www.psychspace.com心理学空间网The possibilities of patient-centered medicine*
ENID BALINT, B.Sc.
London
Case work consultant, Tavistock Institute of Human Relations, London; honorary secretary, TrainingCommittee, British Psycho-analytical Society
IN his paper, The Structure of the Training cum Research Seminar and its Implicationfor Medicine, Michael Balint spoke about two classes of pathological conditions:Class I comprises conditions in which a localizable 'illness' can be found. In this classscientific examinations can identify a fault either in the body or in one of the partfunctions in the body. In this way of thinking, the prime aim is to find a localizablefault, diagnose it as an illness and then treat it. This is what we call 'illness-orientatedmedicine.'
In contrast, there is another way of medical thinking which we call 'patient-centredmedicine'. Here, in addition to trying to discover a localizable illness or illnesses, thedoctor also has to examine the whole person in order to form what we call an 'overalldiagnosis'. This should include everything that the doctor knows and understandsabout his patient; the patient, in fact, has to be understood as a unique human-being.The illness which can be described in terms of a 'traditional diagnosis' is either anincident like a broken leg, or a part like accident proneness which makes better senseif understood in terms of the whole.
The question which has recently been occupying our minds is: How does a practisingdoctor avoid a split in himself? How can he avoid being a general practitioner to someof his patients and a competent psychotherapist to others? Or, expressed in our newterminology: How can he avoid practising 'illness-orientated medicine' with some patientsand 'patient-orientated medicine' with others.
Before proceeding it is necessary to state the problem in a slightly different way:What was our aim when, in 1950, we started advertising in the medical press in Londonthat we proposed to hold seminars on the psychological problems in general practice?Did we, in fact, have in mind to teach our doctors to be minor psychotherapists? Didwe aim in establishing this sort of split?
If this were so, why are we so worried about it now, because clearly if this had beenour aim, we could not have expected our doctors to remain whole doctors with oneprofessional activity as they were bound, it would seem, to do 'psychotherapy' withsome patients and 'general practice' with others. Leaving on one side their patients,requirements, the size of their practices alone would not permit them to do minorpsychotherapy with all their patients. Furthermore, if they wished to become psychotherapists they could take the necessary training and leave general practice altogether.
No, there was never any doubt in our minds that the aim of the seminars was to studythe emotional problems found in general practice in the hope that if it were found to benecessary the general practitioner's whole medical approach might be changed; whichmeans that new skills would have to be evolved.
In the later 1950's we thought that we had made some progress, but nevertheless,we began to be anxious about the problem of the split doctor. Our doctors told usthat although they had not altered their way of treating all their patients their wholework had nevertheless changed since they joined our seminars. They could not tell ushow, but they felt themselves to be different kinds of doctors, even different kinds ofpeople since they started work with us. They insisted, nevertheless, that their ordinary'surgeries', i.e. the time they spent in their consulting rooms, were much as they hadbeen before they started; and we found this puzzling.
We had already tried several times to discover how the doctors decided to chooseone patient for psychotherapy rather than another. No answer could be found. Thedoctors realized that their choice was often irrational. That many people who neededinvestigation did not get it and that the most needy were not always chosen for specialattention. Why was this?
When, therefore, in 1962, I was asked to lead a group of experienced generalpractitioners at the Tavistock Clinic I brought the subject up for discussion. This waswith a group of doctors who had already had some experience in the training schemeand were ready to undertake some kind of research. Quite early in our work we decidedto study randomly selected patients in contrast to our usual practice of studying onlythose patients whom the doctors selected specially for discussion.
During this study we made various discoveries.*
Here is the gist of what we found:
First, it seems as if our doctors felt compelled to identify with two professionswhen they joined our seminars; the profession of the general practitioner and theprofession of the psychiatrist and psycho-analyst. All the participants were practisingdoctors but they felt that their work and ours as practising psychiatrists and psychoanalysts was utterly different. They wished us to remember this. It was important tothem to preserve their identity as general practitioners; there were times when theystrongly identified with us, but there were times when they did not wish to do so.Secondly, they saw us, on the one hand, as trying to turn them into psycho-analysts,without the time or the opportunity to do so and on the other forbidding them to practiseanything remotely resembling psycho-analysis. They wanted to show us how exactingour demands were on them and how frustrating and unrealistic. They thought thatwhen we expected them to do more than they did we did not realize how good they wereanyway.
Because of the difficulties inherent in all of this, we felt that we must examine thesituation further and it was for this reason that when this seminar had to be terminatedMichael Balint and I assembled a dozen of our most experienced general practitioners(this time at University College Hospital) and asked them if they would like to co-operatewith us in a research into how much 'patient-orientated medicine' can be done in theordinary run of their practices. This time we did not want to examine randomly chosencases. We wanted the doctors themselves to choose the cases where they felt one brieffive- to ten-minute consultation had started a 'patient-orientated medicine' and we wantedto follow up the cases that the doctors chose over a long period. We called this aresearch into six-minute psychotherapy; but, of course, we did not want to impose astrict time limit on our doctors but to make a distinction between this kind of psychological understanding and therapy and the traditional long interview kind.
