Physician mistrust and the end of the doctor-patient relationship

KevinMD.com published a post a couple of days ago from medical student Joyce Ho in which she admitted to discomfort raising the topic of religion with patients.  As a "polarizing" issue that could make the doctor-patient relationship "more unprofessional," Ms. Ho imagined that patients would fear playing into their doctors' prejudices, particularly if the doctor were atheist, and that this fear would push some patients away from the inquiring doctor.  Despite her instructor's recommendation to ask gentle, open-ended questions about faith and spirituality in the context of a patient's support systems, "personally, I still will not actively ask about religious preferences if the patient does not bring the issue up." As a new reader of KevinMD, I was first to comment — a mistake, in retrospect.  I imagined her concerns were merely new-doctor jitters, a phenomenon as old as medicine itself.  I pointed out that students at first find religion, sex, and many other topics difficult to broach with patients.  Yet uncomfortable topics such as these are often important, and may go unmentioned unless the doctor asks.  Trying to be supportive, I noted that patients usually worry less about a doctor's own religious beliefs, or lack thereof, than they do about their doctor's care and concern.  Frankly, I didn't imagine my comment was controversial in the least.

To my dismay, comment after comment followed that a patient's religion is none of his or her doctor's business.  To some extent this was conflated with complaints of unbidden chaplains appearing at hospital bedsides, and awkward offers by medical staff to pray with a patient who wanted no such thing.  But even leaving aside those obvious blunders, there was rampant mistrust of doctors even inquiring about religion, spirituality, or faith.

Apparently, Joyce Ho was right.  Commenters on the blog assumed we doctors jump to false conclusions — "assume certain things about certain religions" — and are apt to over-interpret based on limited information; that we are "busybodies" to ask about such matters; that the information is irrelevant at best; that "doctors might judge you"; and that we cannot help but oversimplify the beliefs of any patient who has given religion or spirituality serious thought.  A self-identified atheist living in the Bible Belt was grateful no doctor had ever asked: "We in the South have enough problems ... without also having doctors who think they should be discussing religion with their patients...."  The comment with the most "agrees" was this anonymous one-liner:

I wouldn't want my doctor asking about my religion. That's not necessary. I'm glad mine don't do that.

How has it come to this?  Haven't patient advocates and caring doctors fought for years — decades — to retain humanism in a medical system that inexorably drifts toward the impersonal and mechanical?  What happened to the hope, if not expectation, that one's doctor sees the person behind the symptoms, the whole patient?  And what on earth happened to the premise that one's doctor can be trusted with sensitive personal information?  Religion, after all, is hardly the riskiest thing one might tell a physician in confidence.

A close look at the commentary reveals the sad truth.  The healing doctor-patient relationship is no more.  The Bible Belt atheist sees religion as a source of doctor-patient antagonism.  For the rest, the patient's relationship is not to a doctor, but to a "system of care."  This system aims to fill blanks in an electronic record; one commenter advised doctors to ask, "Would you like me to list a religious affiliation?" in order that this particular blank can be left unfilled if the patient desires.

Of course, antagonism and "listing" a religion in a database are not why medical students learn to take a patient's social history, including hobbies, interests, and social supports secular and otherwise.  It's to know their patients as people, to build rapport, to honor beliefs and relationships their patients hold dear, to appreciate their patients' strengths as well as weaknesses.  It's to offer personalized counsel, so that (to take the most basic example) the non-religious are not advised to seek solace in church, nor the faithful to neglect it.  Occasionally it's to develop a differential diagnosis for a medical condition unexpectedly related to a patient's social interests or behavior.  And often it's to learn a patient's values and preferences regarding end of life care, so that when that patient is unable to express them, his or her trusted doctor already knows.

All of this applies to a doctor, a well-meaning, trustworthy (if fallible) human fiduciary who listens in confidence.  In stark contrast, systems of care suffer diffusion of responsibility.  They spread personal information in unpredictable ways, outside the patient's control and awareness.  Thus, one commenter wrote, "I don't want that kind of information in my medical record," while another elaborated, "Blue Cross and the xray technician and everyone else who comes in contact with the chart have no need to know what religion the patient is unless the patient chose to share it with everybody."

