of being therapeutic—responding to the depths of the patient—not when we write ourselves out of the clinical equation—for no sooner do we dissociate our personal self from the clinical situation than we turn the patient into an inanimate object—but when we can recognize that we are always a part of the clinical equation. The psychodynamic model discussed here does not in any way impugn the biomedical model. Our situation is perhaps analogous to that of the blind men attempting to describe the elephant in terms of the particular part of the elephant's anatomy that each was touching. We should not have to make a choice between the medical

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model and the psychodynamic one, for in fact they complement each other as they consist of two different maps of the same clinical reality. Reflection and action, affect and cognition, intuition and empiricism deserve to be allies rather than adversaries. Indeed, it is only when we employ the biomedical framework primarily as a defense that it becomes an exclusive, closed system. Optimally, as we become familiar and comfortable with various perspectives on any clinical problem, how and when to use a particular framework will supersede the earlier question of whether it is of value.

ETHNIC ISSUES IN COUNTERTRANSFERENCE In medical training and practice, the physician will encounter patients of a variety of ethnic and national origins. Although highly trained professionally in biomedicine, he or she will nonetheless continue to be influenced by ethnic characteristics—particularly at emotionally charged moments and when confronted by a patient whose cultural difference appears exotic or bizarre. Ethnic difference is often a source of physician frustration, attraction, revulsion, or fascination—in short, of countertransference. Ethnicity is fertile ground for sowing misunderstanding between doctor and patient and for reaping bad feelings, missed opportunities, and mistaken judgments. The physician may take the behavior of a culturally different patient, such as lateness for an appointment, as a personal affront, whereas the patient may be simply operating out of his or her own cultural frame of reference about time. Cultural difference can quickly become a problem in the clinical relationship, each participant assigning responsibility for the problem to the other. In the preceding example, when physician and patient live according to differing (and usually implicit) timetables, the physician may assume that the patient's lateness automatically implies the patient's passive aggressiveness toward the physician, which in turn may prompt the physician to defend him- or herself against the patient instead of inquiring into the patient's time perception. The doctor may tend to assume that the patient is pretty much the same as the self, or at least ought to be so. We often experience the culturally different as the flawed and therefore as inferior. Cultural difference compounds patient compliance issues, for

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noncompliance may signify differing priorities (for example, health itself as a paramount value versus family, occupation, and so on), differing understandings and expectations of the clinical situation, and differing strategies for dealing with it. Countertransference complicates the situation by mistaking the physician's self-issues for the patient's response to illness. Control issues interfere with understanding the patient who may feel rejected by the physician. Two responses to cultural difference may be present in countertransference: (1) The clinician may perceive the patient (or family) as more similar to him- or herself ("They are just like me") to minimize real differences that feel threatening. (2) The clinician may inadvertently exaggerate visible or stated differences and thereby fail in empathy ("You are too different from me, so I can't identify with you"). Usually, the exaggeration of differences bears the burden of negative countertransference, whereas the minimization of differences bears the burden of positive countertransference. Both, however, distort the patient's reality. Discounting culture and overemphasizing the rigidity of culture are twin seductions of clinical encounters with culturally different people. Moreover, just as culture may be used defensively by patient and family, the physician may employ his or her professional culture for defensive purposes, for example, as a way of disavowing the influence of the physician's own ethnicity. The physician may likewise use a keen interest in a patient's ethnicity as a way of masking underlying emotional issues that the physician is reluctant to face in the patient and in him- or herself. In a paper on "Value Differentials in Counseling American Indians," after having outlined numerous differences between American Indians and Anglos or mainstream Americans and discussed differences in therapeutic strategies between the two groups, Trimble (1981) concludes: There are dangers inherent in working with clients from other cultures. The counselor knows that the client is different, not only because he or she may act out the stereotype of expected behavior, but also because the client does belong to another culture. The counselor, by becoming so engrossed in the cultural differences that lie hidden in the client's every sentence or gesture, might completely ignore the problem. This can occur to even experienced intercultural counselors w h o may not be aware of their unintended fascination and preoccupation (cf. Trimble 1975) with the client. (P. 223)