Now I want to report something about this research. Many of the attitudes foundin the first research seminar were repeated here. At the beginning it seemed that sometimes our doctors wanted to show us how little they did rather than how much. Inthe usual way, when the same doctors reported on cases the emphasis was on the doctorpatient relationship; and on the way they felt about the patient and why they werefinding difficulties in helping him; whereas, when they reported on their 'six-minutecases', they did so rather in the traditional manner; they based their understanding of thepatient more on traditional medicine (although it might sometimes be from the psychiatricpoint of view). That is, they discussed their findings in terms of dependency or somesimilar cliche and less on the patient's active communication at the time of the interviewand how this could be understood and used for therapy. These were cases where thedoctor did not want to have long interviews and was right in making this decision; butthey could not see that something important for the patient had happened and perhapseven some help had been given to him in the short contact in the consulting room. Otherparticipants in the group might see this but the general practitioner in charge of the caseseldom did. They thought at these times that a formal proper course of psychotherapywith 50-minute interview might be of use, but that nothing else would. They ignoredthe usefulness, which they knew well theoretically, of their unique setting insofar as itgave them the opportunity to see their patients for short times over a number of years.About a year after this research group started work we all realized that we were indifficulties. This became particularly clear when we were listening to the reports onthe follow-ups of our original cases. During the discussion on these cases it appearedthat very good and conscientious and respectable work had been done, but still thetherapeutic results were somewhat disappointing. For instance, although the doctorshad understood very well and worked competently with the patient's illness in terms ofthe present and the past and had seriously tried to identify the area of the patient's lifewhere conflict was most acute and had tried to formulate the iatrogenous and the autogenous illness the work seemed rather flat and undynamic. These ideas, which we hadworked out in our seminars over the years, seemed less useful here than usual: perhapswe did not yet know how to use them in the new setting which we were examiningi.e. in the 'six-minute interview'. Or, were they, in fact, being forced onto the patient?
One doctor said that so far the emphasis had been on what the doctor had tried toget from the patient, rather than on what the patient had tried to get from the doctor;that the doctors seemed to have enjoyed acquiring the skills of detective inspectors.They had learned to spot the patterns of human behaviour underlying the patient'spresenting complaints and ferret out his carefully hidden secrets and fears, but theyhad often failed to shed much light on what the patient tried to get from his doctorwhen the treatment started. This doctor thought that the shift in our work should befrom an overall picture of the patient to the patient's immediate needs. Another doctorthought it might help if we defined different therapeutic aims. The first aim he calledthe 'big bang aim' where the doctor tries to make the overall diagnosis as comprehensiveas possible and then to influence the patient in the major area of his life situation.His success should then be the equivalent of a 'big bang result'. He called the secondaim a 'steady state aim' where the doctor tries to maintain the status quo or restore thebalance of control which the patient appears temporarily to have lost. The third whichhe called the 'little bang aim' was to search modestly into the limited areas of mutualunderstanding between the patient and the doctor. The doctor should try to be on thesame wave-length as the patient and to capitalize such little gains as could be madeeach time so that on subsequent visits work could proceed with a little more done eachtime. This doctor felt that this latter type of aim the 'little bang aim' seemed to be themost promising and realistic for general practitioners during their office hours.
Questions we should be asking were not so much-Is this man getting upper respiratory infections because his wife is bullying him? Or, Does that boy want to stay offwork because he is frightened of his homosexuality? But more, Why is this girl complaining of eye-strain today? Does she want me to see something for her or instead of her?
Does she want more than eye-drops? Why is she sitting still; the last time she came shefiddled around restlessly? Or, of another patient: Why did he ask me whether it wasall right to have the repeat prescription again? He had it for a year without any bother,and so on, and so on.
Now, of course, all this seems quite obvious. We all know that these observationsare often the ones that count: but it is apparently so much easier to think about moreorganized 'problems' such as dependency and castration anxiety, and furthermore wedid not know whether these kinds of observation would be useful in ordinary consultinghours, or where they would lead. Would they inevitably force the poor overworkeddoctors to arrange yet another out of hours interview, which would then have to befollowed up by many, many more, i.e. a usual long-term psychotherapy would result?I will now report one sample case which followed these discussions to show thekind of thing that slowly emerged.
I think most doctors would sympathize with this opinion: There is so much to dowith so many patients to see. Also, our doctor knew nothing about the patient's pastso if he wanted to link up the past with the present he would have to start at the beginning.However, another member of our group did not altogether agree. She said, "AlthoughI agree that I would not want to go through the whole thing, stage by stage, year byyear, this is all the more reason that it should be a 'six-minute' case".We had a follow-up from Dr C on his patient four months later. He reportedthat he had seen his patient twice since last reporting. The first time was one week andthe second two weeks after the original interview. Since then he had not seen her;that is to say, she had not been seen for about three and a half months. He told us thatthe first interview had lasted ten minutes and the second 20. He said, "This was forcemajeure as you will see". At the first interview the patient said she was better and then,encouraged by Dr C, tried to understand what it was that made her drive herself towork. While doing this she began to reminisce about her early life. How, when shewas 17, she had come to London from Yorkshire and how hard it had been; how shehad trained as a nurse and then married. This marriage, she said, had never been asuccess and she finally got a divorce. She said she had had many jobs in factories sincethen and talked on freely and expanded on these various themes. Our doctor thenbrought her back to the way she pressed herself; always seemed to overwork. He didnot feel that much progress had been made in his understanding of any of this, but thepatient had spoken much more freely and a much less superficial atmosphere hadbeen created.
