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One morning, in the early days of the first COVID-19 surge in the northeast USA, a colleague left the hospital after a busy stretch in the intensive care unit. It had not been an easy night, but he had seen worse. He pulled over at a grocery store on the way home and walked inside the familiar building's sliding glass doors, looked around at the half-stocked shelves and crowded aisles and had the first panic attack of his life. One does not panic because the store is running low on supplies. One panics because long-standing illusions of certainty and control are undermined or because of the threatened eruption into awareness of what one has tried so hard not to know. More than a century of clinical observation, as well as thousands of years of philosophy, art, and literature attest to the notion that, alongside social disparities and socioeconomic factors, the knowledge and feelings we habitually hide from ourselves form the core of some of our greatest struggles, both internal and communal. Individual and collective self-obfuscation has a role in problems from climate change to implicit biases to the denial of scientific and medical knowledge we have seen from some quarters during the COVID-19 pandemic.

tually hide from ourselves form the core of some of our greatest struggles, both internal and communal. Individual and collective self-obfuscation has a role in problems from climate change to implicit biases to the denial of scientific and medical knowledge we have seen from some quarters during the COVID-19 pandemic. The characteristic dynamics of our unconscious life are shaped in early childhood by a multitude of internal and external factors. It has been observed that some of the most powerful communication we receive is neither that which is spoken nor that which is deliberately silenced. Rather, we can be profoundly affected by whatever is unutterable in the milieu of our upbringing. Something becomes unutterable when we know or feel it but do not want to know or feel it. Often this feeling knowledge remains raw and unarticulated, unconscious for the most part. One thinks of Ludmila Dontsova, the radiologist in Aleksandr Solzhenitsyn's novel, Cancer Ward, who uses her intellectual attributes to avoid the reality of her own worsening stomach cancer. René Magritte, Not to be Reproduced (La reproduction interdite), 1937© 2021 © ADAGP, Paris and DACS, London 2021/Photo © Fine Art Images/Bridgeman Images2021 René Magritte, Not to be Reproduced (La reproduction interdite), 1937

The characteristic dynamics of our unconscious life are shaped in early childhood by a multitude of internal and external factors. It has been observed that some of the most powerful communication we receive is neither that which is spoken nor that which is deliberately silenced. Rather, we can be profoundly affected by whatever is unutterable in the milieu of our upbringing. Something becomes unutterable when we know or feel it but do not want to know or feel it. Often this feeling knowledge remains raw and unarticulated, unconscious for the most part. One thinks of Ludmila Dontsova, the radiologist in Aleksandr Solzhenitsyn's novel, Cancer Ward, who uses her intellectual attributes to avoid the reality of her own worsening stomach cancer. René Magritte, Not to be Reproduced (La reproduction interdite), 1937© 2021 © ADAGP, Paris and DACS, London 2021/Photo © Fine Art Images/Bridgeman Images2021 René Magritte, Not to be Reproduced (La reproduction interdite), 1937 Medicine, psychiatry included, tends to give the unconscious a wide berth. It is certainly understandable for fields concerned with quantification and categorisation of clinical data to avoid such a complex and often paradoxical realm of the mind, but we believe this to be an unfortunate omission, entailing two primary problems. One is the intellectual loss of a vast area of inquiry: an area, meanwhile, vigorously explored by art, philosophy, and neuroscience. Another problem is the impoverishment of practical understanding that results from ignoring a complicated yet fundamental element of human experience, which can affect rapport, clinical decision making, diagnostic precision, and ethical judgment, among much else.

igorously explored by art, philosophy, and neuroscience. Another problem is the impoverishment of practical understanding that results from ignoring a complicated yet fundamental element of human experience, which can affect rapport, clinical decision making, diagnostic precision, and ethical judgment, among much else. We have all heard of patients like Ludmila Dontsova, presenting with conspicuous signs and symptoms, even visible malignancies, that have gone unacknowledged by close friends and family members as though subject to some tacit agreement of silence. Although the end results may be dramatic, the everyday, unspoken, and unacknowledged collusions between people, including patients and clinicians, are usually quite subtle. There may be tension or anxiety in the consultation room that gets swept aside by the conveniently insatiable demands of the computer, or a stressful topic may be danced around, or a patient may cultivate an particular affect or attitude that soothes a clinician's own underlying anxieties but obscures harder truths of the presentation. To avoid discomfort and despair, knowledge is sent underground.

the conveniently insatiable demands of the computer, or a stressful topic may be danced around, or a patient may cultivate an particular affect or attitude that soothes a clinician's own underlying anxieties but obscures harder truths of the presentation. To avoid discomfort and despair, knowledge is sent underground. In medicine we must endeavour to explore the things we tend to keep from ourselves. We should also consider seriously how we are able to keep things from ourselves, and that we routinely do so in ways that receive little attention in education or clinical practice and yet have implications for how we might understand and treat ourselves and our patients. Difficult cases, whether they involve chronic illness or sudden and unexpected clinical scenarios, can contain seemingly contradictory or unintuitive elements. Words do not line up with behaviour. In these moments, it may be helpful to think about what is going on beneath the surface for clinician and patient alike. It can be helpful to ask oneself what is the underlying communication I am giving or receiving? What is the question behind the question? One might also ask what is unutterable here? What have we not thought to put into words? The answers to these questions may not come in the moment they are asked. They may not come ever. But we suggest that the very act of asking oneself these questions might have salutary effects.

