The Psychiatrist-Patient Relationship
Now the relationship between psychiatrists and patients in the framework of examination and treatment will be discussed. Here psychiatrists are in their primary role, primary in the sense that this role is the oldest, the main role, and the most important one. The roles of scientist and social arbitrator are spin-offs.
Szasz distinguishes the contractual psychiatric-patient relationship from the institutional one. I will discuss the former form first and afterwards some other aspects of relationships in psychiatry, keeping in mind the perspective of power and powerlessness. The institutional relationship will be discussed in Chapter VII.
Usually quite a bit has transpired before a person turns to a psychiatrist for help. First of all, the person has noticed that all sorts of things in life are no longer the way he would like them to be, that he is no longer able to do things that he is used to being able to do, and that all sorts of thoughts and feelings plague and impair him. He has sought explanations inside himself and possibly found some, but this did not bring about the hoped for relief. He has probably discussed it with other people but this too, did not help enough. He no longer succeeds at the things that he used to. Although there are all sorts of variations in this it usually takes a long time for a person to come to the decision to consult a psychiatrist, whether or not others have advised him to do so. Resistance against such a decision is high although probably less today than in the past. As a rule such a person has already tried all sorts of things on his own. His unsuccessful attempts have repeatedly caused him feelings of powerlessness, helplessness, and inferiority.
This helplessness makes patients weak and psychiatrists, as people who may be able to achieve what patients could not, strong. When patients have more or less resisted contact with the psychiatrist and were finally pressured into it by others their position is possibly even weaker. Not only can those patients not solve their problems but they cannot even see them in focus or are afraid to see them and try to shelter themselves against them. The feeling of helplessness will be even stronger in a culture that values competence, self-reliance, and responsibility. Furthermore, there is the problem of saving face.
So the relationship with the helping professional begins with an inequality of power. Psychiatrists, as experts, are strong. Patients, helpless, are weak. In addition, patients need psychiatrists because they are in usually serious difficulties, and feel dependent on the psychiatrist for their solution. Psychiatrists need patients too, of course, as that is how they make their livings. But this need carries much less weight because every psychiatrist has many patients and his dependence on them is spread across this whole group. Additional reasons will be mentioned below. When psychiatrists are many and patients are few, psychiatrists’ needs for patients are much more obvious.
So already at the beginning of the contact between psychiatrists and patients there is as a rule a clear imbalance. The former are independent while the latter are dependent on the other. The former are competent and the latter incompetent. It is not realistic to presume, as does Szasz, that these are two voluntary partners who agree on a contract in a symmetric relationship. In a more formal way, also, the relationship is asymmetric because psychiatrists can, for instance, prescribe medicines that patients cannot buy on their own, or can block access to certain services or treatments.
Furthermore, a number of clear rules apply to the patient-psychiatrist relationship. For instance, patients have the right to discontinue the relationship any moment they wish whereas psychiatrists, once having accepted a patient, are obligated to carry out the pledged treatment. Psychiatrists are obligated to assist their patients as well as they can and know how while patients are obliged to see to it that the fees are paid. Finally, last but not least, there are rules that psychiatrists may not compel patients to do anything they do not want to (except for when the relationship is not voluntary which will be discussed in Chapter VII) and they are obliged to observe confidentiality. In summary, the psychiatric relationship is asymmetrical with contractual aspects based on patients’ hope and trust that their psychiatrist will offer the desired help.
Oddly, precisely this role of professional helper much more than the role of social arbitrator has become the subject of discussion and criticism. The problem posed in the criticism is patients’ powerlessness and inability to judge whether they are receiving the best possible help. That is a call for inspection and regulation of psychiatry. In itself that is a fine thing. If such can be realized mistakes and bad decisions can be corrected which benefits both psychiatrists and patients.
All sorts of such regulatory measures have been invented and carried out. My position is that nearly all of these measures and developments in this aspect have a contrary effect and only make patients more powerless. I will list them briefly here, dividing them into the measures taken by psychiatrists themselves (1a-d), medical insurance providers (2), and the state (3).
1a. In an effort to improve treatments multi-disciplinary teams were formed. This development is to be applauded from the point of view that it is necessary to combine types of expertise. But it led and still leads to confusion about who is responsible and who should be addressed. “Democratization” of the multi-disciplinary team, so desired by the different members, puts patients under the care of a group instead of an individual. When a patient has a complaint it is he against a group instead of one on one. Leenen asserts that “the increase in the number of teams of professional helpers in health care fosters paternalism.” This risk is certainly present and reflects a shift in power to patients’ detriment.
1b. This risk is especially present when a committee is charged with deciding on someone’s suitability for a particular therapy. Although motivated to make a careful decision such a committee becomes an anonymous power that makes decisions about patients in their absence. Protesting such a decision becomes less possible the more experts participate in it.