At the second follow-up interview a week later the patient came into the doctor's roomlooking radiant; he hardly recognized her. She said her headaches had gone and ourdoctor proceeded to find out what had happened. The patient then told him that comingdown on the bus (to see the doctor) she had suddenly realized that her husband must belonely without her and that he was very good to her. She recounted how he got upin the morning and made her tea and cut her sandwiches and how he was alone fromearly in the morning until quite late in the evening. She then suddenly realized thathe must love her. This, she said, was an absolute revelation to her and as she spokeher face lit up. Dr C said there was quite an amazing feeling in the interview and he saidto her "Didn't you feel that he loved you before?" and she said "Well, yes, but it hadn'tmeant much to me"; and then said: "I will tell you something that I haven't told anybodyelse in my life", and went on to say that the first thing she remembered was when shewas five, that she was living with her parents and one evening her mother put on adress to go to a dance and her father came in and tore the dress off her. She did notknow why, but her mother went out of the room and then came back and smackedher and said that it was all her fault. The next memory she had was two years laterwhen thfre was a baby brother born and she thought how funny he looked; and thensoon her mother left and she was put in an orphanage. She then paused, but went onto say that she knew it sounded silly and like something in a novel, but that in fact yougo on and on hoping that somebody is going to visit you and then gradually, as theyears go by, nobody visits you and you realize that nobody is going to visit you so yousay to yourself "it doesn't matter if nobody visits me I'll get on myself", and she did.Then, when she was 14 somebody did come to visit her. She thought to herself "I knowwhy they have come, they want me to work for them". And, indeed, she was taken outof the orphanage and put into domestic service. Dr C said you could see in her facethe gradual feeling of being left, peering in vain through the gates for someone to come.She said, love and affection was something foreign to her and it had just come to herhead that her husband cared for her. She thought she would go back to work and thengradually give it up.
What happened here? Naturally enough, the group of doctors was very interestedto discover what had brought about this change. Various ideas were put forward.
The doctor who had spoken in favour of not trying to be too ambitious with this patientbecause it would take too long, said laughingly, "Can I just to be beastly say that youcould not have done that in ten minutes". Dr C answered, "But I did not need 50minutes". It had been done, in fact, in ordinary office hours. Dr C thought he hadenabled the patient to feel that someone wanted her. The seminar thought that if DrC had not prodded the patient slightly she would have withdrawn when her headachewas better, but they realized that it was the doctor's observation before he reported thecase that started the treatment. His prodding only consisted of asking her "Whydo you push yourself to work so much?" The rest had followed. In this case thedoctor made no attempt to make links between the past and the present; the patientwas allowed, as our doctor expressed it, to reminisce, and made what links were usefulto her; the doctor did not interfere. But we must remember that many worrying 4spectsof the case were left on one side. For instance, although it had been felt that the patientmight be depressed and that there might be hidden menopausal problems and in additionthe fact that she had no children would be likely to give her more and not less troubleas time went on-none of these were touched upon. But, whereas this unfinished jobmight cause uneasiness to the specialist, it did not worry the general practitionersbecause they knew that the patient would be seen again and again over the years and soa watch could be kept.
We know that not every patient is responsive to our sort of approach and we knowthat some patients are responsive at certain times and not at others. Or, we could putit another way; we know that some patients when entering the doctor's offices arewondering at the back of their minds whether they can ask him something or discusssomething with him; and that others are not. And, some of them may even be hopingthat the doctor will not observe some frightening secret. Both observations are, or maybe, useful to the doctor.
One of our aims now is therefore to look for diagnostic criteria, which will tell uswhat to expect and what to do. We know that these criteria cannot be in terms of suchcliches as oral dependence, castrating mothers, immature egos, sexual inadequacy andso on, or what really amounts to 'illness-centred medicine', but in terms of observablesigns of a patient's preparedness or wish to talk or communicate or to remain silent.Conditions which can seldom be described usefully in our usual terminology.
In general practice where the doctors see their patients over long periods there maybe opportunities for them to notice changes in the patient or for them to recognize somesigns which make them think that the patient may want to communicate. This thought,this idea, in the doctor's mind then has to be examined. Clearly, it does not necessarilymean that the doctor is right. But, he should be responsible to the thought in himselfand be willing to look further in a receptive way. The sign might not be a depressedpatient who had been undepressed before, or anything as traditional as this, because inour experience the kind of 'little bang work' that we are attempting often starts in quitea different way.
Another aspect of our work is to study a technique of responding to these littleshifts. How can we use them? If we start, how far should we go? Sometimes in ourexperience, the doctors would like to go further but the patients prefer to stop. Perhapsthis is because the doctors proceed too much in the traditional manner, looking for atraditional general problem like impotence, or a castration anxiety, or resentmentand in so doing fail to follow the patient. At other times the patient shows signs ofwanting to go on but the doctor is reluctant fearing dependence or domination by hispatient. A patient may only want one 'dynamic' interview and may then be able, oreven prefer, to go home and manage on his own; but we do not know which cases wantwhich treatment and it is one object in our research seminar to study these things byvery long term follow-ups.
