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Learning from the patient
Article in Humane medicine · January 1994
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Greben, S.E., Seeman, M.V.: Learning from the patient. Humane Med. 10(3): 193-198
(1994).
LEARNING
FROM
THE
PATIENT*
COOPERATION
AND
MUTUAL
RESPECT
STANLEY
E.
GREBEN,
MD,
FRCPC;†
MARY
V.
SEEMAN,
MD,
FRCPC‡
Happy
is
the
time
when
the
great
listen
to
the
small,
for
in
such
a
generation
the
small
shall
listen
to
the
great.
The
Talmud
Rosh
Hashanah
256
In
all
of
medicine,
including
psychiatry,
history-‐taking
provides
the
greatest
amount
of
information
about
the
patient
and
his
or
her
illness.
The
authors
describe
incidents
through
which
they
learned
important
lessons
from
their
patients
-‐lessons
not
only
about
illness,
health
and
the
effectiveness
of
treatments,
but
about
life
and
its
vicissitudes.
A
patient-‐physician
relationship
of
cooperation
and
mutual
respect
is
essential
in
the
practice
of
medicine.
The
authors
believe
students
and
residents
must
be
taught,
and
shown
through
example,
that
the
patient
can
be
a
valuable
source
of
information.
In
the
practice
of
psychiatry
there
exists
a
principle
of
great
clinical
significance:
the
clinician
learns
through
careful
history-‐taking.
Patients
develop
trust
for
their
clinician
when
they
are
listened
to,
attentively
and
seriously.
The
mutual
respect
in
their
relationship
helps
establish
an
effective
therapeutic
alliance.1
Careful
listening
is
an
essential
beginning.
Having
gathered
information
from
the
patient,
the
clinician
is
then
called
upon
to
respond.
Thus,
both
the
consultation
and
ongoing
psychotherapy
are
collaborative
interactions
between
patient
and
clinician.2
Patients
tell
clinicians
what
is
troublesome,
with
respect
to
both
their
symptoms
and
their
medical
history,
as
well
as
what
makes
them
feel
better
or
worse.
This
includes
their
view
of
what
has
been
useful
or
hurtful
in
previous
medical
or
psychotherapeutic
encounters.
Patients
are
not
always
correct
in
their
conclusions;
their
resistances
and
vulnerabilities
often
cloud
their
capacity
to
be
objective,
fair
observers.
However,
their
observations
of
their
therapeutic
experiences
deserve
serious
consideration.
Experienced,
intuitive
clinicians
discover
that
in
most
cases
they
can
reach
a
correct
provisional
diagnosis
from
information
elicited
directly
from
the
patient.
From
this
belief
we
have
developed
an
approach
that
has
both
therapeutic
and
educational
value,
and
we
demonstrate
its
importance
through
our
clinical
experience.
The
Psychotic
Patient
as
a
Teacher
The
psychotic
patient,
by
some
definitions
irrational,
can
be
a
teacher.
There
is
something
valuable
to
be
learned
from
a
patient
who
views
the
world
from
a
perspective
that
is
not
objectively
verifiable
nor
generally
held
to
be
true.
Unfortunately,
psychiatrists-‐in-‐training
are
taught,
at
least
by
example,
that
psychotic
patients
cannot
be
believed
and
that
these
patients'
views
and
opinions
are
inaccurate
and
unhelpful.
Several
incidents,
as
seen
from
the
standpoint
of
a
clinician
[M.V.S.],
illustrate
the
importance
of
listening
to
psychotic
patients
-‐"listening"
not
only
to
their
words
but
to
their
deeds.
Nonverbal
Communication
In
my
first
year
of
training,
one
of
my
acutely
disturbed
patients
vomited
in
front
of
my
office
door.
Although
I
was
not
practised
at
reading
meaning
into
behaviour,
intuition
told
me
that
this
patient
did
not
like
me.
To
my
regret,
I
dismissed
my
feeling
as
illogical.
A
few
days
later
the
same
patient
walked
into
a
seminar
room
and
punched
me.
