What is "Psychological Mindedness"?

The timing is always curious: in both my Introduction to Psychotherapy/Counseling course this week, and also on Twitter at the same time, questions were raised about how you might assess someone's suitability for psychotherapy, especially psychodynamic treatment. I told my students last night of one disastrous situation in which I ignored my own doubts about a particular patient and took this person into treatment anyway even though during the intake and first several sessions I could detect no serious "psychological mindedness." I had--I now realized--foolishly told myself that it was probably just very hidden and there was a chance it could emerge or even develop. It didn't and I discharged the patient with what I regard as very little change, alas. 

But what, my students rightly persisted, does "psychological mindedness" actually mean and look like in concrete ways? We were very nearly at the end of our time, so I gave them a quick three-sentence summary last night with a promise of more practical details next week. Here are those details, drawn, as so often happens with me, from the incomparable Nina Coltart's second chapter of Slouching Towards Bethlehem: and Further Psychoanalytical Explorations. "Psychological mindedness" is, in fact, her phrase in that chapter. (It was, in fact, this chapter that convinced me, in the fall of 1994, that I had the requisite ability to undertake psychoanalysis myself, and so when I say she changed my life, it is this that I mean more than anything.) 

Coltart gives some preliminary considerations before launching into a list of 9 things to watch for. These "preliminaries" include, during an intake, watching out for "intelligence, moral character, and money." Here is where she is at her most practical and also Freudian, noting how the great master said you cannot work with people who have no capacity for insight or understanding, who lead morally repellent or even criminal lives, and who are too poor to pay your fee. 

Beyond these things, she says to watch out for the following, which I have summarized under my own headings and with some detail or elaboration as appropriate. 

1) Emotional Distance on the Self: This she says is also known as the "autonomous ego" or the "observing ego." The would-be patient must have some capacity to take even a modest distance on his/her struggles to be able to talk about them. Obviously, she stresses, this must be "nicely judged" as you do not want a patient who is prone to "severe denial, splitting, or repression."

2) Elaboration and Extension: If, she says, you allow pauses, gaps, and silence in the intake (which I always do: a preliminary sense of how a patient can handle silence is invaluable to me), can the patient go beyond the mere narration of facts into a deeper elaboration of various emotional dynamics? Even a few minutes into an intake, if you are listening with the "bare attention" she elsewhere discusses in the book, may for the first time prompt the patient to take the risk of elaboration. If this is totally absent, she says, it may indicate "severe inhibitions" that prevent, in whole or in part, free association from happening.

3) Affectively Charged Memories: Can the would-be patient bring forth different memories with different affects that are more or less appropriate? A lot of memories without affect are suspect, as is a total lack of the same. 

4) Relationship between Past and Present: Can the patient see any connections, however tentative, between past experiences and present difficulties? Can they see, as Bollas might put it, how the shadow of the objects of one's past, including past relationships, falls on present ones? (As a former supervisor of mine once succinctly put it: is this person a reliable historian?)

5) Internal and External Worlds and their Conflicts: Does your would-be patient have an ability to see connections between their internalized objects and outer relationships and conflicts? Do they see conflicts in their mind? And do they have a capacity to tolerate difference from and conflict between inner objects and the therapeutic relationship and working alliance? (In other, more classical, terms, can they develop a transference neurosis?)

6) Curiosity and Playfulness: Coltart says the would-be patient must show even a scintilla of curiosity about their inner world and its intra-psychic conflicts (and those with external parties) and a capacity to play with those in a "lively" way. Do they show signs of being glad to obtain greater insight? Are they curious about how their mind works, and how it plays a part in current problems? Absent this, Coltart warns, you should not proceed with a recommendation for psychodynamic therapy, which has "nothing to offer a patient who only wishes to be relieved of his suffering." Instead, the would-be patient must show "some real pleasure in finding out some tiny thing about himself." This, she says, "is one of the best criteria for the analytical approach." This curiosity will be an invaluable adjunct to and support of the working alliance when things turn difficult and the transference is at its trickiest. 

7) Imagination and Fantasy: Can they even mention a fantasy, detailed or not? Or, better, still, a dream, which Coltart says you should jump on immediately to see what they can do with it. This indicates great promise for psychological mindedness during treatment. 

8) Self-Deception: Do they consent to recognize that we may in fact be divided, opposed to ourselves, and deceiving ourselves? Are they aware that they may not in fact have a complete or completely accurate sense of their own mind and desires, but are willing to work to increase such? 

9) Success or Achievement in Some Area: She reiterates the "truism" that if the would-be patient has not succeeded in some area--work, school, relationships--then they will not succeed at psychodynamic therapy.