Can anything be said at this stage about any new skills that we have developedduring the past year? My idea would be that the skills are rather in the way that thedoctor allows the patient to use him, rather than in the way the doctor responds to thepatient by his interpretations and theories. This should not surprise psycho-analystsbecause many of us think of the way that the patient uses the analyst, perhaps morethan and certainly in addition to the way that the analyst understands and interpretsthe patient's free associations. We do not think much of a description of a psychoanalytic treatment which talks only about the doctor's interpretations and nothingabout the atmosphere in which he works with that particular patient and the way inwhich the patient relates to or uses him.
So too, with traditional medicine; the traditional family doctor is used in a particularway which is very good and reliable because both doctor and patient know the rules.But if our doctors are prepared to watch their responses to their patients demands andcommunications and the subtle ways in which their patients change in their use ofthem, they may learn to be 'used' in different or more varied ways. In my experiencewhat has prevented them from doing this in the past is not because it involved them ina new way of thinking but because they feared that if they let the patient loose, so tospeak, they would be overwhelmed; patients would get too close to them and wouldbecome unbearably dependent and demanding. I do not want to suggest that thereare no such patients; but they are not so difficult to deal with, if the doctor has a clearidea of what he is being asked for. Nor do I want to suggest that all doctors shouldgive their patients what they ask for; quite the contrary; but the better the doctor understands the more likely he is to take appropriate action.
The doctor, as always, has the responsibility to be aware not only of his patients'communications and demands but of his own immediate response to them before hecan decide what action is appropriate.
It may be, therefore, that our doctors are beginning to feel that they are not endangered if they allow their patients to tell them what they want in their own time and intheir own way and they find that they are not turned into psychotherapists if they dothis.
May I return to where we started? Are we any nearer to answering the questionnow as to whether the doctor can avoid a split in himself? Whether he can avoid beinga 'general practitioner' to some of his patients and a 'competent psychotherapist' to,others? Or, to formulate it in other words: practising 'illness-orientated medicine'.with some of his patients and 'patient-centred medicine' with others. I have describedhow, in trying to answer this question, our research seminar has examined selectedpatients who have been seen during the doctor's ordinary consulting hours. The patientswho have been chosen by the doctors were those with whom they have felt that theyhad opened the way towards 'patient-centred medicine'; often when, in the doctor'sopinion, the patients needed both a general practitioner and a psychotherapist.I have described some cases where the doctor has succeeded. We do not yet know,however, how often success can be achieved: nor what dangers the doctor has to face.At the time of writing this paper the majority of the group think that the shift ofemphasis in our research was from expecting the doctor to be a sort of detective inspectorto a study of the varieties of response open to the doctor; or to put it in other words tothe variety of ways the doctor can be used. This may be one of the changes which willlead us to understand the possibilities and techniques of 'patient-centred medicine' andthus to undo the split in the doctor.www.psychspace.com心理学空间网
ENID BALINT, B.Sc.
London
Case work consultant, Tavistock Institute of Human Relations, London; honorary secretary, TrainingCommittee, British Psycho-analytical Society
IN his paper, The Structure of the Training cum Research Seminar and its Implicationfor Medicine, Michael Balint spoke about two classes of pathological conditions:Class I comprises conditions in which a localizable 'illness' can be found. In this classscientific examinations can identify a fault either in the body or in one of the partfunctions in the body. In this way of thinking, the prime aim is to find a localizablefault, diagnose it as an illness and then treat it. This is what we call 'illness-orientatedmedicine.'
In contrast, there is another way of medical thinking which we call 'patient-centredmedicine'. Here, in addition to trying to discover a localizable illness or illnesses, thedoctor also has to examine the whole person in order to form what we call an 'overalldiagnosis'. This should include everything that the doctor knows and understandsabout his patient; the patient, in fact, has to be understood as a unique human-being.The illness which can be described in terms of a 'traditional diagnosis' is either anincident like a broken leg, or a part like accident proneness which makes better senseif understood in terms of the whole.
The question which has recently been occupying our minds is: How does a practisingdoctor avoid a split in himself? How can he avoid being a general practitioner to someof his patients and a competent psychotherapist to others? Or, expressed in our newterminology: How can he avoid practising 'illness-orientated medicine' with some patientsand 'patient-orientated medicine' with others.
Before proceeding it is necessary to state the problem in a slightly different way:What was our aim when, in 1950, we started advertising in the medical press in Londonthat we proposed to hold seminars on the psychological problems in general practice?Did we, in fact, have in mind to teach our doctors to be minor psychotherapists? Didwe aim in establishing this sort of split?
If this were so, why are we so worried about it now, because clearly if this had beenour aim, we could not have expected our doctors to remain whole doctors with oneprofessional activity as they were bound, it would seem, to do 'psychotherapy' withsome patients and 'general practice' with others. Leaving on one side their patients,requirements, the size of their practices alone would not permit them to do minorpsychotherapy with all their patients. Furthermore, if they wished to become psychotherapists they could take the necessary training and leave general practice altogether.