1c. Another type of quality control is intervision. This is when colleagues discuss psychotherapies among themselves. This, too, is a double-edged sword. On the one hand there is the irrefutable advantage that psychotherapists can correct each other and point out matters that have escaped attention. On the other hand such a team serves as a backing for the psychotherapist, confirming his unquestionable authority.
1d. A similar situation occurs with intercollegiate examination. Here the risk is that it may cause an event to be incompletely reported and thus the examination may have to go much farther than strictly necessary for basing a decision. This risk is perhaps even more imminent in psychiatry than in somatic medicine. Furthermore, it is unclear how the person whose deficient treatment strategy has come to light will deal with such an experience. Among the possible responses are increased insecurity about his own functioning, feeling insulted, and anger. In itself that is not so terrible but in psychiatry, there is always the risk that tension or insecurity on the part of the therapist adversely affects treatment. This holds true as well for conflicts in the treatment teams. Perhaps it is advisable to caution that the effect of such conflicts is a reduction in the quality of care. The assumption that this should not occur is correct, but, I fear, unrealistic. Finally, intercollegiate examination may result in fewer risks being taken, a preference for trodden paths rather than sticking out one’s neck, and choosing routine procedures when a different one may be more risky but also potentially more effective. In psychiatry, due to the legal possibilities for involuntary measures, this can be especially risky and detrimental to the patient. Halleck poses that intercollegiate examination serves the interests of the profession at least as much as patients’ interests.
2. In the Netherlands providers of medical insurance are increasingly regulating treatments. The institutions that foot the bill wish to substantiate the necessity of in particular the more expensive treatments such as psychotherapy, and their quality. Therefore such treatments have to be requested separately by the therapist. The institution doing the regulating has to be supplied with information in order consider the request. One might wonder whether this does not excessively violate patients’ privacy in spite of all parties’ oath of confidentiality, so that here again patients’ interests are jeopardized by regulation. In addition, when the application is rejected, that is done by an institution which is anonymous to the patient without hearing his point of view.
It is doubtful that this measure affords protection for patients. Providers of medical insurance are preoccupied with financial aspects. Their involvement should be viewed in the context of spending the premiums paid by the insurers as responsibly as possible. This perspective inescapably influences their decisions. That is in fact as it should be. Mixing this aspect with regulation of providers of treatment (physicians, therapists, etc.) is, at least partly, inappropriate and detrimental to the interests of all parties.
Probably more important than the above is the development that providers of medical insurance and providers of treatment have become negotiating parties. The funding of treatment is done almost totally without patients’ involvement. Patients often do not have the faintest inkling as to the cost of their treatment. This can cause a misplaced atmosphere of benevolence to exist in the therapeutic relationship as therapists offer treatment seemingly for free.
3. In the Netherlands the state increasingly intervenes in the physician-patient relationship. It does this, among other ways, by determining the social organization of the profession’s work. It also does so by direct intervention in the content of matters such as the meaning, value, and restrictions of psychotherapy. Precisely psychotherapy is individualistic in the sense that more than any other type of psychiatric treatment it takes place in the privacy of the contact between the patient and his psychotherapist. It is difficult to avoid the impression that precisely this exclusive and private nature of therapy, in addition to its unfathomability for outsiders, is the provocation for violating the psychotherapeutic relationship and its premise of privacy. The inclination to regulate may well shake the pillars on which psychotherapy is built, bringing about its downfall, or compelling modifications which defeat the very purpose for which it came about* . For the sake of brevity I will not carry this further.
The state, too, tends to present itself as the patients’ spokesperson and advocate. Again one must seriously wonder whether the state is capable of taking on the role of patients’ guardian without conflicts of interest in view of the state’s other roles such as regulating the socio-economic aspects of helping professions and maintaining public order. Many people brush with psychiatry (partly) because the structure and order of our society poses problems for them. Precisely psychiatry, therefore, is in a certain opposition with the state which is ultimately responsible for this order. Szasz has correctly pointed this out time and again.
State policy aims among other things to create an efficient pattern of services. It achieves that at the expense of competition among psychiatrists and institutions due to their monopolistic positions. This lack of competition is disadvantageous in particular for patients who are rendered powerless by these monopolies. Any kind of conflict between patient and institution is likely to compel the patient to have to return to that same institution “tail between legs.” These monopolistic positions are augmented even more by regionalization, another goal of state policy. Patients have less of a chance to use the facilities of regions other than where they happen to live.
The significance of the above comes into focus when it is realized that the number of different kinds of treatment within one institution is usually limited. Patients as a rule are treated with one of the methods that the particular institution happens to have on offer. It should be possible for patients who don’t find any of the treatments on offer suitable to have the opportunity to seek a different psychiatrist or institution.