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So we may confidently speak not only of possible resistance to ethnicity by the physician but also of the physician's subtle use of ethnicity (interest in the patient's culture) as a form of resistance. Being human, we all tend to extend our self-model to the world. This may lead us to assume that a patient has a similar if not identical way of life and style of problem solving when there is in fact considerable difference. This is a particular trap which the clinician who shares the patient's ethnicity may fall into—a reality at odds with the conviction held by many that only a clinician sharing the same culture as the patient can truly treat the patient. In a recent article titled "Intraethnic Characteristics and the Patient-Physician Interaction: 'Cultural Blind Spot Syndrome,'" Lin (1983; also abstracted and reviewed by Stein 1983), a Westerntrained Chinese physician, questions the widely held belief that similarities in the cultural background of patient and physician invariably enhance clinical communication and outcomes. The fact of sharing a common cultural heritage does not eliminate intraethnic variation influenced by such factors as age, sex, personality, political orientation, socioeconomic class, rural/urban differences, region of origin, dialect, religion, occupation, education, family structure, and extent of acculturation to mainstream American culture. Especially when the physician indentifies him- or herself as ethnically the same as the patient, "cultural stereotyping results in superficial generalizations that are often misleading in the case of individualized patients" (p. 92). Lin's paper challenges the politically as well as intellectually fashionable assumption that shared ethnicity between physician (or any other care provider) and patient makes for greater and quicker rapport, better mutual comprehension, and improved clinical outcomes over that possible when the participants are ethnically different. I would add that the physician's countertransference may lead him or her to overestimate the singular effect of ethnicity per se upon the patient's health-seeking behavior and to act as if the patient were an ethnic stereotype rather than an individual person. A cultural blind spot often occurs because the clinician mistakes the mote in the patient's eye for the beam in his or her own. Although Lin makes her point with respect to Chinese patients and herself, I have observed similar difficulties between black clinicians and their patients, midwestern white (German, Czech, English, Irish) family physicians with a wheat-farming background and patients of a similar life situation, and so forth.

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I have experienced a kindred oversimplification of the role of ethnicity in my own life by several medical colleagues w h o do not share my ethnic origins (Jewish, Eastern-Central Europe). Here is one example. After I had worked many years with a senior colleague for w h o m I have deep respect and affection, he began telling me with conviction the reasons why I had decided to settle in Bethany, Oklahoma. His logic was that since I was Jewish and Bethany is a Jewish place name in the Bible, I must have thought it was a Jewish community in Oklahoma—not realizing that in fact it had been settled by a group of Nazarenes early in the twentieth century. His logic was as impeccable as his certainty was firm. Yet my own reasons for deciding to live in Bethany differed markedly from his assumptions: At the time of choosing a residence, my sister-in-law's family lived in Bethany and my wife and I wished to live within regular visiting distance (a few miles) of their home. Bethany also retained something of the small town, provincial atmosphere of the small industrial town in western Pennsylvania in which I had been raised—but in any case it was the ambiance rather than the ethnicity that drew me. My friend had assumed for several years that his logic was my reality: he had attempted to put himself in my shoes without ever checking whether the shoes he thought I wore were in fact those on my feet. He was genuinely surprised to find that he was wrong. W h a t this story illustrates is the fact that we not only tend to act on generalizations about those of our own ethnicity but on those of differing ethnicities as well. We construe our constructions or interpretations to be their realities. On the one hand, clinicians are often perplexed to find that they and their patients do not always think and act alike, share the same values and priorities. On the other hand, when major and clinically consequential cultural differences are found and the discrepancy cannot be made to disappear, physicians often feel that such differences are personal and professional affronts, challenges to their knowledge and authority, to which they may respond by retreating deeper into their own ethnic and professional culture. Cultural disparities of this kind mobilize the physician's defensive aggressiveness in behalf of his or her professional identity. Freud's (1930) concept of the "narcissism of minor differences" (p. 114) may be appropriate here; for differences, even when objectively small, may be experienced as subjectively great (Westerlundh