No, there was never any doubt in our minds that the aim of the seminars was to studythe emotional problems found in general practice in the hope that if it were found to benecessary the general practitioner's whole medical approach might be changed; whichmeans that new skills would have to be evolved.
In the later 1950's we thought that we had made some progress, but nevertheless,we began to be anxious about the problem of the split doctor. Our doctors told usthat although they had not altered their way of treating all their patients their wholework had nevertheless changed since they joined our seminars. They could not tell ushow, but they felt themselves to be different kinds of doctors, even different kinds ofpeople since they started work with us. They insisted, nevertheless, that their ordinary'surgeries', i.e. the time they spent in their consulting rooms, were much as they hadbeen before they started; and we found this puzzling.
We had already tried several times to discover how the doctors decided to chooseone patient for psychotherapy rather than another. No answer could be found. Thedoctors realized that their choice was often irrational. That many people who neededinvestigation did not get it and that the most needy were not always chosen for specialattention. Why was this?
When, therefore, in 1962, I was asked to lead a group of experienced generalpractitioners at the Tavistock Clinic I brought the subject up for discussion. This waswith a group of doctors who had already had some experience in the training schemeand were ready to undertake some kind of research. Quite early in our work we decidedto study randomly selected patients in contrast to our usual practice of studying onlythose patients whom the doctors selected specially for discussion.
During this study we made various discoveries.*
Here is the gist of what we found:
First, it seems as if our doctors felt compelled to identify with two professionswhen they joined our seminars; the profession of the general practitioner and theprofession of the psychiatrist and psycho-analyst. All the participants were practisingdoctors but they felt that their work and ours as practising psychiatrists and psychoanalysts was utterly different. They wished us to remember this. It was important tothem to preserve their identity as general practitioners; there were times when theystrongly identified with us, but there were times when they did not wish to do so.Secondly, they saw us, on the one hand, as trying to turn them into psycho-analysts,without the time or the opportunity to do so and on the other forbidding them to practiseanything remotely resembling psycho-analysis. They wanted to show us how exactingour demands were on them and how frustrating and unrealistic. They thought thatwhen we expected them to do more than they did we did not realize how good they wereanyway.
Because of the difficulties inherent in all of this, we felt that we must examine thesituation further and it was for this reason that when this seminar had to be terminatedMichael Balint and I assembled a dozen of our most experienced general practitioners(this time at University College Hospital) and asked them if they would like to co-operatewith us in a research into how much 'patient-orientated medicine' can be done in theordinary run of their practices. This time we did not want to examine randomly chosencases. We wanted the doctors themselves to choose the cases where they felt one brieffive- to ten-minute consultation had started a 'patient-orientated medicine' and we wantedto follow up the cases that the doctors chose over a long period. We called this aresearch into six-minute psychotherapy; but, of course, we did not want to impose astrict time limit on our doctors but to make a distinction between this kind of psychological understanding and therapy and the traditional long interview kind.
Now I want to report something about this research. Many of the attitudes foundin the first research seminar were repeated here. At the beginning it seemed that sometimes our doctors wanted to show us how little they did rather than how much. Inthe usual way, when the same doctors reported on cases the emphasis was on the doctorpatient relationship; and on the way they felt about the patient and why they werefinding difficulties in helping him; whereas, when they reported on their 'six-minutecases', they did so rather in the traditional manner; they based their understanding of thepatient more on traditional medicine (although it might sometimes be from the psychiatricpoint of view). That is, they discussed their findings in terms of dependency or somesimilar cliche and less on the patient's active communication at the time of the interviewand how this could be understood and used for therapy. These were cases where thedoctor did not want to have long interviews and was right in making this decision; butthey could not see that something important for the patient had happened and perhapseven some help had been given to him in the short contact in the consulting room. Otherparticipants in the group might see this but the general practitioner in charge of the caseseldom did. They thought at these times that a formal proper course of psychotherapywith 50-minute interview might be of use, but that nothing else would. They ignoredthe usefulness, which they knew well theoretically, of their unique setting insofar as itgave them the opportunity to see their patients for short times over a number of years.About a year after this research group started work we all realized that we were indifficulties. This became particularly clear when we were listening to the reports onthe follow-ups of our original cases. During the discussion on these cases it appearedthat very good and conscientious and respectable work had been done, but still thetherapeutic results were somewhat disappointing. For instance, although the doctorshad understood very well and worked competently with the patient's illness in terms ofthe present and the past and had seriously tried to identify the area of the patient's lifewhere conflict was most acute and had tried to formulate the iatrogenous and the autogenous illness the work seemed rather flat and undynamic. These ideas, which we hadworked out in our seminars over the years, seemed less useful here than usual: perhapswe did not yet know how to use them in the new setting which we were examiningi.e. in the 'six-minute interview'. Or, were they, in fact, being forced onto the patient?
