Getting Inside The Patient’s Mind

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.

3 Responses to Getting Inside The Patient’s Mind

  1. else says:

    I’m not a psychiatrist but I’m very much enjoying reading your blog.

    After viewing the video, I tried to imagine if I was the patient, how would I explain to a doctor/psychiatrist what had happened? It was tremendously difficult and that’s with otherwise fine cognition… It strikes me as particularly hard to put it into a narrative where you retain some sense of self. Part of the function of therapist might be to assist in putting words to the experiences? and to validate the subject, the self that is trying to cope in amongst all the clamour?

    Ta for the link to the psychiatric news article. As a teacher I am always trying to find ways of understanding the experiences of my students – I learned to write with my non-dominant hand and learned sign language in an attempt to try and understand junior literacy challenges, for eg. I think these are worthy pursuits. We can’t ever fully inhabit the experiences of the Other, but there is lots to learn along the way.

    Thank you for a thoughtful post. I will be reading more. 🙂

  2. mainlyblue says:

    Having worked with the psychiatric population for the last decade, I applaud your recognition of the person inside the disease. My blog directly addresses this issue along with the stigma mental illness presents. You may be interested in a documentary called”Searching for Sanity”in a nutshell 3 esteemed psychiatrists with nearly a century of experience follow a group of 10 participants through everyday social events, work experience, and other group projects, they have to identify the 5 of 10 participants with a psychiatric diagnosis, the results were astounding to both the psychiatrists and at least this viewer. check for more info. Nice to hear that a psychiatrist and a recreation director are on the same page!

  3. Bec says:

    This was a revelation! Its great to hear that some doctors are attempting to understand what their patients go through.
    The movie definitely displayed some of what I have experienced. I wish I could convey the fear and adrenaline rush that occurs with this. The opening of the door. The phone call.
    Imagine that same anxiety and intense rush that would occur when you walk down a dark street at night and suddenly someone passes you, or you think you may be being followed.
    Or imagine the annoyance and frustration of people who are more aware of the voices and just want some peace and quiet to read the paper and do a crossword.

    And finally imagine this every day.

    Every Day.

    Some one who previously had dreams of studying, travelling overseas, learning to drive, now struggling to get through every day life.

    Thank god my meds are great!!!! :-p

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