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and Smith 1982), and difference is often experienced as criticism, to which we respond by reaffirming the correctness of our own position. Thus a patient's failure to comply with a physician's prescribed medical regimen may evoke a self-protective reaction in the physician that ascribes the failure to some stereotyped (that is, exteriorized) perception of the patient instead of a more empathic inquiry into the patient's own explanatory model for coping with his or her situation. I have observed this countertransference not only between physicians and patients having differing cultural backgrounds but also between physicians and patients having a common ethnicity. Here what often occurs is that education, professionalization, and social mobility are used in part by the physician as a way of gaining emotional if not spatial distance from conflicts originating in the physician's family and culture of origin. When the physician is confronted by a patient who reminds him or her of an often disavowed past, the physician may experience feelings of disgust and a need to distance the self from the patient. This, of course, interferes with a more empathic response in which the physician would take the time to elicit the patient's understanding of his or her own illness. In this situation the practitioner has repudiated the inner bond with the patient and accuses the patient of having attributes that the clinician must repudiate in the self. Cultural stereotypes about various ethnic groups often interfere with our ability to perceive a patient apart from the characteristics embodied in the stereotype. For instance, a white family therapist colleague who has long worked with black patients and families acknowledged that he has only recently come to realize the extent of emotional devastation experienced by black patients and families over the breakup of love relationships and marriages and the inability to attain middle-class income and its associated life-style. His perceptions of the supposed strength of the female-headed family and its acceptance of the "culture of poverty" had left him unprepared for black expressions of grief over the loss of a mate or despair at unfulfilled economic aspirations. The therapist's cultural relativism had been used to put a greater distance between himself and his black clients than was actually the case: "The kinds of things that make them happy and sad are really not that different from those that make us feel that way too." Professionals may adhere to cultural stereotypes about ethnic

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groups because through these stereotypes the groups play out unacceptable aspects of themselves. The rigidity of the boundary between the ethnic group and the clinician protects the clinician from the pain of those unintegrated parts of the self. In the preceding example, the dominant group-sanctioned fantasy about the free-and-easy, uninvolved, present-oriented character of black family life permitted the clinician to avoid unacceptable feelings about separation, loss, disappointment, and sexuality in himself while rationalizing such avoidance as an attribute of blacks themselves. Through cultural stereotypes, then, patients may often play out disavowed emotions of the clinician, making therapeutic change difficult in both clinician and patient because the clinician becomes dependent on the presence of the disavowed characteristics in members of these groups. Closely allied with a rigid interpretation of cultural relativism in the use of ethnic stereotypes is what might be called the fallacy of exoticism, which argues that the more bizarre or exotic appearing a cultural item (such as a value), the greater the absolute distance between that person (or that person's culture) and the physician. Devereux (1967) writes: Many characterizations of ethnic personalities are lopsided chiefly because of an arbitrary stressing of traits which are inconspicuous in our own ethnic personality and because of a corresponding minimization of personality traits also characteristic of our own group. . . . The exotic fallacy in culture-and-personality studies is sometimes combined with—and reinforced by—an oversimplified conception of personality structure which exaggerates man's plasticity. As a result, quite extreme psychological characteristics—or else beliefs requiring singularly unambivalent and extreme psychological attitudes—are presented to us as being "the whole story." N o one stops to ask how so unbalanced a psychological position can be maintained indefinitely; no effort is made to discover the compensatory attitudes and beliefs which make the—often superficial—"official" view, or social fiction, possible. (P. 209)

For instance, psychoanalyst Sudhir Kakar (1982) writes from his experience in India that from my own experience of Hindu patients (and others), I find that in spite of the Indian cultural highlighting of the dividual [the fluidity of

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personal boundaries] and the relational, the patients are more individual in their unconscious than they realize and often seek out Western-style psychotherapy in order to be comfortable with their individual strivings and needs. Conversely, it is quite conceivable that in spite of the Western cultural emphasis on autonomous individuality, the Western patients are more relational in their unconscious than they realize. (P. 275)

Clinicians and clinical researchers alike have the difficult task of navigating the channel between the Scylla of attempting to rationalize the different to a more familiar and comfortable scheme and the Charybdis of distancing the self from the familiar by making it into something bizarre or exotic.

MEDICINE AS INTERPRETATION By entering each examining room with the expectation of moving between various levels of clinical reality, the physician is most likely able to identify clinically pertinent data at all levels and formulate an intervention that takes them into account. In a letter to Pfister, Freud (1963) wrote: I do not know if you have detected the secret link between the Lay Analysis and the Illusion [The Future of an Illusion]. In the former I wish to protect analysis from the doctors and in the latter from the priests. I should like to hand it over to a profession which does not yet exist, a profession of lay curers of souls who need not be doctors and should not be priests. (P. 26)

There is, I believe, another issue besides the lay/medical analysis controversy and the preservation of psychoanalytic autonomy, that is, the need to train doctors (if not personnel of all medical specialities) in the life of the mind. At issue is not only whether analysts need also be doctors but also whether doctors need to have access to the inescapable variable of the unconscious. In this book I have suggested that doctors become impaired when they are unaware of the existence and consequences of this variable. Although such writers as Eissler (1965) and Fine (1981) have discussed at length what Freud (1926) called the "question of lay analysis," much remains to be said about the lack of preparation medical students, resident physicians, and other health professionals have for their encounter with the unconscious in themselves,