One doctor said that so far the emphasis had been on what the doctor had tried toget from the patient, rather than on what the patient had tried to get from the doctor;that the doctors seemed to have enjoyed acquiring the skills of detective inspectors.They had learned to spot the patterns of human behaviour underlying the patient'spresenting complaints and ferret out his carefully hidden secrets and fears, but theyhad often failed to shed much light on what the patient tried to get from his doctorwhen the treatment started. This doctor thought that the shift in our work should befrom an overall picture of the patient to the patient's immediate needs. Another doctorthought it might help if we defined different therapeutic aims. The first aim he calledthe 'big bang aim' where the doctor tries to make the overall diagnosis as comprehensiveas possible and then to influence the patient in the major area of his life situation.His success should then be the equivalent of a 'big bang result'. He called the secondaim a 'steady state aim' where the doctor tries to maintain the status quo or restore thebalance of control which the patient appears temporarily to have lost. The third whichhe called the 'little bang aim' was to search modestly into the limited areas of mutualunderstanding between the patient and the doctor. The doctor should try to be on thesame wave-length as the patient and to capitalize such little gains as could be madeeach time so that on subsequent visits work could proceed with a little more done eachtime. This doctor felt that this latter type of aim the 'little bang aim' seemed to be themost promising and realistic for general practitioners during their office hours.
Questions we should be asking were not so much-Is this man getting upper respiratory infections because his wife is bullying him? Or, Does that boy want to stay offwork because he is frightened of his homosexuality? But more, Why is this girl complaining of eye-strain today? Does she want me to see something for her or instead of her?
Does she want more than eye-drops? Why is she sitting still; the last time she came shefiddled around restlessly? Or, of another patient: Why did he ask me whether it wasall right to have the repeat prescription again? He had it for a year without any bother,and so on, and so on.
Now, of course, all this seems quite obvious. We all know that these observationsare often the ones that count: but it is apparently so much easier to think about moreorganized 'problems' such as dependency and castration anxiety, and furthermore wedid not know whether these kinds of observation would be useful in ordinary consultinghours, or where they would lead. Would they inevitably force the poor overworkeddoctors to arrange yet another out of hours interview, which would then have to befollowed up by many, many more, i.e. a usual long-term psychotherapy would result?I will now report one sample case which followed these discussions to show thekind of thing that slowly emerged.
The reporting doctor was Dr C and his patient was Mrs Grace R, aged 56. She had been on ourdoctor's list for more than 15 years and had been seen by either our doctor himself or by one of hispartners five or six times a year during this period. The patient was a machine operator and was tiarriedfor the second time to a retired stoker at a power station, aged about 68. Dr C said that he had decidedto report the case because, although he had known the patient for so long, she had never become'alive tohim before this interview and he thought also that he would almost certainly see her again fairly soon.This is really what should be our criteria. He had spent the usual few minutes with this patient, whohad come to see her doctor complaining of headaches. Dr C said that he supposed that the traditionaldiagnosis was tension headaches. The patient attributed them to the noises at work. The doctorsaid that he knew very little about Mrs Grace R, although he knew a great deal about her previousillnesses. He gave us a long list of these in traditional terms; for instance, she had had an appendicectomy,osteoarthritis of the knee, cystitis, 'flu, irregular menses and back pain. She had also had severe headaches two years ago which had then been accompanied by vomiting and vertigo. The contact with thepatient over all these illnesses had been good although very superficial. In fact, it was only at thisinterview, that our doctor learned that this was the patient's second marriage and that her husband was12 years older than she was. When speaking of her husband the patient said that he was only interestedin football and bed. When Dr C asked the obvious question, she said Oh no, that wasn't what shemeant at all. They had not had intercourse for five years or more. She added that she never reallyenjoyed it and was quite relieved when it was given up and that she was glad that she never had anychildren because they only grew up to be cannon fodder. She then paused and added that her husbandwanted her to give up work for sometime but she felt that she must do something and that she couldnever sit still.During the discussion which followed this presentation one of the doctors said,"I find that when there is a history of psychosomatic disturbances like dysmenorrhoeaand so on, by the time that they are 50 or 60 I wonder if there is any point in going throughit-there is so much, it would take so long-I find that my time is so short that I tendto give it to the younger people-this woman would really leave me feeling like makingsome sort of collusion because it would take so much time to go through all this, andwould it be worth it?
Dr C's overall diagnosis was that the patient was an unhappy woman, who had attempted to denythe more frustrated feminine parts of herself, but had solved part of her problem by marrying a ratherpassive older man. She was fighting off depression by activity and she was unfeminine rather thanmasculine. His therapeutic decision was to bring out her feelings into the open if he got the chance andto see why she had to drive herself to breaking point all the time. He gave the patient a certificate fora week so that she should not go back to work. This would involve her coming to see the doctor againin order to get a certificate to re-start work.
I think most doctors would sympathize with this opinion: There is so much to dowith so many patients to see. Also, our doctor knew nothing about the patient's pastso if he wanted to link up the past with the present he would have to start at the beginning.However, another member of our group did not altogether agree. She said, "AlthoughI agree that I would not want to go through the whole thing, stage by stage, year byyear, this is all the more reason that it should be a 'six-minute' case".We had a follow-up from Dr C on his patient four months later. He reportedthat he had seen his patient twice since last reporting. The first time was one week andthe second two weeks after the original interview. Since then he had not seen her;that is to say, she had not been seen for about three and a half months. He told us thatthe first interview had lasted ten minutes and the second 20. He said, "This was forcemajeure as you will see". At the first interview the patient said she was better and then,encouraged by Dr C, tried to understand what it was that made her drive herself towork. While doing this she began to reminisce about her early life. How, when shewas 17, she had come to London from Yorkshire and how hard it had been; how shehad trained as a nurse and then married. This marriage, she said, had never been asuccess and she finally got a divorce. She said she had had many jobs in factories sincethen and talked on freely and expanded on these various themes. Our doctor thenbrought her back to the way she pressed herself; always seemed to overwork. He didnot feel that much progress had been made in his understanding of any of this, but thepatient had spoken much more freely and a much less superficial atmosphere hadbeen created.
