The Freudian encouraging her patient to experience her transference is encouraging insight through process work. The Jungian who uses active imagination to meet dream figures on paper is using a process paradigm. The Gestalt therapist requiring her client to act out a dream is dramatizing an experience which has been secondary. The neo-Reichian working through resistances to aggression in body work is touching the process work paradigm if these resistances are allowed to express themselves and are not simply ‘broken through.’ The process paradigm is not new; it plays a crucial role in all psychotherapies, and is accepted as a basic concept everywhere in psychology. The process paradigm may even be considered a central pattern in our earliest sciences. Alchemy is based upon cooking what is incomplete and Taoism encourages one to discover the patterns behind reality and to folloiv their unfolding with appreciation and awareness.       My background in process work is based upon the finalistic philosophy applied by Jung to psychological situations. He looked for the meaning of things; he was not interested in pathologizing them, but attempted to take them as facts for themselves. Since he was himself a physician he recognized the usefulness of the medicial model, but extended it by concentrating on the fantasy world produced by the client.*26\227\8*

PSYCHIATRIC DIMENSIONS OF MEDICAL PRACTICE: COMPETENCE TO REFUSE MEDICAL ADVICE-INVOKING THE LAW: GUARDIANSHIP AND THE SURROGATE’S RESPONSIBILITYAlthough physicians can determine that a patient is psychologically incompetent (i.e., lacks decision-making capacity), only judges can determine that a patient is legally incompetent (i.e., lacks decision-making authority). When physicians or hospitals petition for guardianship, they believe that the patient cannot act in her own best interest and that her right to direct her own affairs should therefore be preempted (at least as far as health care is concerned). The guardianship process requires a judicial hearing during which the patient has the right to be present, to engage counsel, to offer evidence, and to cross-examine witnesses. If the judge finds that the patient’s cognitive capacity meets the legal definition of incompetence, a guardian will be appointed.     The Surrogate’s Responsibility The actions of a surrogate decision maker or guardian should be based, if possible, on preferences expressed by the patient when she was competent. Ideally, such preferences will have been recorded in an advance directive and will be clearly applicable to the situation at hand. When instructions of this type are not avail-able, the surrogate or guardian should be guided by the patient’s past values and beliefs. These may be known to relatives and friends but not to individuals who have never met the patient before (a situation that might arise if a social worker at Adult Protective Services is given guardianship of a homeless person whose family cannot be located). When the patient’s preferences and values are unknown, surrogates and guardians should act in the patient’s best interest.     Although these standards are straightforward in theory, they may be difficult to apply in practice. Sometimes, for example, the surrogate role is jointly assumed by the patient’s children. If they agree about her preferences and values, the decision-making process goes well; if they do not, a bitter deadlock can result. Even so “objective” a standard as the patient’s best interest can be difficult to apply, especially when what is best for the patient may not be best for the surrogate. *69\172\2*

SCHIZOPHRENIA AND ALTERED STATES: FLIPPINGThe last program I want to mention is the one which happens most frequently in schizophrenia: exchanging the primary process (like the victim) for the secondary process (like Jesus, the healer), dropping the metacommunicator who, like most censors, may be too rigid to let this altered state happen, and experiencing what the outside world calls a ‘psychotic episode.’ This flip has much in common with the processes of suicidal fantasies, channel blocking, channel switching and accessing secondary processes. Why nature prefers one method over another will be discussed in the next chapter. For the moment, we need to remember that the same process of flipping which creates the episode is the process which can reverse it, and that one of the. many functions of flipping is to avoid pain and to allow secondary processes to come up. We need to remember that belonging to the ‘grower’s club’ means suffering the conflict between the primary and secondary processes and experiencing the pain and conflict which happens when the one begins to transform the other. Nature has provided us with many organic methods of avoiding pain and confrontations between the primary and secondary systems. If we do not learn to follow these processes, then nature does it for us by producing experiences such as schizophrenia and epilepsy. We see how these may be avoided in certain cases through following the individual processes of pain avoidance with expertise and appreciation.*67\227\8*