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patients, families, staff, and society. In a history of nonmedical psychoanalysis, Fine writes that "psychiatric diagnosis today is still confused and confusing. The DSM III is no more of a reliable guide to any dynamic understanding than its predecessor. . . . Furthermore, diagnosis is often used as a cover-up for therapeutic incompetence or inability" (p. 109). The essence of all medicine, indeed its core clinical task, is interpretation (Good and Good 1981; Kleinman 1980). What we often mistake as pure or raw facts are in fact interpretations or constructions of the world from within particular frameworks (Whitehead 1925). I hasten to add that this point applies as much to this book as it does to everything else in science and medicine. Observation itself is an act of interpretation. We should, for example, talk about "interpreting" rather than "reading" an X-ray or EKG, for since Immanuel Kant we know that there is always a transaction between the observer and the observed. This is not to claim that all interpretations are equally sound. The assertions of the Flat Earth Society and the photographs by the American astronauts of the earth from its moon do not have the same status from the point of view of scientific method, just as the magic bullet theory of pharmacokinesis is far removed from the painstaking biomedical research in drug action. To claim that the Ptolemaic model of the universe is as good as the Copernican and Galilean system is to deny the very possibility of science and of clinical advance. Indeed, one of my chief purposes in discussing physician countertransference in this book is my hope that in familiarizing the clinical reader with this interpretive framework, countertransference may become less a source of distortion in clinical encounters and decision making. What we do clinically, how we act, always follows from an interpretation, partly conscious and partly unconscious, impressionistic or systematic, of the clinical situation. But even what I might wish to call a better interpretation is still an interpretation. As soon as one way of observing becomes the only way of seeing, we can be certain that we are using that framework for defensive purposes. This is why, by making interpretation itself the central issue in medicine, we stand a good chance of correcting ourselves instead of embracing closed systems of thought. Good and Good (1981) propose "a meaning-centered, approach to understanding clinical practice [that] recognizes all clinical trans-

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actions to be fundamentally 167). They continue:

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or interpretive'" (pp. 166,

All clinicians routinely engage in translating across medical subcultures or systems of medical meanings and interpreting patients' experiences. A healer or physician abstracts from a sufferer's complaints information considered relevant and interprets the complaints as resulting from an underlying pathology. This reality is communicated to the client and becomes the object of therapeutic efforts. Because the patient's symptoms and the identified pathology represent personal and group conceptualizations, not merely biological reality, analysis of therapeutic transactions should focus on the interpretive strategy of the clinician. Thus, in a meaning-centered approach to understanding clinical practice, the cultural or meaningful character of symptoms and the clinical task of understanding and interpreting those symptoms are central issues. (P. 167)

To argue therefore that the consideration of countertransference has a proper place in medicine is not to argue that an exception be made within medicine to include it but that it be recognized as part of the meaningfulness of the clinical relationship and of all medical subject matter. Countertransference can be understood to constitute one particular type of interpretation, one that must take its place among multiple types of interpretation. Good clinical decision making would thus consist of the ability to shift back and forth among these types when making diagnoses, treatment plans, evaluations of outcomes, and so forth. Countertransference becomes a kind of interpretation of the clinician's self in relation to the patient, the family, and the disease. There would also be the interpretation of the biomedical disease, the illness including the patient's transference, the family including the family's response to the disease and its meaning for them, and the patient's and clinician's culture or ethnicity in the transference/countertransference. The interpretive clinical task does not, however, end with this pluralism of frameworks and the ability to navigate deftly among them. We have equally the integrative task of determining h o w — and whether—these various frameworks fit together in our understanding of the sickness episode and our intervention in it. We also have the critical task of using a framework as a provisional, partial map of the still incompletely known clinical territory. Such a selfcritical approach should not impede thought and action but should

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lead us to new insights and therefore better interpretations and interventions. The patient's transference and the practitioner's countertransference are as much a part of clinical communication throughout the wide spectrum of Western medicine as they are in the training and practice of psychoanalysis. Since those defenses that warn us of internal danger and protect us from anxiety are common to all of us, surely medical education and residency training too are incomplete without giving those defenses and what they defend against their due. Virtually any interviewing technique or medical procedure in the medical relationship can be therapeutic or antitherapeutic; whether it is one or the other depends at least in part on the physician's ability to assess the meaning of that technique or procedure for both patient and self. Just as clinical procedure often consists of the repair of the body, so is the unconscious agenda of clinical relationships often the repair of the self. Moreover, the physician's ability to identify with the patient or the need to defend him- or herself against the patient will likewise determine whether the physician's response is therapeutic or countertherapeutic. What Volkan (1981) writes of the analysand following psychoanalytic training is a worthwhile goal in the training of all physicians: We expect him to have become familiar with his own transference projections and his analyst's [or supervisor's, attending physician's, or teacher's] reactions to them. Thus he "learns" through identification how to be subject to these projections and to remain in the therapeutic position. (P. 4 4 3 )

