I have written many posts in which I use examples from my patients to illuminate an aspect of pschodynamics. In all such cases, I disguise the patients in ways which make their identity impossible to establish. I apply the understanding of the individual dynamics to the behavior of larger groups of people with the goal of understanding why people believe some of the things they believe and behave in the ways they behave.
For example, I have used the example of a young patient developing a paranoid delusion as a way to illuminate the uses of conspiracy theories among groups prone to such beliefs. This is not meant to diagnose people who believe, for instance, that George W Bush and/or Dick Cheney were behind 9/11, but to explain why such beliefs can gain traction and what purpose they serve for those who believe in such conspiracy theories.
This has led to a misunderstanding that I should have anticipated but failed to recognize because of certain assumptions I had made. Unfortunately, I had neglected to examine my own assumptions and this has led to the present confusion.
A number of commenters have noted, from time to time, that I have diagnosed my political opponents. That has never been my intent but I can understand how such a misunderstanding could arise.
There are two crucial assumptions that differentiate an exploration of psychodynamics in groups and psychiatric diagnosis of the individual.
The first assumption is that describing psychodynamics is the same as diagnosis; the two are related but quiet different in practice and theory.
When I work with a patient in Psychoanalysis or Psychotherapy I am rarely interested in their diagnosis, though I am very interested in their psychodynamics. The concept of a diagnosis primarily has utility for questions related to insurance coverage and as a shorthand way to convey the kinds of medication treatment appropriate for a particular person.
In other words, while there is some necessity for making diagnoses in the context of patients with severe enough symptoms to warrant medication, in practice, Psychiatric treatment is directed at symptoms, not at underlying causality (our understanding of which, despite some protestations to the contrary, remains at a rudimentary level.)
[It is important to differentiate a person having hallucinations who is depressed from a person with hallucinations who may be depressed but has an underlying Schizophrenic disorder but that involves recognizing sometimes subtle signs and symptoms in the context of the more overt symptomatology.]
At the same time, whether a patient requires, or benefits from, medication is only partially related to the work of Psychodynamic Psychotherapy in which we explore all aspects of the conscious and unconscious mind, ie the arrangement of defenses, drives, adaptations, development, ego structures, etc, that comprise the character.
Along with this is a crucial piece of information I failed to emphasize: defenses are universal and all defenses are used, at one time or another, by almost everyone. More primitive defenses, like projection, are more often used by those who are more disturbed, but even a so-called "healthy neurotic" (ie, a "normal" person) will tend to use primitive defenses from time to time. A description of a defensive structure may be part of a diagnosis (eg, Paranoid Schizophrenics use projection extensively, but is not sufficient for the diagnosis. Projection is a ubiquitous defensive maneuver.
Dr. Sanity has done an invaluable favor by posting Psychiatry 101- Defense Mechanisms, which does an excellent job of describing some basic defense mechanisms and how they are used. I would add a caveat to her description, in that even her Level One defenses, the most pathological, a normal person under stress can temporarily resort to their use in a psychological emergency. The most common reaction upon hearing of the sudden loss of a loved one is denial. ("No! It can't be!") If a person persists in denial beyond a reasonable amount of time, then we consider them in need of treatment. This suggests an aspect of diagnoses that occurs with the individual but not with the group, the presence or absence of reality testing.
Reality testing refers to the ability of the ego (executive functions of the mind) to test one's beliefs against reality and adjust when necessary. A person who initially denies the death of a loved one is able, once th shock has lessened, to accept the loss and begin the difficult task of mourning. A person who is unable to tolerate the loss and persists in denial would be considered to have impaired reality testing. A person who simply refuses to accept the loss and persists in believing that the lost person is actually living in a different city, and begins to act as if that were true despite all evidence to the contrary, has lost their reality testing ability.
This leads to the second significant difference between diagnosing an individual and describing a population. A delusion is a fixed, false belief. However, what is usually assumed in the definition is that it is an idiosyncratic fixed false belief. In other words, if a person believes that Cheney was behind 9/11, despite the absence of evidence, we would not consider that alone evidence that the person is delusional; sadly, a great many people believe the same thing and while some of them may be deeply disturbed individuals, the majority are likely to be indistinguishable from the general population and would hardly warrant a Psychiatric diagnosis solely based on their belief in a particularly pernicious conspiracy theory. However, if a person believed that not only was Cheney behind 9/11 but he had an active association with aliens from Rigel who had given him a high tech death ray to destroy the twin towers, we would have no trouble determining that his beliefs were so far removed from the mainstream, even the mainstream among his cohort of conspiracy theorists, that he would be diagnosable.
Please keep in mind these two points when reading future posts which describe individual psychodynamics and apply them to analogous behavior of groups:
1) The description of a particular defensive maneuver or structure is not diagnostic for groups; it is meant to explore the purpose of the defense and why/how it is used.
2) Psychiatric diagnoses, especially of psychosis, depend upon the degree to which a behavior or belief is idiosyncratic.
I will attempt to show how this is applied in my post tomorrow.
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