Another disadvantage of monopolization is that the mechanism of direct feedback on the quality of facilities’ functioning is lost. As with everything the opinions of friends and acquaintances, or the experiences of the family doctor, help shape how patients feel about institutions. Monopolies of functions in the mental health service destroy this feedback. At the same time it drastically reduces patients’ influence on the system.
Furthermore, by merging institutions, huge impersonal, anonymous, bureaucratic units are formed that leave dissatisfied patients with the “You can’t fight city hall” feeling.
If in psychiatry diseases could be treated as though they are concrete facts, if psychiatrists had a large body of concrete knowledge making it possible to state directly and clearly what would be the right treatment, then this whole development would not be as dangerous as it is. But that is not what psychiatry is like in reality. Psychiatry desperately needs that feedback from patients. It can flourish only on a human scale. It is realized in interpersonal contacts in which an atmosphere of frankness, transparency, and trust are essential. The increasing power of psychiatry and increasing powerlessness of patients are alarming for both patients and psychiatry.
I wish to point out a special aspect of state intervention. The state aims to create a comprehensive system of services. That means that it must be accessible to everybody and offer solutions to all kinds of psychiatric problems. Everyone should have the right to be treated for every disorder. My position is that this is a dangerous illusion and that this political goal might lead to diametrically opposed results which would constitute a danger to people’s health.
My arguments for this position are as follows. The state’s goal, being a bureaucratic ideal described in detail, namely a closed circuit of facilities, is linked to a human and therefore fallible industry, namely the practice of psychiatry. This is comparable to building a network of motor highways with the intention of having it traveled by horse-drawn covered wagons and expecting that the wagons will match the speed, comfort, and efficiency with which we associate highways. In other words, psychiatry as an applied science and helping profession is simply not developed enough to provide a satisfactory solution to every problem.
The role of helping professionals is to solve problems. That is what they expect and demand from themselves. Therefore the pressure to do something is always already greater than the pressure to do nothing in doubtful cases. This inclination will be even stronger when the helping professional is employed in an expensive chain of facilities which was erected apparently in the expectation that things have to happen. The former adage “When in doubt leave it out” has long been replaced with the attitude that it must be assumed that someone is ill and needs treatment unless the opposite has been proved.
Frances et at point out, “In actual practice, therapists tend to recommend treatment almost automatically and without a careful consideration of its necessity or possibly harmful effects.” They note that little research has been done regarding disorders that do not respond to treatment, worsen when treated, or disappear without treatment. They recommend in difficult cases, “particularly in response to what is often a desperate or chaotic situation,” having the decision to refrain from treatment made by two psychiatrists. So deciding to refrain from treatment is as difficult as deciding on an invasive and risky therapy for which the same ethical code applies.
The closed system has the purpose of relieving need and thus must do that, for better or for worse. The highest authority must intervene when others know no solution. There is no place left in the system for doubt, powerlessness, or not knowing what to do. Doing nothing is impossible even when doing nothing would be preferable. The price paid for order is thus becoming very high.
As described above, all sorts of people and institutions present themselves as (uninvited) patient advocates and defenders of patients’ interests. Such a system raises the question, who regulates the regulators? This can set off the formation of another layer of “advocate” people and institutions. It was argued that this in fact only makes the patient more powerless. All these measures aimed at increasing patients’ power may achieve some reduction in the power imbalance. Although a thorough discussion of this would go beyond the scope of this book, I would like to make a few comments about it, disregarding legal aspects.
First of all, the imbalance of power can be limited by being aware of it. By this I mean that it is better to realize that this imbalance of power exists than to try to instill all sorts of manipulations in the hope of being able to eliminate the imbalance. Acknowledging the imbalance of power is a first step towards dealing with it.
Secondly, the imbalance of power can be limited by the nature of the helping professions themselves. In our pluriform society with its highly developed specializations it is not realistic to assume that anything a person cannot do for himself makes him less autonomous. Quite the contrary, using the abilities of another person to make headway in a problem experienced as insoluble may attest to responsibility. This does not mean that psychiatrists’ main role is solving their patients’ problems but that they should endeavor to increase their patients’ ability to solve their own problems. This can be done by teaching them skills or by finding and recognizing the obstacles that make people powerless in certain situations. Ruddick sketches the therapeutic relationship as that between a worker (psychiatrist) and a colleague (patient). In this case the latter can insist on thorough information and discussion of alternative possibilities with all their limitations so that they are sharing not only the decisions but also their implementation. Ruddick’s model fits well into a biopsychosocial disease concept and provides opportunities for helping professions that attempt to minimize patients’ powerlessness.