We could reply that such expectations are unrealistic for biomedicine. Yet if realism toward the patient—that is, the ability to assess and work within the patient's context—is in fact clinically indispensable, such expectations are completely in accord with the nature of the clinical task. This in turn places responsibility not exclusively or even primarily on the physician trainee alone but also on medical educators and administrators who decide what is to be learned and how it is to be taught. We might despair that since the medical profession and its educational institutions are a product of the wider American cultural ethos, it is pointless to urge the teaching of ideas that so go against the American grain. That grain, however, is not altogether

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homogeneous or consistent; there are subsidiary, even contradicting, emphases in our culture as well. Indeed, the United States is one of the few nations on earth in which individuals are free to explore the influence of the unconscious. In our dawning awareness of unconscious influences upon patient care lies our hope. W e have already begun to learn (and teach) to observe patients better in order to serve them better. W e are only now beginning to realize that we must learn how better to observe ourselves toward the same end.

REFERENCES Devereux, George. 1967. From Anxiety to Method in the Behavioral Sciences. The Hague: Mouton. Eissler, Kurt R. 1965. Medical Orthodoxy and the Future of Psychoanalysis. New York: International Universities Press. Erikson, Erik H. 1964. The Golden Rule in the Light of New Insight. In Insight and Responsibility. New York: W. W. Norton. Pp. 2 1 9 - 2 4 3 . Fine, Reuben. 1981. On the History, Theory and Future of Nonmedical Psychoanalysis. Journal of Psychoanalytic Anthropology 4(1):93-119. Freud, Sigmund. 1926. The Question of Lay Analysis. Standard Edition of the Complete Psychological Works of Sigmund Freud (SE), vol. 20. London: Hogarth Press. . 1930. Civilization and Its Discontents (SE), vol. 21. London: Hogarth Press, 1961. . 1963. Psychoanalysis and Faith: Letters of Freud and Pfister. New York: Basic Books. Good, Byron J., and Mary-Jo Delvecchio Good. 1981. The Meaning of Symptoms: A Cultural Hermeneutic Model for Clinical Practice." In The Relevance of Social Science for Medicine, edited by Leon Eisenberg and Arthur Kleinman. Dordrecht, Holland: D. Reidel. Pp. 1 6 5 - 1 9 6 . Kakar, Sudhir. 1982. Shamans, Mystics and Doctors: A Psychological Inquiry into India and Its Healing Traditions. New York: Alfred A. Knopf. Kleinman, Arthur. 1980. Patients and Healers in the Context of Culture. Berkeley, Los Angeles, London: University of California Press. Lin, Elizabeth Hiok-Boon. 1983. Intraethnic Characteristics and the Patient-Physician Interaction: "Cultural Blind Spot Syndrome." Journal of Family Practice 1 6 ( l ) : 9 1 - 9 8 . Stein, Howard F. 1983. Review of Intraethnic Characteristics and the Patient-Physician Interaction: "Cultural Blind Spot Syndrome" (by