Health reform provides long-overdue expansion of health coverage.  On the supply side, it promotes systems of care to enhance efficiency and decrease costs.  It's important to realize what we may already be losing in the bargain: the traditional personal relationship with a physician entrusted to handle intimate details of one's life with discretion and wisdom.  If it is no longer safe to divulge one's religion, what about one's sexual habits, recreational drug use, risky hobbies, and myriad other touchy subjects?  Widespread self-censoring of this information, to prevent it from entering large medical databases, may turn out to be more hazardous to public health than all the inefficiencies of the old approach.

Narcissists, psychopaths, and other bad guys

A patient of mine recently observed that the increasing use of the the term "psychopath" in popular media is really a disguised way of criticizing selfishness.  Dressing up selfishness as an odd and frightening clinical disorder — slapping a diagnostic label on it — makes for catchy news copy, and grants pundits emotional distance between themselves and those monsters who look just like us, but who lack the empathy and remorse that make us human. I immediately thought of how narcissism had its heyday in popular culture very recently as well, and to similar ends.  Narcissists and psychopaths care only about themselves, and have no qualms about hurting and sacrificing others when it suits their purposes.  These are dangerous people lurking among us; all the more reason to publish lightweight magazine and newspaper pieces on how to spot them in the wild.

Both labels sound like psychiatric diagnoses, but actually they're not.  According to Heinz Kohut and other theorists, narcissism is a quality everyone has to a greater or lesser degree.  It normally develops in infancy: the sense all babies have that the world revolves around them.  However, we gradually learn that we are not the center of the world, and that other people, including our primary caregivers, have their own goals and perspectives separate from our own.  Infantile narcissism is thus tempered by the reality of healthy relationships, although its vestiges are present in our self-pride, and perhaps in our proven tendency to overestimate our own efficacy and performance.  Pathological narcissism in this view is infantile normality carried abnormally into adulthood.  It only becomes a psychiatric diagnosis when the condition fulfills certain observable criteria and impairs social and/or occupational functioning.  Likewise, psychopathy is a personality trait, not a diagnosis.  Renowned psychopathy researcher Robert Hare notes that "psychopathy is dimensional (i.e., more or less), not categorical (i.e., either or)."  DSM-IV doesn't include a diagnosis called "psychopathy" or "sociopathy."  Instead, there is antisocial personality disorder, which overlaps with psychopathy but is not the same thing.

These terms, psychopath and narcissist, are loosely applied personality labels when popularized in the media.  What do they add over simply calling someone callous or selfish?  First, they offer an explanation — a pseudo-explanation really — of frightening and/or mystifying behavior.  Our feeling of powerlessness is eased by the label, as though now that the threat is identified, we may be able to do something about it.  Second, such labels imply that misbehavior is a function of one's character, a categorical determination.  Yet categorical psychiatric diagnosis, especially of personality, is controversial in general.  Moreover, we often overestimate personality factors and underestimate situational ones (the "fundamental attribution error") in explaining the behavior of others.  Using a label like psychopath or narcissist to describe another person (whom we've only heard about in the news, and haven't formally evaluated) reaches for a premature conclusion about the cause of that person's behavior.  In a way, we are falsely reassured.

Third, the label adds power to our verbal disapproval.    We have a long history of abusing psychiatric labels in the service of putting others down.  Consider "idiot," "moron," and "imbecile," all originally coined as official categories describing low IQ.  Or "cretin," which originally referred to physical and mental disability due to congenital thyroid deficiency.  Or the casual use of "crazy" and its synonyms.  Some patient advocates argue further that any diagnostic label used as a noun is demeaning, i.e., calling someone a schizophrenic, a neurotic, a borderline, etc.  Instead, it is more respectful to refer to a person (or patient) who has schizophrenia, or a narcissistic personality.  But that's exactly the point of the popular use of terms like psychopath and narcissist: To show disrespect and disdain, to disapprove.  And to underscore the difference between ourselves and the person with the label.

Our earliest social categories are "good guys" and "bad guys," defining one against the other.  From "cops and robbers," to team sports, to bipartisan politics, to our allies and foes on the world stage, we divide self and other at every level, calling the former good and the latter bad.  Callousness and selfishness are in all of us to some degree, and it hurts to admit it; it damages our self-image.  Instead, we psychologically defend against this realization in ourselves by projecting these traits onto others using a broad brush and pejorative terms.  While some people truly are unusually callous or selfish, the popular use of scientific-sounding labels serves our own psychological needs by identifying "bad guys" and making us feel better about ourselves.