I
was
not
only
humiliated
but
suffered
a
broken
nose
in
the
process.
I
later
realized
that
her
action
was
retaliation
for
the
several
ways
in
which
I
had
humiliated
her
during
the
assessment
interview.
This
acutely
psychotic
and
verbally
uncommunicative
patient
had
given
fair
warning,
but
I
had
not
heeded
it.
A
Sad
Ending
A
young
patient
told
me
that
the
new
antipsychotic
medication
I
had
prescribed
did
not
agree
with
her;
she
felt
worse
instead
of
better.
Because
this
patient
had
a
long
history
of
psychosis
and
was
then
delusional,
I
decided
that
her
opinion
could
be
disregarded.
A
few
days
later
she
suffered
an
opisthotonic
crisis,
a
reaction
to
her
antipsychotic
medication,
and
choked
to
death.
It
was
not
known
then,
but
is
now,
that
subjective
dysphoria
in
response
to
antipsychotic
drugs
is
an
indication
for
drug
withdrawal.3
A
Happy
Ending
A
patient
had
been
mute
and
in
hospital
for
13
years
when
she
was
transferred
into
my
care.
She
painted
prodigiously
in
art
class.
Her
paintings
had
three
unique
features:
first,
she
meticulously
divided
the
paper
into
little
squares;
second,
she
left
a
white,
unpainted
space
around
each
of
the
human
beings
in
her
paintings;
third,
all
the
human
beings
were
painted
as
seen
from
the
back.
I
took
this
to
mean
that
she
should
be
approached
little
by
little
(one
"square"
at
a
time),
that
I
had
to
keep
my
distance,
physically
and
psychologically,
to
avoid
crossing
the
white,
unpainted
spaces,
and
that
I
had
to
avoid
frontal
interpretive
assaults.
I
have
communicated
with
this
patient
by
letter
for
30
years
-‐
an
unparalleled
opportunity
to
learn
why
she
finally
began
to
talk
and
to
emerge,
little
by
little,
from
the
white
spaces
in
which
she
had
enveloped
herself.
This
patient
was
one
who
overcame
schizophrenia.4
She
not
only
began
to
speak
but
was
eventually
discharged
from
the
hospital.
She
has
worked
steadily
since
then
and
has
never
been
re-‐
hospitalized.
She
still
paints,
but
now
there
are
no
squares,
no
unpainted
spaces
and
her
people
face
the
front.5
Listening
to
the
Meaning
Behind
the
Words
I
was
in
my
second
year
of
psychiatric
residency,
working
on
a
women's
ward,
when
Marilyn
Monroe
died.
Eight
patients
stated
that
they
identified
with
Marilyn
Monroe;
they
believed
they
were
Marilyn
Monroe.
I
thought
I
had
discovered
something
new,
a
"folie
à
eight
misidentification
syndrome"!
It
seemed
like
a
good
therapeutic
idea
to
put
these
eight
women
together
into
a
"Marilyn
Monroe
group."
As
conceived,
the
group
would
meet
once
a
week
to
discuss
the
shared
defences
of
identification
and
introjection
and
to
reflect
on
the
role
of
societal
values
in
the
formation
of
the
ego-‐
ideal.
However,
what
I
had
not
done
was
listen
to
what
my
patients
were
telling
me:
they
identified
with
Marilyn
Monroe,
and
she
had
taken
her
life.
That
part
somehow
escaped
me
until,
one
by
one,
the
women
in
this
group
made
(unsuccessful)
attempts
at
suicide.
My
supervisor,
who
had
been
out
of
town
when
I
organized
this
untherapeutic
group,
quickly
put
an
end
to
it
upon
his
return.
The
Patient
as
Observer
Sometimes
we
learn
not
only
subjective
reality
but
objective
facts
from
patients.
For
example,
the
side
effects
of
neuroleptics
are
worse
if
these
medications
are
taken
after
a
heavy
carbohydrate
meal,
and
akathisia
is
worse
after
the
ingestion
of
alcohol.6,7
Scientific
breakthroughs
have
often
come
from
patients'
personal
observations.