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E. H.-B. Un, Journal of Family Practice 1 6 ( l ) [ 1 9 8 3 ] : 9 1 - 9 8 ) . Continuing Education for the Family Physician 1 8 ( 8 ) : 7 6 8 - 7 6 9 . . 1984. The Emotional Separation Syndrome Among Recent Oklahoma Migrants: Description, Explanation, and Clinical Implications. Journal of the Oklahoma State Medical Association 77(5): 1 5 2 - 1 5 7 . Trimble, Joseph E. 1975. The Intrusion of Western Psychological Thought on Native American Ethos: Divergence and Conflict among the Lakota. In Applied Cross-Cultural Psychology: Selected Papers from the Second International Conference of the International Association for CrossCultural Psychology, edited by J. W. Berry and W. J . Lonner. Amsterdam: Swets and Zeitlinger B.V. Pp. 3 0 3 - 3 0 8 . . 1981. Value Differentials and Their Importance in Counseling American Indians. In Counseling Across Cultures, rev. ed., edited by Paul P. Pedersen, Juris G. Draguns, Walter J . Lonner, and Joseph E. Trimble. Honolulu: University Press of Hawaii/East-West Culture Learning Institute. Pp. 2 0 3 - 2 2 6 . Volkan, Vamik D. 1981. Transference and Countertransference: An Examination from the Point of View of Internalized Object Relations. In Object and Self: A Developmental Approach, edited by S. Tuttman, C. Kaye, and M. Zimmerman. New York: International Universities Press. Pp. 429—451. Westerlundh, Bert, and Gudmund Smith. 1982. Perceptgenesis and the Psychodynamics of Perception. Unpublished manuscript, Department of Psychology, Lund University. Whitehead, Alfred North. 1925. Science and the Modem World. New York: Macmillan. . 1926. Religion in the Making. New York: Macmillan.

Index

Acting out, ix, x, 2, 3, 11, 48, 103, 135, 151 Adler, G., 50, 71 Aged/aging, 8, 14, 22, 80-87 Aggression, x, 10, 28, 31, 66, 70, 71, 96, 177 Alcohol(ic), 9, 32, 68, 71, 94, 132, 164-167 Alexander, F., 103, 116, 117-118 Alexander, L., 91, 143 Anger, 6, 10, 33, 37, 40, 66-77, 94, 119, 162-163 Anorexia nervosa, 14, 37, 157, 160, 161 Anstett, R., 119 Aries, P., 77 Asch, S. S., 128 Asklepios, 58 Balint groups, 75 Balint, M., ix, 2, 58, 59 Basic assumption(s), 22 Bateson, G., 31, 118 Beavers, W. R., 157 Behavioral science, ix, xi, 14, 15, 24, 29, 41, 51, 89, 90, 98, 100-101, 104-107, 137, 144, 172 Benedict, R., 131 Berg, A., 119, 140n Binion, R., 20 Biomedical model/biomedicine, . 12, 13, 31, 35, 58, 68, 100, 102, 106, 107-108,109, 116,136-138, 146,

168, 173-174, 183 Bion, W. R., 11, 22, 31 Boszormenyi-Nagy, I., 148, 153 Boundary of the symptom, 113, 116, 144 Bowen, M., 31, 104, 129, 145, 156 Boyer, L. B., 54, 166 Breuer, J., 31 Brown, P. H., 128 Bruch, H., 160 Buber, M., 60 Büchner, G., 119 Burnside, J. W., 13 Candib, L., 58 Carlyon, W. H., 50 Cartesian split, 78 Caster, J. H. and E. Gatens-Robinson, 13 Chrisman, N. J., 44, 45 Closed system, 146 Communication, 12, 19, 23, 31, 36, 46, 47, 51, 60, 68, 75, 100, 106, 113,136,139,158,176,182,183 Compliance/compliant, 4, 12, 18, 35, 43, 44, 55, 66, 68, 69, 100, 108, 116, 117, 119, 130, 134, 174 Condensation(s), 5, 10-11, 34, 55, 118 Container(s), 6, 8, 11, 50, 55, 58 Control, 7, 15, 24, 28, 33, 34, 38, 42—44, 51, 54, 58, 66, 68-70, 72, 75-77, 79, 9 9 , 1 0 8 , 1 1 3 - 1 4 0 , 1 5 1 187

Index

188 156, 175 Crocks, 38, 72, 161 Cultural blind spot, 176

Foster, G., 14, 144 Freud, S., 2 9 , 3 1 , 4 7 , 5 6 , 77, 78, 103, 110, 116, 151, 171, 177, 180

Dalmau, C. J., 127 Death/dying, 10, 2 4 - 2 7 , 28, 37, 5 0 , 5 2 , 5 5 , 6 6 , 68, 7 7 - 8 3 , 85, 98, 108, 128, 163 deMause, L., 2 2 , 4 9 , 5 0 , 54, 102 Depressed/depression, 3 4 , 39, 4 0 , 71, 8 5 - 8 8 , 98 Devereux, G., 2 3 , 2 4 , 3 9 , 5 0 , 54, 5 6 , 67, 7 1 , 75, 92, 93, 94, 96, 103, 107, 1 0 9 , 1 2 8 , 1 3 9 , 1 4 6 , 1 5 8 , 1 5 9 , 179 Diagnostic and Statistical Manual (DSM III), 103, 181