Therapy for therapists

Tara Parker-Pope of the New York Times blog Well featured my prior post, on the feelings some patients have as they imagine whether their psychotherapists have been in therapy themselves.  My post was about patients' fantasies, not the reality of therapy for therapists.  Nonetheless, many of the comments argued for the great value of such therapy, and one or two expressed amazement that such therapy is not universally required.  I agree that psychotherapists have much to gain from personal therapy, and in this follow-up post I'll offer some reasons why. Is therapy required in order to become a therapist?  In the U.S., generally not.  According to Geller, Norcross, and Orlinsky [1]: "In most European countries, a requisite number of hours of personal therapy is obligatory in order to become accredited or licensed as a psychotherapist.  In the United States, by contrast, only analytic training institutes and a few graduate programs require a course of personal therapy."

A "training analysis" is required to become a psychoanalyst.  I.e., one must be analyzed oneself.  However, in the U.S. personal therapy is not required to practice other schools of psychotherapy, nor to obtain licensure in mental health disciplines such as psychiatry, clinical psychology, etc.  Specific training programs within a discipline may require it, and certainly a large number of programs recommend personal psychotherapy for their trainees.  Indeed, many strongly encourage it by offering referrals to therapists, low-fee therapy, time off from training to attend therapy, and so forth.  In a 1994 survey of psychologists by Kenneth Pope and Barbara Tabachnick, 84% reported having had psychotherapy themselves, although only 13% had attended a graduate program requiring personal therapy for therapists-in-training [2].  Whether by mandate, urging, or independent choice, many practicing psychotherapists can claim experience in "the other chair."

At the most commonsense level, a therapist who knows what it is like to be a patient may be more empathic, and may anticipate unstated feelings more readily than a therapist without this first-hand knowledge.  For example, vacation breaks can feel extraordinarily disruptive to patients, a fact that can be taught in lectures or textbooks (or blogs), but may not be fully appreciated until it is experienced oneself.  Transference in general is better understood experientially than learned academically.  Even non-analytic therapists can benefit by recognizing transference and other common "real-time" emotional reactions, conscious and unconscious, in their patients or clients; these can affect rapport, treatment adherence, and so forth.  Psychodynamically informed practice is a hallmark of psychiatry, even when psychodynamic treatment is not offered.  The same, I would argue, is true of other mental health disciplines.  Psychologists conducting CBT and clinical social workers leading support groups should know about psychodynamics too.  And the best way to learn dynamics is experientially, in one's own psychotherapy.

The argument is even stronger for therapists who practice traditional psychodynamic therapy, where transference and countertransference are essential treatment tools.  As I wrote last year, it takes self-knowledge to use countertransference therapeutically. Without this self-knowledge it would be impossible to sort out the patient's issues from one's own.  In seminars for psychiatry residents, I point out that our field has no blood test or brain scan to directly measure thoughts and feelings in the interpersonal space.  Our own feelings, countertransference broadly defined, is the sensitive instrument we bring into the consultation room.  The therapist's own psychotherapy "calibrates the instrument" so he or she can better trust its readings when applied to patients.

To me, this is the main reason to recommend therapy for therapists.  In addition, others have argued that it normalizes and destigmatizes being in therapy (assuming the therapist discloses his or her personal therapy to the patient); that it improves one's performance as a therapist non-specifically, by relieving stress and tension; and that it may give the therapist "a valuable perspective on what works and what doesn't." Several commenters on the NY Times blog believe the therapist's own therapy encourages humility, and may decrease errors based on hubris and unexamined countertransference:

We are to be one of the self monitoring professions, responsible in a unique way as the stewards of our treatment with our clients.... Having our own issues worked with ... goes a long way toward ensuring a unique quality of care.

I would be very wary of a therapist who had never sought therapy for him or herself. To me it would smack of an "I don't need it — it's for messed up folks like you" attitude.

I am also frequently shocked by the stories my patients will tell me about being in therapy with someone who clearly hasn't worked on their issues. It can be very damaging to a patient...

A personal psychotherapy does not guarantee that a therapist will be caring, non-abusive, technically proficient, or effective.  But there is little in psychotherapy, or in life, that is guaranteed.  Psychotherapeutic work, particularly the psychoanalytic and psychodynamic varieties, seems closely tied to the therapist's self-knowledge and willingness to self-reflect.  If we are to use our own perceptions and reactions as sensitive instruments in the consultation room, we are well-advised to take good care of the equipment.

