A career in forensic psychiatry: the ultimate unconscious resistance?

I never really believed in the idea of unconscious resistance in psychotherapy. For the four years of my training in a predominantly psychoanalytic residency program, I tried my best to understand the basic tenets of psychodynamic therapy, but none of it came easily to me. When I was growing up, my family never talked about feelings. In fact, we never talked about anything other than rational thoughts and practical obstacles; to do otherwise would have been unthinkable in our community of industrious Asian immigrants. Feelings were just not important where I came from, and, even after several years of residency training, psychodynamic thinking was still foreign to me. Like most psychiatry residents, I saw outpatients in a hospital clinic, and I had little choice about which patients were referred to me. During the winter of my third year of residency, I was assigned the case of Annie (not her real name, of course, but similar to the anglicized nickname she preferred to be called), a young Asian-American woman who was being discharged from the inpatient psychiatric unit after a suicide attempt. It was my task to provide follow-up outpatient care—whatever that meant. As I walked out to the waiting room at 8 a.m. on a Monday morning, I secretly prayed that she wouldn’t show up, both because I needed the time to catch up on paperwork and because I already felt overburdened by my patients. It was the dead of winter, and morale was low. However, as I spotted Annie standing at the front desk, it was clear that she was not my usual low-functioning, disadvantaged patient with a severe psychiatric disorder. She was an artistic-appearing young woman dressed in a stylish green wool coat and jaunty hat who was making pleasant conversation with the receptionist. Patients like this didn’t come around every day in our clinic, and I was intrigued. During our first few meetings, Annie gave me a rough sketch of her life. She had been born in Asia and while still a toddler had moved with her family to our city, where she had lived ever since. As a young child, her parents asked a lot of her: take care of her younger siblings, cook dinner for the family, and get perfect grades in school. She had earned both her bachelor’s and graduate degrees at a distinguished university, and she had gone on to work in one of the top firms in her field. She had married the man her mother suggested would be a good match, and they had bought a house close to her parents soon after the wedding. A year later, she gave birth to twins. For any Asian family—for any family at all—Annie was a model child. I learned early on that Annie was unhappy in her marriage and that this unhappiness had been the main precipitant of her suicide attempt. She complained that her husband was extremely demanding and unpredictable in his moods, and his behavior filled her with a mixture of anger and fear. Still, she said that she loved him, and she was deeply ashamed of the suicide attempt and subsequent hospitalization. It quickly became evident that she was also ashamed of being in psychotherapy, as she saw it as a sign of weakness and disease. She was obsessed with Dr. Kapoor is Forensic Psychiatry Fellow, Department of Psychiatry, Yale University School of Medicine, New Haven, CT. Address correspondence to: Reena Kapoor, MD, Connecticut Mental Health Center, Division of Law and Psychiatry, 34 Park Street, Room 157, New Haven, CT 06519. E-mail: [email protected]