The Doctor/Patient Relationship Comes First, Last, and Always

Pinel, the father of modern psychiatry, is famous for liberating his patients from their chains. But he did a whole lot more. Pinel spent long hours listening attentively to each patient’s life story so that he could correlate their life experiences with the onset and course of symptoms.

Pinel got to know his patients well enough to like them as people. When given the choice of joining Napoleon as personal physician or staying on at the hospital, Pinel picked his psychiatric patients over his emperor. Pinel’s closest collaborator and teacher was a former patient who became chief administrator. Together they developed a diagnostic classification and a treatment approach that combined cognitive, social skills, and humanistic methods.

When I started my training in psychiatry 45 years ago, the prevailing model for understanding mental disorders was broadly bio/psycho/social-in the grand tradition of Pinel. When psychiatry is practiced well, it integrates insights from all the different ways of understanding human nature.

But, along the way, an unfortunate reductionism has limited the scope of much of psychiatric practice. The psychological and the social viewpoints survive, but only in truncated form. For many practitioners and training programs the biological leg of the tripod has been unduly emphasized at the expense of a fully rounded picture of the patient.

Many interacting contributions promote a biological reductionism that reduces the richness and effectiveness of psychiatry. The brilliant findings of basic neuroscience blind people to the fact that so far these have had absolutely no impact on day to day clinical practice. Big Pharma sells the misleading idea that mental ills are all due to chemical imbalance and always require pill solutions. Psychological factors and social context are difficult to evaluate in the too brief visits approved by insurance reimbursement. And training programs often overemphasize DSM checklist diagnosis at the expense of more broadly based and fully realised evaluations.

See my recent blogs for a wonderful conversation with Eleanor Longden. Eleanor was a victim both of incapacitating psychiatric symptoms and of harmful psychiatric treatment. She was able to find her way back to a remarkably productive life partly through the application of her own inner resources, but also with the help of the Hearing Voices Network and her psychiatrist Pat Bracken.

Aside from being a terrific clinician, Pat has a strong interest in the role of meaning, relationship, and values in psychiatric care. He is a founder of the Critical Psychiatry Network.

I asked him where psychiatry should be headed. This is Pat’s response:

A technological approach to mental health problems currently dominates in most of the Western world. This paradigm is associated with a particular way of framing and responding to states of distress and dislocation. See

http://bjp.rcpsych.org/content/201/6/430.abstract

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By technological, I mean an approach to experiences (eg, low mood, hearing voices, suicidality, self harm, fearfulness, and elation) that sees them primarily as problems that need to be fixed by some sort of professional intervention. Non-technical, non-specific, aspects of mental health care have been pushed to the margins. The technical approach does not totally ignore questions of relationships, values, and meanings- but it does see them as only as secondary concerns.

The technical paradigm dominates in our publications, research agendas, teaching, and service priorities- and it is generally accepted that technical knowledge should trump all other ways of framing and thinking about mental health issues.

The balance of evidence does not support this idea that mental health problems are best grasped through a technical idiom or that good mental health work can be characterised as a series of discrete interventions. This is not to say that medical knowledge and expertise are not relevant (even vital) in the field of mental health. However, the problems we grapple with cry out for a more nuanced form of medical understanding and practice.

The mind is not simply another organ of the body. It is impossible to understand mental illness without understanding the experiences, meanings, relationships, and values of the person and his social context. A purely medical approach that works well in the field of cardiology or respiratory medicine is incomplete for psychiatry. It is our task to develop a medical discourse that takes a broader view.

A post-technological psychiatry would not replace all the theories and treatments we use today, but would develop a primary discourse that is hermeneutic and ethical in nature and from which choices would be made about what research should be prioritised, what training our professionals should have, and what sort of services we should develop.

Such a discourse cannot be developed by professionals on their own and clearly requires conversations and negotiation with the growing service-user/consumer movement (individuals who are ‘experts by experience’).

I believe that the Hearing Voices Network offers a very good example of how such collaborations can yield significant positives results for patients and professionals alike.

Thanks so much, Pat. I think we should expand your critique of technological reductionism beyond psychiatry and apply it to all of medicine.

Sad to say, most doctors ignore Hippocrates’ precious advice from 2500 years ago: "It is more important to know the patient who has the disease than the disease the patient has."

Knowing the whole patient has taken a back seat to knowing the patient’s lab values. Most doctors barely talk to (or even look at or touch) their patients in the brief and cold contacts that now pass for a medical visit. They are too busy focusing on the computer screen and ordering an endless battery of often unnecessary and sometimes very harmful tests.

The result of any purely technological medicine is bad medicine-one that loses the patient in the profusion of procedures and treatments.

Seeing one movie will illustrate this folly much better than reading a thousand of my blogs. I heartily recommend that everyone view Paddy Chayefsky’s The Hospital-the most brilliant and biting and hauntingly funny depiction of all the medical wrongs that can occur when a patient loses his identity in the maze of simple minded technical virtuosity.

Psychiatry is still by far the most human and humane of the medical specialties. But it too has been handicapped by the privileging of its still inadequate science base over its enduring foundation in the art of human relationships.

It will be likely be many decades before neuroscience has any dramatic impact on psychiatric practice. The breathtaking complexities of brain functioning will continue to defy quick and easy answers.

Meanwhile, we have patients who need help and we have the tools to help them. Some of these tools are technical and specific (meds; CBT); but even these work best only in the context of a rich therapeutic relationship that is based on all that makes us human.

Pat has pointed the way back toward a full bodied, big hearted, mindful, and patient based psychiatry-the kind Pinel taught us to practice and that Pat himself embodies.