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Doctors and Patients
David Zigmond Psychiatry often defined as the science of pathological behaviour and mental life. This definition may have seman is acceptability but raises many practical problems that are not immediately apparent but account for much confusion and paradox which continue to trouble psychiatry at every level of practice. This article is an attempt to explore, define and explain some of these difficulties so that areas of confusion are at least recognized ind understood, even if they cannot be resolved easily. Doctors' training and temperament tend towards theoretical and practical formulations that are clearcut, to tangible and relatively certain by scientific parameters. In optimum conditions the doctor is working with problems where the patient's complaint may be dealt with on a technical scientific basis while the doctor at all times retains executive control over problem definition irid problem management—in our own language 'diagnosis' and 'therapy'. When working within this medical model the doctor relies on objectively observable data and the assumption that disease in the patient is due to a fault in the machinery of his body which functions autonomously of the 'whole person' with all his experiences (Zigmond 1977). Such exclusion is due to the fact that phenomena such as thoughts, sensations a nd feelings are not directly accessible to the observer and therefore difficult to include in any scientific formulation. This being so, it becomes necessary to use additional and alternative methods to the medical model in order to place the defined illness in the context of the whole person. Although this may powerfully facilitate understanding and treatment of illness, there is great resistance on the part of most doctors to using alternatives to the medical model. As we shall see, this resistance derives from the doctor's training, temperament and therapeutic dilemma.
Some Biases in Medical Education; the Doctor's Self Image Because illness is conceived in mechanical terms, the future doctor's education and training are predominantly in those sciences which foster analyses that deal with overt and measurable phenomena. Speculation in matters not accessible to scientific measurement and precision is either disregarded or dismissed. The world of covert events, however important, becomes eclipsed by the respectable and traditional preoccupation with amassing scientific facts. Scientific postures in medical practice, apart from their actual effectiveness, also have many significant psychological implications for the doctor. At its most apt, the scientific approach really does offer both the doctor and his patient precise and effective guidelines as to what may be expected and done in a specified situation. At other' times, however, this approach may be a defence against the anxiety of uncertainty to which both therapist and patient are susceptible in their own ways when faced with complex and difficult problems. No doctor finds an unstructured and uncertain situation easy to tolerate as he feels he should be potent, knowledgeable and commanding in any problem his patient brings him. Reciprocally, every patient wishes his doctor to be imbued with superhuman powers of understanding and intervention. Both the fantasy and the reality of psychic or physical disintegration are primitive and powerful threats to the self. Real or imagined disease is likely to challenge severely the foundations of our security and integrity, thereby evoking the most disturbing fantasies or sensations of helplessness and suffering. With such enormously demanding problems it is hardly surprising that the doctor is often faced with situations which outstrip his real abilities in knowledge and therapy. This may be a complex intrapsychic problem or a poorly understood physical syndrome; the dilemma for the participants in the medical transaction remain the same in either case. Both the patient and his doctor will collude together to structure the problem and dispel uncertainty. For the patient uncertainty means the possibility of pain, loss of functions or death. For the doctor uncertainty negates his essential tools of knowledge and therapeutic potency. The patient is afraid of helplessnes and ignorance, while the doctor is afraid lest he should not be omnipotent and omniscient. What happens when the patient presents his doctor with a problem that is not quickly and easily solved by medical methods is then predictable. The doctor continues to offer his patient conventional technical examinations, investigations and impressively inscrutable jargon. The patient is at least temporarily grateful that his problem has been structured, encapsulated and taken away from him. What is common to both of them is the fear of uncertainty and the fear that roles may break down—for the patient that he may not be helped and for the doctor that he might not cope in helping. The doctor's air of authority, white coat, professional titles, technical gadgetry and scientific jargon all have their authentic and very real uses, but they have their ritualistic functions too. A patient suitably impressed by this professional armour is more likely to be compliant, unchallenging and apparently anxiety-free; the doctor can continue edified (if not deified), and, like the patient, allay the anxiety of uncertainty. Scientific ritualization and role-definition in medical practice are also essential in containing and distancing the doctor's fantasies and fears regarding his own potential illness and mortality. Like our patients, we too are gravely afraid of disintegration, decay and death. The sharing of our patients' experiences directly is likely to ignite all these fears with their attendant anguish. Professional and scientific postures carried beyond the demands of a situation in its purely technical aspects indicate a defence for the doctor and his patient equally in distancing them from the frightening intrusion of illness. The placebo and the nominal diagnosis are conventional rituals which ward off the peril of illness for both parties in the therapeutic contract. They symbolize the entrapment, containment and exteriorization of the illness process so that the patient feels safe and the doctor in control (Balint 1964). Materialism and Psychiatry Because