Getting Inside The Patient’s Mind

March 4, 2011

As a profession, medicine concerns itself with the treatment of individual human beings, but primarily through a scientific or “objective” lens.  What really counts is not so much a person’s feelings or attitudes (although we try to pay attention to the patient’s subjective experience), but instead the pathology that contributes to those feelings or that experience: the malignant lesion, the abnormal lab value, the broken bone, or the infected tissue.

In psychiatry, despite the impressive inroads of biology, pharmacology, molecular genetics into our field—and despite the bold predictions that accurate molecular diagnosis is right around the corner—the reverse is true, at least from the patient’s perspective.  Patients (generally) don’t care about which molecules are responsible for their depression or anxiety; they do know that they’re depressed or anxious and want help.  Psychiatry is getting ever closer to ignoring this essential reality.

Lately I’ve come across a few great reminders of this principle.  My colleagues over at Shrink Rap recently posted an article about working with patients who are struggling with problems that resemble those that the psychiatrist once experienced.  Indeed, a debate exists within the field as to whether providers should divulge details of their own personal experiences, or whether they should remain detached and objective.  Many psychiatrists see themselves in the latter group, simply offering themselves as a sounding board for the patient’s words and restricting their involvement to medications or other therapeutic interventions that have been planned and agreed to in advance.  This may, however, prevent them from sharing information that may be vital in helping the patient make great progress.

A few weeks ago a friend sent me a link to this video produced by the Janssen pharmaceutical company (makers of Risperdal and Invega, two atypical antipsychotic medications).

The video purports to simulate the experience of a person experiencing psychotic symptoms.  While I can’t attest to its accuracy, it certainly is consistent with written accounts of psychotic experiences, and is (reassuringly!) compatible with what we screen for in the evaluation of a psychotic patient.  Almost like reading a narrative of someone with mental illness (like Andrew Solomon’s Noonday Demon, William Styron’s Darkness Visible, or An Unquiet Mind by Kay Redfield Jamison), videos and vignettes like this one may help psychiatrists to understand more deeply the personal aspect of what we treat.

I also stumbled upon an editorial in the January 2011 issue of Schizophrenia Bulletin by John Strauss, a Yale psychiatrist, entitled “Subjectivity and Severe Psychiatric Disorders.” In it, he argues that in order to practice psychiatry as a “human science” we must pay as much attention to a patient’s subjective experience as we do to the symptoms they report or the signs we observe.  But he also points out that our research tools and our descriptors—the terms we use to describe the dimensions of a person’s disease state—fail to do this.

Strauss argues that, as difficult as it sounds, we must divorce ourselves from the objective scientific tradition that we value so highly, and employ different approaches to understand and experience the subjective phenomena that our patients encounter—essentially to develop a “second kind of knowledge” (the first being the textbook knowledge that all doctors obtain through their training) that is immensely valuable in understanding a patient’s suffering.  He encourages role-playing, journaling, and other experiential tools to help physicians relate to the qualia of a patient’s suffering.

It’s hard to quantify subjective experiences for purposes of insurance billing, or for standardized outcomes measurements like surveys or questionnaires, or for large clinical trials of new pharmaceutical agents.  And because these constitute the reality of today’s medical practice, it is hard for physicians to draw their attention to the subjective experience of patients.  Nevertheless, physicians—and particularly psychiatrists—should remind themselves every so often that they’re dealing with people, not diseases or symptoms, and to challenge themselves to know what that actually means.

By the same token, patients have a right to know that their thoughts and feelings are not just heard, but understood, by their providers.  While the degree of understanding will (obviously) not be precise, patients may truly benefit from a clinician who “knows” more than meets the eye.

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