At the second follow-up interview a week later the patient came into the doctor's roomlooking radiant; he hardly recognized her. She said her headaches had gone and ourdoctor proceeded to find out what had happened. The patient then told him that comingdown on the bus (to see the doctor) she had suddenly realized that her husband must belonely without her and that he was very good to her. She recounted how he got upin the morning and made her tea and cut her sandwiches and how he was alone fromearly in the morning until quite late in the evening. She then suddenly realized thathe must love her. This, she said, was an absolute revelation to her and as she spokeher face lit up. Dr C said there was quite an amazing feeling in the interview and he saidto her "Didn't you feel that he loved you before?" and she said "Well, yes, but it hadn'tmeant much to me"; and then said: "I will tell you something that I haven't told anybodyelse in my life", and went on to say that the first thing she remembered was when shewas five, that she was living with her parents and one evening her mother put on adress to go to a dance and her father came in and tore the dress off her. She did notknow why, but her mother went out of the room and then came back and smackedher and said that it was all her fault. The next memory she had was two years laterwhen thfre was a baby brother born and she thought how funny he looked; and thensoon her mother left and she was put in an orphanage. She then paused, but went onto say that she knew it sounded silly and like something in a novel, but that in fact yougo on and on hoping that somebody is going to visit you and then gradually, as theyears go by, nobody visits you and you realize that nobody is going to visit you so yousay to yourself "it doesn't matter if nobody visits me I'll get on myself", and she did.Then, when she was 14 somebody did come to visit her. She thought to herself "I knowwhy they have come, they want me to work for them". And, indeed, she was taken outof the orphanage and put into domestic service. Dr C said you could see in her facethe gradual feeling of being left, peering in vain through the gates for someone to come.She said, love and affection was something foreign to her and it had just come to herhead that her husband cared for her. She thought she would go back to work and thengradually give it up.
What happened here? Naturally enough, the group of doctors was very interestedto discover what had brought about this change. Various ideas were put forward.
The doctor who had spoken in favour of not trying to be too ambitious with this patientbecause it would take too long, said laughingly, "Can I just to be beastly say that youcould not have done that in ten minutes". Dr C answered, "But I did not need 50minutes". It had been done, in fact, in ordinary office hours. Dr C thought he hadenabled the patient to feel that someone wanted her. The seminar thought that if DrC had not prodded the patient slightly she would have withdrawn when her headachewas better, but they realized that it was the doctor's observation before he reported thecase that started the treatment. His prodding only consisted of asking her "Whydo you push yourself to work so much?" The rest had followed. In this case thedoctor made no attempt to make links between the past and the present; the patientwas allowed, as our doctor expressed it, to reminisce, and made what links were usefulto her; the doctor did not interfere. But we must remember that many worrying 4spectsof the case were left on one side. For instance, although it had been felt that the patientmight be depressed and that there might be hidden menopausal problems and in additionthe fact that she had no children would be likely to give her more and not less troubleas time went on-none of these were touched upon. But, whereas this unfinished jobmight cause uneasiness to the specialist, it did not worry the general practitionersbecause they knew that the patient would be seen again and again over the years and soa watch could be kept.
We know that not every patient is responsive to our sort of approach and we knowthat some patients are responsive at certain times and not at others. Or, we could putit another way; we know that some patients when entering the doctor's offices arewondering at the back of their minds whether they can ask him something or discusssomething with him; and that others are not. And, some of them may even be hopingthat the doctor will not observe some frightening secret. Both observations are, or maybe, useful to the doctor.
One of our aims now is therefore to look for diagnostic criteria, which will tell uswhat to expect and what to do. We know that these criteria cannot be in terms of suchcliches as oral dependence, castrating mothers, immature egos, sexual inadequacy andso on, or what really amounts to 'illness-centred medicine', but in terms of observablesigns of a patient's preparedness or wish to talk or communicate or to remain silent.Conditions which can seldom be described usefully in our usual terminology.
In general practice where the doctors see their patients over long periods there maybe opportunities for them to notice changes in the patient or for them to recognize somesigns which make them think that the patient may want to communicate. This thought,this idea, in the doctor's mind then has to be examined. Clearly, it does not necessarilymean that the doctor is right. But, he should be responsible to the thought in himselfand be willing to look further in a receptive way. The sign might not be a depressedpatient who had been undepressed before, or anything as traditional as this, because inour experience the kind of 'little bang work' that we are attempting often starts in quitea different way.