psychiatrists are trained first as doctors it is not surprising that problems within psychiatry are chelated within the medical model. The infinite varieties of dis-eased emotional patterns and derivative behaviour are consequently subsumed under categories of 'mental illness', implying that the maladaption (as it usually is) is akin to a lesion or excrescence that may be removed by a therapist. It implies that 'mental illness' has an autonomous existence unrelated to a person's life position. This kind of model is well-suited and generally agreed upon in certain rare organic brain syndromes such as Huntingdon's chorea, neurosyphilis or Alzheimer's presenile dementia. However, it is in no way adequately demonstrable or agreed upon in the bulk of problems that come under the care of the psychiatrist. Professor Henry Miller has decreed that 'Psychiatry is neurology without physical signs'; this probably tells us more about our own training and defence mechanisms than about the subject we are studying. Although we might try to formulate psychiatry in terms of behaviour and physical signs we would have to adopt an extreme and largely fruitless or unworkable position to deny the cardinal importance of mental life in its developmental, perceptual and transactional aspects. However exhaustive and sophisticated our research and observations via cerebral electrochemistry or personality grids or inventories, these do not give us direct access to experience and consciousness which themselves remain unmeasurable quantities. We can only share the crucial subtleties of a person's inner life by making a relationship with him. Electrical discharges, changes in neurochemistry and behaviour may be an index of psychic phenomena but this cannot be guaranteed. In this respect such quantifiable events must be regarded as epiphenomena and parallel events, but not necessarily the cause of the problem. Nevertheless, because of the power, respectability and security of materialistic explanations, these are pursued in preference to other approaches. For example, it has been found that depression is often associated with a brain amine depletion which is thus heralded as the 'cause'. In exactness, however, it remains only one measurable aspect of a complex phenomenon which is still largely unmeasurable. Within the territory of psychiatric problems it is all too easy to equate mediation with causation. All mental events are accompanied by electrical and chemical parallels in the brain and other parts of the body. It necessarily follows that any large change in mental life or behaviour will yield to the biochemist or neurologist significant organic findings. Sometimes these somatic changes may indeed be causal but this is always very difficult to prove conclusively. Even when an organic change precedes emotional disturbance it may be simplistic to assign a simple cause-and-effect formulation. By analogy it was once argued that lightning causes thunder because it precedes it, although we now know that they are both manifestations of electrical disturbance in clouds. Explanations based on physical findings in psychiatric syndromes must be interpreted with the greatest caution; such formulations may derive more from our ideology than the actual disease process.
Psychatric Materialism and Regression Henry Miller's view is shared by many psychiatrists who claim to be scientific in their practice and outlook. Disturbance of the mind and behaviour is conceived as being secondary to cerebral dysfunction which itself rests on ill-defined anomalies of electrochemistry autonomous of the person in his totality; he is 'ill' in the sense that there is a fault in the machine. Mental illness is seen as a mysterious and alien intrusion into otherwise healthy mental life; a man suffers from depressive illness rather than suffering with a depressive reaction or life position. Such a view does not incorporate into mental or organic illness any notion of the function of communication or stiategy between the patient and others. Let us take the schizophrenic syndrome as an example. Schizophrenia may be thought of as being due to occult neurological disease where the signs are those of withdrawal, affectual blunting and fatuity, thought disorder, passivity feelings, referential ideation, auditory hallucinosis and so forth. However, if we take our analysis into less 'scientific' areas the picture may become much richer in terms of our understanding of the illness as a strategy and communication. Guntrip has said we do not grow out of childhood, we grow over it (Guntrip 1964). There is a child in all of us that we manage to encapsulate more or less successfully at different times. Being a child means having no responsibility for actions or feelings, holding others responsible for survival and fate, indulging in vivid fantasy life without being able to distinguish this from reality and being unable to understand that other people have individual and independent needs and existences. The schizophrenic, although adult in years and language formation, is locked into this child system of percepts and responses. He believes he has no autonomy of his own and thus is not responsible for how he feels or behaves. Like the true child he sees himself fused to the outside world in a way that renders him either impotent or omnipotent. Phenomenologically he may express his self-perception via passivity feelings, paranoid or grandiose delusions or referential thinking. His dilemma, though, is quite clear; he feels lost and powerless and sees all power and responsibility as coming from outside himself. This psychodynamic formulation cannot, of course, be proven or measured but is sufficiently graphic and explanatory to be taken seriously in any attempt at understanding the patient as a whole person. Some schizophrenic reactions may have a large organic component but generally this has not yet been demonstrated with certainty or in detail. As things stand, the view of schizophrenia as a regressive reaction is certainly as helpful as any quasi-organic hypothesis. Strategically, schizophrenia is a way of abdicating aspects of adult autonomy and responsibility that are no longer tolerable. In terms of communication the schizophrenic is saying 'I cannot tolerate certain aspects of my life as an adult and 1 am retreating into the child within me'. Schizophrenic