is the question behind the question? One might also ask what is unutterable here? What have we not thought to put into words? The answers to these questions may not come in the moment they are asked. They may not come ever. But we suggest that the very act of asking oneself these questions might have salutary effects. Just keeping the idea of an unconscious in mind promotes an important interpersonal perspective. Let us call it a general awareness of the mysteries of subjective experience and emotional life. Something that we may sense is present in art and literature and often missing in clinical medicine. This absence may be, in part, what motivates the architects of medical school curricula to send students to museums or offer classes in creative writing. Perhaps this quality is something akin to John Keats's “negative capability”: the capacity to be “in uncertainties, mysteries, doubts, without any irritable reaching after fact or reason”. But it is more radical than that. Although it seems that Keats here makes an artistically useful cartesian split between reason and rawer experience, what we have come to understand about the mind is that there is no such clean distinction to be made. As the work of the neuroscientist Antonio Damasio suggests, cognition is intertwined with emotion, and unconscious processes are foundational to our conscious sense of self.

n split between reason and rawer experience, what we have come to understand about the mind is that there is no such clean distinction to be made. As the work of the neuroscientist Antonio Damasio suggests, cognition is intertwined with emotion, and unconscious processes are foundational to our conscious sense of self. The British paediatrician and psychoanalyst Donald Winnicott wrote about the emergence of our sense of self and how it is influenced by the minds of other people, and he suggested that a task of lifelong development is the constant negotiation between one's subjective, at times hallucinatory, inner world, and the structures, restrictions, and reassurances of external reality. This developmental process is facilitated by what he called a “holding environment”, a concept that might account for elements of the therapeutic value of the clinician–patient relationship.

en one's subjective, at times hallucinatory, inner world, and the structures, restrictions, and reassurances of external reality. This developmental process is facilitated by what he called a “holding environment”, a concept that might account for elements of the therapeutic value of the clinician–patient relationship. Winnicott suggested that the quality of the first holding environment has to do with the way a caregiver “holds the infant in mind”, the conscious and unconscious attunement to the sublinguistic, unrepresented mental states of the infant. Such mental states remain with us our entire lives and constitute the material of more integrated experience. More recently, clinical psychologist and psychoanalyst Peter Fonagy has used empirical studies to look at the effects of parents' state of mind on personality development and attachment in their children. In a paper that draws from both psychoanalysis and attachment theory, Fonagy and colleagues proposed “the parent's capacity to generate a psychological world for the infant is dependent on coherent representations of the mental world of self and other”. In this sense, we are all mind readers, and the people we care for are especially attuned to how we think about them. “Accurate conscious reflection”, Fonagy and co-authors argued, “presupposes the experience of having been the subject of such confident reflection”.

presentations of the mental world of self and other”. In this sense, we are all mind readers, and the people we care for are especially attuned to how we think about them. “Accurate conscious reflection”, Fonagy and co-authors argued, “presupposes the experience of having been the subject of such confident reflection”. Thus, it may be that the most important use of the concept of the unconscious in clinical medicine is simply the appreciation of its existence and of its constant influence on ourselves and others. Of course, it might be helpful here and there to identify defensive patterns, or to use an understanding of repression or transference phenomena to clarify what is occurring in a particularly charged or confusing encounter. Meanwhile, on a deeper level, medicine will continue to struggle with what many patients and clinicians alike sense to be some sort of loss, or continued absence of human connection and understanding, an absence that has implications for individual care as well as public and global health. There are likely to be clinical benefits from paying attention to the unconscious, in all of its formulations and manifestations. And, more generally, the quality of mind thus cultivated among clinicians could help bring a more nuanced and authentic sense of human connection and understanding to the practice of medicine.

There are likely to be clinical benefits from paying attention to the unconscious, in all of its formulations and manifestations. And, more generally, the quality of mind thus cultivated among clinicians could help bring a more nuanced and authentic sense of human connection and understanding to the practice of medicine. Nothing, William Wordsworth wrote in The Recluse, “can breed such fear and awe / As fall upon us often when we look / Into our Minds”. Here we have the discovery in consciousness of feelings and states that have been with us all along. Feelings that perhaps go against the stories we tend to tell ourselves, which others may notice well before we do. It is remarkable and perhaps at times a mixed blessing that we inevitably communicate to others so much of what is in our minds: the content, but also the quality of our attention, comprehension, and curiosity. Winnicott observed that one of the most damaging ways to hold an infant in mind is to see the infant not as they are, but rather as one would wish to see them. To see patients and ourselves as they are means, among much else, to try to acknowledge the ocean of unconscious and unarticulated experience within all of us. Ultimately, it is the trying that matters because it allows for an openness to experiences beyond our own which can be felt by another. Yet even the most sincere effort comes with no formula and no guarantee, for we will always communicate not only more than we are aware of communicating, but also more than we are aware of knowing.