[1] Geller JD, Norcross JC, and Orlinsky DE, The Psychotherapist's Own Psychotherapy: Patient and Clinician Perspectives, Oxford University Press, 2005.

[2] Pope KS and Tabachnick BG, "Therapists as Patients: A National Survey of Psychologists' Experiences, Problems, and Beliefs" Professional Psychology: Research and Practice, 25(3), pp 247-258.

"Have you seen a therapist yourself?"

Recently a patient asked whether I'd ever been in therapy myself.  Without answering his question directly (see my post on psychotherapist disclosure and privacy), I replied that many of us have, and asked what it meant to him.  It would be a bad sign: "How can you help if you need help too?"  We went on to discuss his feeling that being in psychotherapy marked him as defective or deficient.  He would naturally prefer a therapist who did not share similar defects and deficiencies. Many patients take the opposite view.  They believe a doctor who knows what it's like to be a patient can better empathize with them.  So this patient's concern stood out in my mind — he truly feels his psychotherapy is a mark against him, a kind of declaration or admission that he is damaged.  I later reminded myself that professionals — and others, everyone really — regularly use services offered by others in the same field.  Lawyers have their own lawyers, doctors see their own doctors.  Chefs eat meals made by other chefs, barbers get haircuts from other barbers.  The only problematic examples that come to mind are when the condition being treated is shameful or morally repugnant, or when the condition could directly affect the service being offered.  Examples of the former: police officers who require the "services" of other police officers after committing crimes, and clergy who need spiritual or moral counseling for their own transgressions.  Examples of the latter: a neurologist with brain damage, and a business consultant who cannot maintain his or her own business and needs outside help.  How does this apply to psychotherapists, and what light does it shed on patients' feelings about seeing therapists themselves?

The need for psychotherapy feels to many people like a sign of defect/deficiency/damage.  In speaking with patients I often highlight the "need" in that sentence, and contrast it with "want" or "could benefit by."  Some patients make themselves feel worse by telling themselves they "need" therapy, when it would be just as accurate to say they are apt to benefit by it, or even that they desire it.  I don't believe it devalues psychotherapy, or psychiatric medications for that matter, to note that they're frequently optional.  Most depression improves on its own eventually, and people may choose to muddle along in life dissatisfied, angry, or in a series of bad relationships.  Remembering that psychotherapy is a choice may take some of the shame out of it.

That's only part of it, though.  No one worries or cares if one's proctologist also needed to see a proctologist at some point, even though proctological conditions feel shameful to many people.  In addition to shame, there is moral repugnance associated with mental illness, even, or perhaps especially, the apparently milder problems that lead people into psychotherapy.  Often unstated is the notion that one chooses to be emotionally weak, distraught, hotheaded, or whatever, and that this choice is selfish, unfair to others, or otherwise immoral.  Moreover, that seeking professional help to "snap out of it" or pull oneself together is self-indulgent and akin to laziness.  While the idea isn't totally groundless — there is some choice in how to act, and even how to feel sometimes — it assumes far too much conscious choice.  Most troubled patients would give anything to be happier, at least consciously.  In returning to my patient's question, perhaps he would not trust a doctor who willingly made himself dependent on others to help steer his life back on course.  It may feel as morally suspect as the corrupt police officer or clergyman: a character flaw in the traditional sense.

Alternatively, there may be concern that a psychotherapist who needed therapy ("needed" in scare-quotes as noted above) cannot perform well as a therapist.  This would be analogous to the brain-damaged neurologist or the business consultant whose own business is failing.  The logic may be pragmatic:  A psychotherapist should have his or her own life in order before claiming to be able to help others.  Or it may be fear that residual pathology lurking in the therapist may be harmful to the patient.  Or it may be a transferential need for an idealized, faultless therapist.  Each of these can be addressed as it arises.  We each have our blind spots, and can help others without necessarily being able to help ourselves.  It is better to have sought treatment for potentially hurtful pathology, than to have ignored or denied it.  No therapist is perfect.

Any or all of these concerns about the therapist may also apply to the patient himself.  Being in therapy may make a patient feel ashamed, or morally bad or wrong.  It may highlight a fear of incompetence or harmfulness.  It may clash with a need to be perfect.  Asking the therapist "Have you seen a therapist yourself?" may be an easier way for the patient to broach sensitive feelings about his or her own participation in therapy.  This seemingly simple question can carry a lot of meaning, and if explored in detail, can help a patient understand himself better.