Gadpaille, W. J . , 134 Gardner, L., 100 Genogram, 33—36, 104 Goffman, E., 9 2 Good, B., 116, 146 Good, B. and M-J. D. Good, 181 Grace, 5 8 - 6 0

Ebel, H., 106, 114 Edelwich, J . and A. Brodsky, 57 Ego defense(s), 4, 5 - 6 , 7, 4 4 , 5 1 Eisenberg, L., 137, 146, 168 Eissler, K. R., 180 Empathy, 3 , 7, 9, 12, 2 0 , 2 1 , 58, 60, 70, 100, 175, 178 Erikson, E. H., 171, 173 Ethnography/ethnographic, xi, 1 5 16, 19, 3 0 , 4 1 , 65, 97, 102, 109, 110, 1 3 2 , 1 4 0 , 143, 1 4 5 , 1 6 0 , 1 6 1 , 168 Ewing, J. R., 128 Exotic fallacy, 78, 179 Explanatory models (EMs), 5, 12—14, 2 2 , 4 4 , 115, 136, 166, 178 Externalization, 2, 4 , 5, 6, 8, 10, 11, 34, 4 6 , 5 4 , 5 5 , 92, 97 Fabrega, H. Jr., 144 Fail/failure, 3 3 , 3 9 , 4 6 , 66, 6 8 , 71, 74, 90, 134 Family myth, 129, 131, 146, 148, 153, 154 Fenichel, O., 48 Ferreira, A. J . , 129, 131, 146, 148 Fine, R., 180, 181

Haley, J., 3 1 Hall, E. T., 5 0 , 7 5 , 152 Hamlet, 11 Hayden, G. F., 4 2 Hippler, A. E., 38 Homeostat—homeostatic, 114, 116 Hypochondriacs, 7 1 Interpretation, 19, 3 5 , 4 3 , 87, 115, 177, 179, 1 8 0 - 1 8 4 Jackson, D., 31 Johnson, A. and S. Szurek, 8 Kakar, S., 179 Kant, I., 181 Kardiner, A., 5 4 Katz, J., 5 7 Kerenyi, C., 58 Kernberg, O. F., 3 Klein, M . , 7, 3 0 , 160 Kleinman, A. M . , 12, 2 2 , 4 7 , 115, 137, 138, 139, 146, 181 Kleinman, A. M . , L. Eisenberg, and B. Good, 115, 116, 137, 145, 146 Kleinman, A. M . and R. Hahn, 137 Kleinman, A. M . , P. Kunstadter, E. R. Alexander, and J. L. Gale, 145 Kohut, H., 4 6 , 56, 66 La Barre, W., xii, 2 3 , 39, 4 8 , 4 9 , 5 0 , 5 4 , 75, 132, 145, 151, 161 Laius, 84, 139, 158

Index La Mettrie, 101 Langs, R., 2 0 Lasswell, H., 5 4 Lawton, H. W., 7 0 Lead by following, 21 Lin, E. H-B., 176 Listen(ing), 20, 3 7 , 4 1 , 135 Macgregor, F. M . , 95 Machine(s), 13, 4 2 , 5 5 , 78, 1 0 0 , 1 0 1 , 130 Magic(al), 2 0 , 5 4 , 55, 56, 57, 93, 181 Mahler, M . , F. Pine, and A. Bergman, 158 Malnutrition, 144, 147, 155, 157, 162, 167 Malpractice, 56, 72 Masochism, 70 Medication, 10, 2 8 , 77, 86, 9 3 - 9 4 , 164 Metaphor, 1 3 , 4 2 , 1 0 0 , 1 0 1 , 1 3 0 , 1 6 7 Methodology/methodological, 1 5 , 2 1 , 2 9 , 65, 106, 107, 109 Meyer, A., L. N. Bollmeier, F. Alexander, 134 Minuchin, S., 3 1 , 1 0 4 , 1 1 3 , 1 1 6 , 1 2 9 Minuchin, S., B. L. Rosman, and L. Baker, 160 Mirsky, I. A., 123 Modell, A. H., 3 0 Murray, G., 115 Mutuality, 173 Narcissism of minor differences, 177 Neel, J. V., 116 Not me, 6, 61 Novick, J. and K. Kelley, 10 Nunberg, H., 103 Oedipal/Oedipus, 7, 11, 66, 84, 88, 90, 91, 132, 139, 158 Omission, 4 3 , 66, 9 5 - 9 9 , 130, 159 Osier, W., 4