To give an example: One patient, Lucy H, aged 73, was a constant attender at Dr F's surgery.She attended at least once a month and had been on the doctor's list for five years. On this occasionshe too came complaining of headaches. Dr F reported that over the years he had made many attemptsto discuss her problems with her, with very limited success, and with no apparent benefit to her. Hefelt he made no contact with this patient and said "There seems to be an inability to relate her symptomsto her problems". But this time (and Dr F does not know why) after a little coaxing the patient spokeabout feeling lonely and soon expressed quite strong resentment because she thought that her four sonsneglected her. She showed some anger and Dr F felt in touch with her for the first time. When leaving,to our doctor's immense surprise, the patient thanked him. A fortnight later Lucy H returned forsome pills. Once again she talked about her misery and anger and her need for human contact. Dr Fwas glad to be in contact with this patient and felt things had gone quite well. However, after thisinterview, the patient disappeared and Dr F learned that she had visited his partner instead. She toldhim (the partner) that she did not like being questioned. Her headaches, though, were better.During the seminar discussion on this case, many doctors thought that Lucy Hhad changed doctors because Dr F had tried too hard. One doctor said "When theycreate a sense of guilt in us we need to be omnipotent and it is that that drives themaway". And another doctor said "If we do well, we must do better and they cannotstand it". Some months later we had a follow-up on this case and were told that LucyH has come back to Dr F after a two months absence and a routine had now beenestablished between them. Each interview started with a discussion of the patient'ssymptoms and the uselessness of the pills previously prescribed by the doctor and thena talk ensued about the patient's loneliness and fear and her wish to be of some use tosomebody. Strangely enough, Dr F does not feel himself to be threatened or burdenedby this patient. She seems a bit livelier and better, but has not given up her symptomsand Dr F does not mind spending ten minutes every two or three weeks with her. Hefeels the patient is starved of attention, which, although no doubt, is due to her complaining and aggressive behaviour to her family, is the patient's illness and can be treated ifthe patient is left to make use of the doctor in the way that I have described.
Another aspect of our work is to study a technique of responding to these littleshifts. How can we use them? If we start, how far should we go? Sometimes in ourexperience, the doctors would like to go further but the patients prefer to stop. Perhapsthis is because the doctors proceed too much in the traditional manner, looking for atraditional general problem like impotence, or a castration anxiety, or resentmentand in so doing fail to follow the patient. At other times the patient shows signs ofwanting to go on but the doctor is reluctant fearing dependence or domination by hispatient. A patient may only want one 'dynamic' interview and may then be able, oreven prefer, to go home and manage on his own; but we do not know which cases wantwhich treatment and it is one object in our research seminar to study these things byvery long term follow-ups.
Can anything be said at this stage about any new skills that we have developedduring the past year? My idea would be that the skills are rather in the way that thedoctor allows the patient to use him, rather than in the way the doctor responds to thepatient by his interpretations and theories. This should not surprise psycho-analystsbecause many of us think of the way that the patient uses the analyst, perhaps morethan and certainly in addition to the way that the analyst understands and interpretsthe patient's free associations. We do not think much of a description of a psychoanalytic treatment which talks only about the doctor's interpretations and nothingabout the atmosphere in which he works with that particular patient and the way inwhich the patient relates to or uses him.
So too, with traditional medicine; the traditional family doctor is used in a particularway which is very good and reliable because both doctor and patient know the rules.But if our doctors are prepared to watch their responses to their patients demands andcommunications and the subtle ways in which their patients change in their use ofthem, they may learn to be 'used' in different or more varied ways. In my experiencewhat has prevented them from doing this in the past is not because it involved them ina new way of thinking but because they feared that if they let the patient loose, so tospeak, they would be overwhelmed; patients would get too close to them and wouldbecome unbearably dependent and demanding. I do not want to suggest that thereare no such patients; but they are not so difficult to deal with, if the doctor has a clearidea of what he is being asked for. Nor do I want to suggest that all doctors shouldgive their patients what they ask for; quite the contrary; but the better the doctor understands the more likely he is to take appropriate action.
The doctor, as always, has the responsibility to be aware not only of his patients'communications and demands but of his own immediate response to them before hecan decide what action is appropriate.
It may be, therefore, that our doctors are beginning to feel that they are not endangered if they allow their patients to tell them what they want in their own time and intheir own way and they find that they are not turned into psychotherapists if they dothis.
May I return to where we started? Are we any nearer to answering the questionnow as to whether the doctor can avoid a split in himself? Whether he can avoid beinga 'general practitioner' to some of his patients and a 'competent psychotherapist' to,others? Or, to formulate it in other words: practising 'illness-orientated medicine'.with some of his patients and 'patient-centred medicine' with others. I have describedhow, in trying to answer this question, our research seminar has examined selectedpatients who have been seen during the doctor's ordinary consulting hours. The patientswho have been chosen by the doctors were those with whom they have felt that theyhad opened the way towards 'patient-centred medicine'; often when, in the doctor'sopinion, the patients needed both a general practitioner and a psychotherapist.I have described some cases where the doctor has succeeded. We do not yet know,however, how often success can be achieved: nor what dangers the doctor has to face.At the time of writing this paper the majority of the group think that the shift ofemphasis in our research was from expecting the doctor to be a sort of detective inspectorto a study of the varieties of response open to the doctor; or to put it in other words tothe variety of ways the doctor can be used. This may be one of the changes which willlead us to understand the possibilities and techniques of 'patient-centred medicine' andthus to undo the split in the doctor.www.psychspace.com心理学空间网