Thirdly, patients’ dependence and powerlessness can be diminished by enlarging their competence, and that in turn can be done by increasing their knowledge. Although a great deal of lip service has been given to health education, dealing with illness and health is so important that it is worth considering granting it more attention as a subject taught in schools. Everybody will be faced with illness sooner or later so it is important for everybody to know more about it. Once a person has accepted the sick role, thorough information, not only about what is wrong and what is likely to happen, but also about his rights and responsibilities, is very important. Here too, however, one must wonder how much formalizing rules about so-called “informed consent” will actually benefit patients.
Fourthly, it seems of utmost importance to me that the psychiatrist-patient relationship remains as transparent as possible to the latter in the sense that the therapist’s task must be clear and unambiguous. By that I mean that it is essential that the therapist does not take conflicting roles upon himself. In the Netherlands medicine is featured in this way by the happy circumstance that treatment and regulation are separate. That has recently been confirmed by the Royal Dutch Society for the Advancement of Medicine. This means that psychiatrists can concentrate on treatment and do not have to be preoccupied with all sorts of interests that are not directly related to it. It also means that they cannot be authorities in addition to their therapeutic activities, with the power to grant or refuse all sorts of matters except as are directly related to the therapy. The interests of therapy and therapeutic relationships come first. Within psychiatry a splitting of tasks can be wise as well. An example is psychotherapy. Patients are asked to reveal their thoughts with as little censure as possible. To render the situation as safe as possible, psychotherapists specifically accept an obligation of confidentiality. For patients to be as independent as possible no advice, declarations, or medicines are provided. Limitation of the realm of what is to be done makes it possible to concentrate on the psychotherapy. If at a certain point it becomes necessary to prescribe medication after all, a different therapist can be involved for that. By limiting the role of both therapists, maximal transparency in both relationships becomes possible.
Fifthly, both psychiatrists and patients should realize that every person has an intrinsic and unalienable responsibility for his own life; that no other person can take on this responsibility; and that it is up to the person himself what will become of his life. This is not an appeal for some kind of hyper-individualism. It is an observation that people cannot relinquish responsibility for their own lives without drastic consequences for their future prospects. No matter how sincerely ideologies, systems, and religions promise people happiness and so forth when they place their trust in them, no matter how heavy a burden responsibility for one’s own life is (see Chapter III, 2.5), every alternative is worse.
Sixthly, there is an important role to be played by patients’ organizations, helping those people who cannot hold their own in the system of helping professions, and letting the helping professions know when they make people more powerless than necessary.
Finally, in his contractual relations with patients, Szasz limits himself to “just talking.” He rejects all sorts of methods that in his opinion violate personal dignity. He never prescribes psychiatric drugs. Seidenburg reveals that Szasz condemns group therapy, marriage counseling, and the use of tape recorders, videos recorders, and one-way mirrors. These means and methods do not strike me as violating a contractual relationship nor interfering with cooperation between psychiatrists and patients as long as they are not used against patients’ wishes. On the contrary, group therapy and marriage or family counseling can be extremely successful forms of therapy. As to psychiatric drugs, when someone is so anxious that he can hardly think about himself and his problems, and if I know that he will be much better able to do so if he temporarily uses an anxiolytic, I do not see how it could be humiliating or insulting if I point this possibility out to him. This would be applying a mixed, causal and hermeneutical approach. Moreover, in case of a person with a manic-depressive psychosis I would consider it negligent of the psychiatrist not to point out the possibility of using lithium preparations to his patient. It is impossible to place these medicines in a hermeneutical framework. They can be applied only in a causal-analytical framework, whereas Szasz disputes the validity of a causal-analytical framework in psychiatry.
Tape recorders, video recorders, and one-way mirrors are aids that are employed in certain therapies. They can be useful. They should never be used without patients’ specific knowledge and consent. I do not see any reason not to use them as long as the patient has given his “informed consent.”
In summary, the therapeutic relationship between psychiatrists and patients is an asymmetric contractual relationship based on, and existing only due to, patients’ hope and trust that their psychiatrists can provide the help they want. It is of utmost importance to recognize and acknowledge the imbalance of power in this relationship, to not make it any larger than it already is, and to reduce it as much as possible.
It has been argued that in this aspect current developments in mental health care in the Netherlands forebode worse to come. External measures for regulating therapists have effects diametrically opposed to their purpose. Therefore I propose finding ways of making patients more expert and powerful.
Finally, the boundaries of what is possible and admissible in therapeutic contractual relationships can and must be taken more broadly than does Szasz, and should be determined by that with which patients, having been informed, can voluntarily cooperate.
*Two decades after the author wrote these words we know his prediction to be correct. – translator
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