Just as incest was hidden from view for many decades until women became .. Many of the relationships between therapist and patient that are. PDF download for The Psychiatrist-Woman Patient Relationship Arms, S.: The Immaculate Deception: A New Look at Women and Childbirth in. With the psychiatrist's help, the patient can come to grips with this the therapist and learning how they relate to past relationships often See my new book, "The Naked Lady Who Stood on Her Head: A Psychiatrist's Stories.
Let me discuss each of them one by one. Factors pertaining to the patient The patient comes to a psychiatrist not only with his presenting symptoms but also with certain expectations.
He has faith in various treatment modalities and expectations about the outcome. Even the presenting symptoms differ from person to person, even though the underlying disease is the same. Factors pertaining to the patient are determined by: The personality of the individual, past experiences, methods of coping with sickness. Dependent personality expects miracles.
Histrionic personalities have a tendency to exaggerate symptoms. Antisocial personalities show a hostile attitude towards a therapist. Paranoids patients show lack of faith in the doctor and doubt every intention and guidance provided by the doctor.
Many of the mental problems are considered a curse or mystical phenomenon.
Hence, relatives may approach a psychiatrist with little faith in the doctor's healing abilities. Economic factors, education, urbanisation: Affluent and educated families expect more time, more explanations and more flexibility from the treating doctor. They perceive doctor more as a friend and a guide. However, those who are not so educated and from non-affluent families expect a more authoritarian approach from the doctor; they treat the doctor as their saviour, and at times God.
Urbanisation has resulted in a more critical approach. This may be determined by psychodynamic conflicts. Factors pertaining to the treating physician A doctor's interaction with his patient depends on many factors: Especially with reference to objectivity, empathy, ethical and legal issues and his own expectations about his patient; His personality: Doctor with paranoid tendencies may feel threatened by the patient or his relatives.
A therapist having a superiority complex may consider his patients as poorly educated and incapable of understanding the nuisances of therapy. Especially about different types of patient and their socio-economic background.
Also, a doctor may believe personality disorders as untreatable and hence his approach to the patient may be negative. Physical and material aspects: If a doctor feels he is not given fair remuneration for his abilities he may ignore the patient. Society's expectations about doctor's behaviour: A doctor is supposed to be a saviour, ever available, non-commercial. The doctor may find it difficult to live up to this role. Approach towards the patient Approach towards the patient should be scientific and is discussed under the following headings: Non-judgmental approach with an open mind: Data from relatives are important, but that should not prejudice one's mind.
Similarly, educational qualifications, social background, financial conditions should not come in the way of making a sound scientific evidence-based diagnosis and treatment plan. Depending on the therapist's approach, both methods can serve the purpose well. A combination of both and judicious mix is the best approach. Good empathy and sincere effort to understand patient's feelings: This is the crux of the approach and can never be over-emphasised.
Involving relatives in an appropriate way: Relatives can offer valuable data and insights into the patient's condition while at times try to unduly influence therapy. It is necessary to ensure the first while being aware the second does not happen.
Especially in psychotherapy, and with all patients, there must be an assurance that their case histories will not be revealed without their consent. Discussion about various treatment modalities: This can be discussed with the patient in case the doctor feels that he has insight into his condition and can understand the same. If that is not possible, the relatives must always be taken into confidence.
To keep the humane factor in mind even while treating patients with limited capacity to assimilate what the psychiatrist is saying or doing. Models of approach We can discuss models of approach under the following heads: In case of treating psychotic patients very active and may be at times an assertive attitude is necessary.
Passive attitude from the doctor is seen in case where he feels nothing further can be done, or when he feels potential legal threats. Defensive approach is prevalent especially in psychiatry to ward off legal threats. At times, clients land up mainly for guidance on certain interpersonal or occupational matters, or seek cooperation to resolve interpersonal stresses, e. The therapist must decide where advice ends and therapy starts. And where advice itself is therapy.
The therapist may have to get involved in a mutual participatory model, wherein there is a lot of give and take of ideas and action plans.
Clients, who prefer to take charge of their lives, but with specialised help, are especially suited for this model. The psychiatrist has more chances to develop social and physical intimacy with his patients.
However, the guidelines maintain that this is unprofessional. However, some areas of debate do still remain. One such area is whether sexual relationships with former patients are ever ethically permissible and, if so, under what circumstances. First, the concepts of boundaries and transference are discussed and a profile of the medical practitioner at risk of offending is drawn. Secondly, three aspects of the doctor—patient relationship are explored: Thirdly, a discussion of the role of autonomous choice and consent is presented.
Boundaries and boundary violations Many boundaries exist in the doctor—patient relationship.
These include boundaries of role, time, place and space, money, gifts and services, clothing, language and physical contact. This does not mean that no such type of relationship may exist, but it has not been researched.
This suggests that the overwhelming outcome for most, if not all, patients is negative. However, the crossing of boundaries per se does not necessarily mean that an unethical act occurred: Nor do all boundary transgressions between doctor and patient ultimately lead to sexual misconduct.
Clues as to what these other factors should be can be gleaned from examining the profiles of offending doctors. Profiles of doctors who violate boundaries A key factor in the identification of doctors at risk of violating boundaries is the enhanced vulnerability of a doctor to the transference—counter-transference dyad which occurs in varying degrees in every doctor—patient relationship. Doctors can mistake the feelings of love that arise in a therapeutic relationship as being the same as love that arises elsewhere; it is not.
Transferences per se, as with boundary crossings, also occur in normal love relationships, 12 and therefore are also a necessary but not sufficient condition for ethical unacceptability.
However, it is the existence and persistence of this type of transference, linked with the fiduciary relationship and unequal power structure, which makes most relationships with former patients ethically unacceptable see following sections.
In turn, to build such a relationship, the unequal power distribution between doctor and patient has to be acknowledged and contained in an ethically correct manner. The onus of responsibility for this last task falls on the person who has the most power in the relationship which, as I will argue, is always the doctor. To explain why this is always the case, even with former patients, it is useful to consider the sources of medical power in light of a framework suggested by family practitioner and ethicist, Howard Brody.
In his book The Healer's Power, 20 Brody outlines three sources of medical power: Aesculapian, Charismatic and Social. It has also been suggested that another source of power —Hierarchical power, the power inherent by one's position in a medical hierarchy e.
Although it does not involve the sexualization of the doctor—patient relationship, it clearly illustrates the importance of recognizing all four types of power, and, in particular, the prominence of Hierarchical power: A consultant specialist was admitted to hospital with a severe multi-system disease causing severe renal impairment.
After 6 weeks in hospital, on the day of his planned discharge, he was accidentally given another patient's medication. Instead of receiving his azathioprine and corticosteroids, he was given a high dose of frusemide and captopril.
Simply by the sheer nature of taking on the role of patient, regardless of any other type of power, there is always an unequal power differential between the doctor and patient. This applies in both general practice and hospital-based medicine, although it may be accentuated by the latter's institutional culture. However, there is also the question of whether this type of power would be accentuated further in a fee-for-service situation, as exists in general practice in Australasia, as opposed to free public hospital treatment.
Doctor-Patient Relationship in Psychiatry
This differential is exacerbated further by any imbalances arising from the other three sources of power. Charismatic power may not always be less on the patient's side depending on the personalities of patient and doctor.
Equally, Social power may vary in doctor— patient relationships depending on the social status of the individuals. This may also relate to the gender roles of the patient and doctor.
The large majority of cases of sexualization occur between female patients and male doctors.