reactions are perhaps extreme and clear examples of the regressive function of illness, but they are by no means unique. All illness has its regressive aspects in that it is alien, controlling and limiting. It places us in a position of dependence upon the disease process, our families and our medical attendants. Often, to be ill is to be looked after. Mental illness in particular allows us to abdicate much of our adult functioning and responsibility without the need to scrutinize and strengthen our inner world and resources. With the countenance or stigma of mental illness we can withdraw, act hurt, helpless or violent, or become increasingly lost in an autistic fantasy world. The medical model in effect says 'In this respect you have no autonomy because you are ill and your illness is an alien affliction about which you can do nothing. Only dependence on suitable medical expertise: can help you.' If one holds, as I do, that most mental illness is the result of regressive maladaption, then it follows that the extreme medical approach fosters dependence and deflects any process of self-exploration or growth that are essential for long-term improvement and the abandonment of illness as a strategy and defence against a more autonomous position in one's life and relationships. This kind of psychiatry colludes with the patient in confirming that he is indeed helpless and at the mercy of alien forces. True, we now talk about depressive and schizophrenic illnesses rather than possession by demons and voodoo, but perhaps the ideology remains the same and only the language has changed; we now talk about brain amines not succubi. Most of our patients need to reclaim, explore and resolve their problems before any long-term radical improvement can become possible. Psychiatry Under Siege: Closing the Ranks and Passing the Time The otolaryngologist, obstetrician and dermatologist are in the enviable position of having well-defined problems and territory that are largely undisputed. Few would deny the validity and expertise involved when these specialists go about their work. There may be disagreements over technique between the experts, but little accountability to others. The psychiatrist has, no such security; unless he takes an extreme and arbitrarily defined role, he has to deal with a miscellany of unhappy and maladapted people of whom only a fraction can be demonstrated to have anything like neurological disease. Unhappiness and maladaption are ubiquitous and ill-defined; it is therefore to be expected that the problems we deal with and the techniques we use are open to the interventions and criticisms of many kinds of people. Educationalists, priests, general practitioners, marriage- guidance councillors, probation workers, The Samaritans, are all alternative agencies for much of the psychiatrist's work. Territorial uncertainty and disputes necessarily follow and psychiatrists are liable to respond by entrenching themselves in the relative security of the medical role. This is a type of professional protectionism in the face of challenge and fundamental questioning. In practice it has led to a widespread movement among psychiatrists to enclose the whole poorly bounded territory of psychiatry within the medical model. It accounts for much scholarly but esoteric and fruitless emphasis on semantic phenomenology, adulterated genetics, fragmented biochemistry, and the doctor's disease of compulsively using portentous long words that are incomprehensible to others. Of course all these activities have their legitimate and effective uses but it is important to recognize how and when they are used as defence mechanisms in the context of psychiatry as a way of warding off uncertainty and territorial erosion. It is hardly surprising, then, that most psychiatric diagnoses fall at the nominal end of the diagnostic spectrum (Zigmond 1977). Much of the psychiatrist's scholarly and ruminative pastimes under such categories as phenomenology or statistics do more for his own edification than to enrich or enlighten the relationship he has with the patient. Indeed, if the psychiatrist is sufficiently successful and 'scientific' he may feel that he can function effectively without having a relationship with his patients at all —something that may be termed executive or administrative psychiatry. This is yet another pay off from 'scientific' pursuits which may be inferred to have their origin in the psychiatrist's own resistances and psychopathology. The Present Position: Treating the Illness vs. Knowing the Patient Last year it was estimated that 4000,000,000 psychotropic tablets were prescribed in the UK. This is a legacy of present trends in 'scientific' psychiatry. Unless one seriously believes, as some do, that primary brain disease is occurring at this level, it is a disturbing reflection of patient-doctor relationships. Much of the responsibility for this must rest with those psychiatrists who propagate the notion that a cluster of symptoms and signs equals a clearly defined disease which should be treated primarily and predominantly by medical methods. For the doctor this may provide short-term confirmation of his medical skills and equally brief disposal and containment of the patient. The long-term outcome, however, is likely to be far from satisfactory. For the patient, in particular, this inapt use of the medical model may be seen as an alienating barrier between him and his doctor. Scientific medicine involves 'doing to' rather than 'being with' people and the more we 'do to' a person the less able he is to do for himself in terms of self-exploration, growth and a more healthy realignment of his strategies of living in a world full of stresses and dilemmas. The bottle of imipramine offered in exchange for a patient's tears usually tells us more about the doctor's training and outlook than anything else. References Balint, M., The Doctor, his Patient and the Illness, Pitman Medical, Tunbridge Wells, 1964. Guntrip, H., Healing the Sick Mind, Allen and Unwin, London, 1964. Zigmond, D., Update, 1977, 15, 159.
Doctors and Patients OCTOBER 1977/UPDATE 677 David Zigmmd, MB, CH.B, DPM, MRCGP, is Registrar in the Department of Psychological Medicine at University College Hospital, London and Member of the Institute of Transactional Analysis.
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