Wednesday 9 April 2014

The doctor-patient relationship in psychiatry

A few years ago now I broke my leg.  A clean break right through the thigh bone:

I was blue-lighted to hospital, where I was admitted to the orthopaedic surgery ward.  In the morning the lead consultant magically appeared by my bed (with an impressively large entourage) to announce he was going to do an operation and that I had jolly well sign the consent form so that he could get through his theatre list and away on his ski holiday.  Er, ok.  A few days later I was discharged, having never seen him (conscious) again - but with a mended leg, beautifully held together by a 50cm titanium rod.  That was that.

I sometimes compare that very clinical experience of a doctor-patient relationship, with my subsequent experiences of mental health care.

A quick Internet search tells me that there are a spectrum of models by which academics have described the doctor-patient relationship within psychiatry.  These range widely, depending on how much weight is placed on technical (ie biophysical), psychological, and social aspects.

An interesting perspective on the problems with a wholly "technical" approach to psychiatry is found in this article in the Psychiatric Times.  The article explains that the technical/physical model dominates in modern western psychiatry, and that this is not surprising. "Big Pharma" is commercially driven to find biophysical causes - and so treatments - for almost all mental illness symptoms.  However, this technical approach belies the fact that the patient, as a whole person, has much to offer in terms of diagnosis, treatment and long term care.  It also fails to recognise that symptoms of mental illness can stem from the rich tapestry of life, and all that makes us human: our values, experiences, family, culture, community, and so on.  

When I broke my leg, I had no opinion on why my leg was broken (other than that horse riding was a silly hobby), what the injury signified in terms of my past behaviour, or how the injury may change my life going forward.  I was happy to put my trust in the orthopaedic consultant and undergo whatever treatment he deemed necessary.  Other than attempting to keep up with my physiotherapy exercises, I had very little to do with my care, and certainly did not question anything. 

When I became psychotic, on the other hand, my relationship with the medical team treating me was very different (at least after the very first few weeks of acute psychosis where I was heavily sedated for much of the time).  I had many opinions on my mental illness: where it may have sprung from, what may have caused it, what else may be mis-firing in my brain.   I also had an insight into what ongoing treatments may work best for me, and how I might best manage my mental health in the future.

You see, it is very difficult - if not impossible - for me to seperate out where my mental illness ends and where "I" begin.  Therefore if my doctor is treating my mental illness, she is also treating "me".  My past, my actions, my emotions, my values, my religion, my family, my loves and my hates.  

I was given powerful drugs to reduce the symptoms of psychosis.  They worked.  But if I was to get truly well, and not be crippled by severe depression during my recovery from psychosis, I also had to come to terms with what had happened and how I was to function in my new role as a mum.  There isn't a pill for that.  I needed to be confident in my ability to keep house and care for my husband and son.  There isn't a pill for that, either.  I needed to face the world again and not be afraid to say what had happened and where I had been for the first three months of my son's life.  No pill for that one, either.

So my treatment (then, and even now) is collaborative.  It takes my thoughts and preferences into account and is based not just on pharmaceutical alleviation of mental illness symptoms but on achieving a good quality of life for me and my family.  I feel lucky to have had this level of care.  And I wonder whether all psychiatric admissions are as fortunate?  I've heard anecdotally of many instances of forced treatment (including face-down restraint). Where is the whole-person treatment in these cases? What has happened to the doctor-patient relationship there?


  1. This is an honest post that I am glad I read. You have touch me today. More than youll ever know. Thanks you. #pocolo

    1. Thank you so much Pixiedust, your comment means such a lot to me. X

  2. What a great post. I do really enjoy the way you write - such honesty and openness and I do believe that it will help many people in a similar position. Thank you for linking to PoCoLo x

    1. Thanks Victoria that's such a lovely thing to write. I hope so!

  3. Totally identify with the where does my illness end and "I" begin! I find myself defending what I perceive to be just part of my personality, I'm an "anxious" type.I like to be in control as much as poss due to fearing the "out of control" which can come with the illness at times, what is simply "me" what is illness?

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