189 Pendagast, E. G. and C. O. Sherman, 33 Placebo, 57, 94 Projection, 2, 4 , 5, 6, 9 - 1 0 , 11, 25, 2 6 , 3 4 , 3 9 , 4 7 , 4 8 , 5 4 , 5 5 , 75, 92, 127, 159, 160 Projective identification, 2, 4 , 5, 6, 7— 9, 10, 11, 24, 34, 5 4 , 5 5 , 69, 89, 92, 127 Psychopath(y), 125, 127, 128, 132, 133, 134, 135, 167 Psychopathology of everyday life, 2 9 , 4 8 , 50, 103 Psychosexuality, 95—96 Radin, P., 133 Red Herring, 3 9 Reich, A., 3, 48 Religion, 5 4 , 57, 60, 84, 103, 155, 176 Rescue fantasy, 55, 89 Resistance, 1, 2 2 , 38, 4 7 , 1 0 8 - 1 0 9 , 167, 176 Return of the repressed, 2 7 , 4 7 , 5 0 , 51, 66, 101 Rochlin, G., 66, 67 Rorschach, 2 5 , 36 Rosen, H. and T. Lidz, 123 Ross, J. M . , 11, 106 Rubin, V., 95 Sackett, D. L., 4 4 Sackett, D. L. and J. C. Snow, 4 4 Sacred, 20, 55, 5 6 , 129 Sander, F. M . , 11, 139, 159 Scapegoat, 106, 1 1 4 - 1 1 5 , 132, 159 Scheingold, L., 68 Schmidt, C. G., 103 Searles, H. F., 70 Segal, J., 113, 116 Separation fears, 7, 8, 10, 2 8 , 5 5 , 69, 153, 156, 163 Sequelae of insulin deficiency, 117, 118 Serendipitous, 30, 105, 168

Index

190 Shaman, 55 Shatzman, R. I., 4 3 , 69 Skinner, B. F., 4 2 Speer, D. C., 157 Spiegel, J . , 13, 4 6 Spiro, M., 4 9 , 84, 109 Stanton, M . D., 115 Stein, H. F., x, 3 , 6, 2 9 , 4 1 , 4 2 , 4 4 , 5 0 , 94, 103, 106, 119, 138, 139, 145, 146, 147, 172, 176 Stein, H. F. and R. F. Hill, 4 2 Stein, H. F. and S. Kayzakian-Rowe, 23, 4 2 , 119, 144, 146, 168 Stein, H. F. and M . D. Kuns, 6 Stein, H. F. and J . M . Pontious, 160 Stephens, G. G., 5 8 , 5 9 Stereotype(s), 2 2 , 5 2 , 92, 100, 132, 176, 178-179 Stierlin, H., 114, 146, 148 Stigma, 66, 75, 9 1 - 9 5 , 130 Subjectivity, 1, 2, 18, 19, 2 0 , 3 8 , 4 3 , 4 7 , 66, 101, 110, 177 Suffer(ing), 58, 59 Sullivan, J., xii, 36, 9 4 Symbiosis, 2 4 , 152 Symbol(s)(ic), 7, 8 , 2 0 , 4 9 , 5 6 , 78, 94, 127, 145, 147, 155, 162, 167 Symposium on Lay Analysis (1927), 103 Taboo, 66, 71, 89, 96, 129 Traded dissociation, 159 Trickster, 133

Trimble, J. E.. 175 Trostle, J. A., W. A. Hauser, and I. S. Süsser, 4 4 Turf(ing), 72, 94, 130 Vogel, A. V., 94 Volkan, V. D., 7, 11, 50, 92, 183 von Mering, O., 144, 146 Watson, J . B., 4 2 Watzlawick, P., 3 1 Watzlawick, P., J. Beavin, and D. Jackson, 129 Watzlawick, P., J . Weakland, and R. Fisch, 1 1 7 , 1 1 8 , 1 3 5 , 1 3 7 , 1 5 2 , 1 6 8 Waxier, N. E., 91 Weakland, J . , 3 1 Weidman, H. H., 135, 136 Weidman, H. H. and J . A. Egeland, 129 Wellness, 5 0 Westerlundh, B. and G. Smith, 1 7 7 178 Whitehead, A. N., 106, 171, 181 Whiting, J . W. M . , 5 4 Wilmer, H., 155 Wilson, T. A., xiii, 143, 144, 149, 155, 157, 161, 168n Witches, 71 Wynne, L., 159 Zinner, J . and R. Shapiro, 8