THE PSYCHIATRIST PATIENT RELATIONSHIP

Alan Eppel

The nature and quality of the relationship between physician and patient is central to all therapeutic endeavors. The relationship is the pivot around which all other activities revolve.

The attributes of the physician patient relationship enhance or impede the process of assessment, diagnosis and treatment. In psychiatry this is more crucial because the therapeutic relationship is also the principal  agent of healing.

In psychotherapy 80% of the variance in outcome is accounted for by the quality of the relationships between patient and therapist. Relationship variables are more predictive  of outcome then the particular theoretical framework employed by the therapist.

Edmond Pellegrino defines the essence of the medical encounter as

 ” One human in distress seeks out another who professes to have the knowledge and skill to help or heal.” (1).

Above all else patients want to be treated with respect. They are very conscious of the asymmetrical nature and of the relationship. The psychiatrist is perceived as having most of the control and power. The patient can feel vulnerable and exposed. The very active seeking help may invoke feelings of shame, humiliation or defeat.

One group of patients, self identified as consumer-survivors, expressed there feelings as follows:

“We are not cases to be managed, but people to be loved, honoured, needed, challenged and understood.” (2).

The relationship between psychiatrist and patient/consumer is a collaborative endeavor in which each brings to bear his or her essential humanity, experience, and knowledge with the purpose of eliminating the effects of psychiatric disorder, promoting recovery and restoring health. Both the psychiatrist and patient are human beings prone to the same human vulnerabilities and vicissitudes. Neither has any inherent superiority of morality, intellect, strength, courage or capacity.

The psychiatrist and patient are equal in the sense that neither can claim superior value or privilege over the other.

However the relationship is not symmetrical when it comes to each of their obligations and expectations. For if the physician is to be of any use to the patient he or she must possess some specialized knowledge and skills to help bring about a healing process. Conversely the patient must be willing to explore openly his or her private thoughts and emotions.

Pellegrino states that the essence of a humanistic ethic is the obligation of the physician to restore the patient’s humanity which has being diminished by illness. The tenets of biomedical ethics are founded on the preservation of autonomy, the obligation to promote good and to avoid harm and to promote justice and fairness. This entails respect for the freedom, dignity, worth and belief systems of the individual person. (1).

In 1995 a number of distinguished American physicians published a patient physician covenant stating among other things that

“Medicine is at its centre a moral enterprise grounded in a covenant of trust. The covenant obliges physicians to be competent and to use their competence in the patient’s best interests…… our first obligation must be to serve the good of those persons who seek our help and trust us to provide it . ” (3).

The famous Canadian physician Norman Bethune wrote:

“… Let us redefine medical ethics, not as a code of medical etiquette between doctors, but as a code of fundamental morality and justice between medicine and the people.” (4).

What emerges from all this is that the physician has a profound obligation based in trust, to apply his or her skills, knowledge, and compassion above any self-interest for the benefit and welfare of the patient.

Psychiatrists must recognize that the patient is a human being with abilities,  hopes and aspirations. They must recognize and respect the unique capacities, strengths and wishes of each individual patient. They must see the treatment enterprise as essentially an encounter between two human beings each with their own strengths aspirations and frailties.

Empathy is essential to the clinical endeavour. Empathy involves “feeling with” the patient, stepping into the patient’s shoes temporarily in order to try to experience and feel what the patient feels. But empathy alone is not enough. The physician must also bring to bear knowledge and skills in the service of healing.

Mutual respect requires attention to terminology. For many who have received psychiatric treatment there has been a revolt against the word “patient”. In many disciplines the term “client” has been substituted. For others the term “consumer” or “consumer-survivor” is more acceptable.

Opposition to the term patient is based on the belief that this term implies a passive and receptive position within the relationship with the physician.  The physician is seen as assuming  an authoritative and paternalistic stance. The patient is seen as having to follow the physician’s recommendations. This runs counter to modern medical practice with promotes a patient centred focus.

The adoption of the term “client” was an attempt to change those connotations and to put the recipient of medical care on a more equal footing. However there has been much distaste in the medical profession for this term as it seemed to imply a predominantly commercial relationship.

The word client comes from the Latin “cliens”,  an individual of lower plebeian standing in Roman times, a vassal under the protection of a patrician or “patron”.

The word patient comes from “patior”  meaning “to bear” or “endure “. To show compassion means “to bear with together”. The verb “to heal” is derived from the word “hale”  to make ” whole”.

The term “consumer” developed out of a movement which fostered a more assertive stance among consumers of goods and services. The consumer movement seeks to protect the public from inferior or dangerous products and services and encourages people to make knowledgeable choices and to be active participants in transactions.

But it is  the terms “physician” and “patient”  that  encompass the centuries’ old covenant of trust which underpins the elemental healing connection.

References

1.Pellegrino ED. Humanism and the Physician. 1979 University of Tennessee Press.

2.Putting People First  the Reform of mental Health Services in Ontario Ministry of Health Ontario 1993

3.Crawshaw R et al. Patient-Physician Covenant. JAMA. 1995: 273;1553

4. Stewart R. Bethune 1973 Shoe String Pr Inc.