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Humanistic approach

in the therapeutic relationshipJean Furtos, MD

Scientific Director of the National Institute for Mental Health Practices correlated with social insecurity (ONSMP), France

THE INDIAN GLOBAL PSYCHIATRIC INITIATIVE 2012ASIAN FEDERATION OF EARLY CAREER PSYCHIATRISTS

2ND TRAINING AND EDUCATION FELLOWSHIP PROGRAM FOR EARLY CAREER PSYCHIATRISTS

15-16 January, 2012

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The psychiatric training teaches young professionals to objectivize signs and symptoms in order to treat them.

The current classification manuals strengthen this attitude.

Of course we all know that our patients are not reduced to disorders, they are human beings.  

 

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But the technical tendancy of medicine in general in

so important that sometimes the best compliment

for a doctor is to be said “human” by his patients :

“He is so human”, as if it was amazing to be both

competent as a doctor and human.I suppose you are perfectly aware of

that, but my today’s purpose is to emphasize on the

therapeutic necessity to be “human” ; that is to say,

to consider the patient as a real human being in

spite of his/her disease, or better, through

his/her disease.

I will give you a few clinical vignettes.

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First vignette 

What is lived by a schizophrenic patient

cannot be reduced to his schizophrenia...

Here is the example of one of my outpatients.

I regularly see him once a month; and he is on

30 mg of olanzapine per os each day .

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If you don’t know anything about his past, you

can’t say he is schizophrenic; except sometimes

when he feels as though he is watched by the

secrete police, especially if he is in love. This

30-year old man has perfectly accepted the

diagnosis, insofar as he considers schizophrenia

as his own identity. That is very “modern”, especially with

users associations.

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If you just listen to him, he is nothing else but

schizophrenic, and he is happy with it; which is

not excellent when he is looking for a job : a boss

is not prone to hire a psychiatric patient, at least in

France.Recently he talked to me about the

near death of his father. He had tears in his eyes, he

was extremely sad.

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My reaction was to tell him : “as I listen to you,

I’am just seeing a son crying for his father

who is in a very bad state, I don’t see a

schizophrenic patient.”He was rather surprised.

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My comments : let us not forget that the

diagnosis can become a new identity covering all

the others, and thus alienating. Why ? Because I

think that we are living in excluding societies

where people have difficulties knowing what they

are and at which social place they are; a diagnosis

can be viewed as a response and a relief.

As far as we are concerned as therapist, we have to

consider the patient in a more complex manner,

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Second vignette 

A 40-year old woman, treated for an invalidating

psychosis from her teenage years onward.

She is living in a therapeutic home and present

with many psychotic symptoms ; one of them was

recently an arousal of a tendancy to erotomania,

with strong feelings that a male nurse was in love

with her ; she was even going to have a baby with

him, but how could she answer his love ?

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All these thoughts were giving her a lot of

sufferings, a lot of doubts about the way she could

manage all that. Of course it was a psychotic symptom her therapist had

listened to with a real empathy . When we both discussed about this

patient, we did agree that all that could also be

understood as anexpression of loneliness: a 40-year old,

unmarriedand childless woman, showing her

unfulfilled need for love.

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I think it is a good understanding to say about this

case that a true psychotic disorder can express a

true human feeling.

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Third vignetteOne of my new outpatient, a 45-year

man, permanently delirious in every aspect

of his life-acosmic and historical delirium- ; he is

what we formerly used to call a paraphrenic

patient.He told me one day that, when he was

at school, he used to think-and was convinced to

be right, that his history teachers were

definitelywrong when explaining history, e.g.

ancient history ; so, he couldn’t help

contradicting them, and every time was shown the door. 

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One day, I said to him : “obviously, your history

teachers did not accept contradiction and criticism.

At the end of this session he was smiling and

relaxed, and declared to me: “doctor, you are a

great intellectual”.I thanked him, understanding that my

remark on the lack of critical sense on part of

his teachers was a way to recognize that his

history delusionswere also a way of thinking, therefore

the sign of a most human faculty.It is important to point out that

delusion is not only a psychiatric symptom to

eradicate, but also a way of thinking.

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Four vignette

I would like to present you with an example which

isn’t rare as soon as we are aware of it.

The medical emergency isn’t in the Vinatier

Hospital called for me one afternoon to inform

me that one of my young schizophrenie patients

was to be hospitalized at a person’s request for a

melancholic episode. His father had already signed

the cheque for the emergency doctor who had to

fillin the first confinement certificate

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I immediately thought a relapse was very unlikely :

I had seen him the week before and he was alright.

He was only affected because the occupational

doctor where he worked didn’t want to allow him

to attend a promotional training accepted by his

superiors (this doctor knew that he was on

neuroleptics). I asked the emergency doctor to

wait until I could come and see the patient at the

end of by consultations. When I saw this 23-year

old young man his face was closed, pale and tense ?

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I tired to communicate with him but he remained

mute, expressionless ; for a certain while he looked

as if he was to implode. As I rememberd the

episode with the occupational doctor i told him

« you must be downhearted not having been

accepted for the training « he raised his eyes and in

a whistle (with a whistling voice) answered « not

downhearted but disgusted » He was from then

present and we could talk. The self-exclusion

synchrome due to despondency that was starting

hadn’t had time to take hold

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On a technical point of view, he hadn’t had time

to sink into the self-exclusion syndrome just

Starting I will present the SES later on in the IGPI

Program.It was in no way a schizophrenic

relapse. I phoned his father to explain the situation. I

then saw this patient twice a week for a fortnight

and everything went back to normal. On the next

consultation, he was quite lucid and said to me « As

far as work is concerned, my handicap is threefold

: I am young, arab and schizophrenic »

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This showed he had no cognitive disorder.

The SES can be observed among any human

psychotic or not, being plunged int an exluding

milieu (here the refuses from the occupational

doctor)

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The ways to enter the SES is : demoralization,despair,shame

At the very beginning state of SES, these

Feelings can be observed and talked about, as

in this case, and then the SES is sometimes

easily reversible, especially when it occurs

with mentally ill patient, (and also with the

anaclitic depression of the new-born, Spitz,

1947).

SES is, beyond demoralisation, a state of

Despair cutting the links with others and

oneself as a knife.

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Mechanism : it is a kind of « switching off » of

the ego (of cerebral parts, too); Reversibility is « switching on »

again. It is nota switching off of the discursive

thoughts, as in meditation, but a switching off of

oneself.It can be studied on a

psychoanalytical as wellas on a neuroscientific point of viewThis mechanism has to be

understood as a disabling way of getting cured from

the suffering of exclusion ; it is the last

liberty before suicide, a true activity of the

self.

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The initial symptomatic tripod of SES : Body transformations, as is pale and tense face

Waning of the emotions, (or manic episode)

Inhibiting of the thoughts (without no other cognitive trouble), as if people were stupid, retarded, or even demented, alzheimerian

One can see that the SES is a «disappearance of

oneself».

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A few principles to conclude 

We must keep in mind than the human subject,

unlike TV sets and computers, functions while and

through disfunctioning.Given that, what I call pathology does

not necessary mean having heavy

disorders, but ratherbeing prevented from acting, thinking,

speaking, loving as humans do with others

humans.In that sense, especially with heavily

sick patients, the therapeutic aim is not to

eradicate the symptom but to render it compatible

with a human and social life.