It
is
a
pity
that,
when
dealing
with
patients
who
suffer
from
severe
psychiatric
illness,
we
tend
to
dismiss
their
observations
as
illusory.
Patients
form
their
judgements
of
us
from
clues
that
we
unwittingly
furnish.
They
observe
us
in
interactions
with
other
patients,
nursing
staff,
housekeeping
staff
or
strangers.
They
watch
how
we
treat
our
secretaries,
they
listen
to
how
we
speak
to
our
children
on
the
telephone,
how
we
address
our
colleagues
and
how
we
look
after
our
plants
(especially
the
ones
they
have
given
us).
The
composite
picture
determines
their
readiness
to
entrust
themselves
to
our
care.
Acknowledging
Patients'
Strengths
We
relearn
constantly
from
seriously
ill
patients
that
it
takes
strength
and
fortitude
to
endure
a
lifetime
of
frightening,
inexplicable
and
changing
affects,
perceptions
and
cognitions,
over
which
they
have
relatively
little
control.8
Over
the
centuries,
psychotics
have
been
referred
to
by
a
variety
of
names,
each
name
focusing
attention
on
what
the
reigning
culture
has
perceived
as
particularly
salient
aspects
of
the
psychotic
experience.
Possessed
emphasized
the
lack
of
rational
control
over
behaviour,
attributing
this
to
an
invasion
by
evil
spirits.
Lunatic
stressed
the
waxing
and
waning
rhythm
and
the
tidal
proportions
of
psychosis.
Insane
("not
healthy")
affirmed
the
"sickness"
or
"medical"
model,
while
the
French
term
aliené
(alienated)
suggested
social
causation.
The
word
patient
carries
the
connotation
that
time
itself
will
bring
about
healing.
Diseased
accentuates
the
loss
of
subjective
ease
or
equilibrium.
Handicapped
focuses
attention
on
the
fundamental
injustice
of
this
condition,
and
disabled
underlines
its
progressive
incapacitation.
The
term
victims
characterizes
the
experience
of
many
psychotics
of
being
oppressed
by
others.
Clients
or
consumers
highlight
the
ideal
of
autonomy,
not
always
attainable.
The
patient
advocacy
movement
has
adopted
the
term
survivors.
This
term
is
apt.
It
allows
that
these
are
people
with
fortitude
and
perseverance;
they
are
our
best
witnesses
to
the
experience
of
psychosis.
Many
patients
have
explained
that
psychosis,
as
awful
as
it
is,
has
its
own
rewards
and
may
serve
useful
purposes.9
Vigorous
attempts
to
deprive
individuals
of
face-‐
saving,
or
comforting,
esteem-‐building
delusions
and
hallucinations
are
likely
to
alienate
rather
than
to
help
them.10,11
Because
many
elements
of
the
psychotic
experience
are
salutary
and
important
to
patients,
it
may
be
difficult
for
them
to
form
a
therapeutic
alliance
with
a
psychotherapist
who
dismisses
these
elements
as
"sickness"
or
"imagination."
We
must
heed
the
totality
of
a
person
s
experience;
the
unusual
as
well
as
the
intelligible,
the
objectionable
as
well
as
the
wholesome,
that
which
is
familiar
as
well
as
that
which
is
alien.
The
Patient
in
Psychotherapy
In
psychotherapy,
a
partnership
of
cooperation
and
mutual
respect
is
called
for.
We
must
listen
to
what
patients
attempt
to
communicate
during
therapy.
This
lesson
should
pervade
medical
teaching:
pay
particular
attention
to
the
patient's
opinions
and
reactions.
This
principle
must
be
taught
to
our
students
and
residents,
explicitly
in
what
we
tell
them
and,
probably
even
more
important,
implicitly
in
how
we
deal
with
them
and
how
we
show
them
that
we
deal
with
patients.
The
profession
of
medicine
begins
with
the
patient.
It
is
his
or
her
needs
that
bring
into
being
the
art
and
science
of
medicine.
This
view
was
incorporated
into
the
goals
of
the
Johns
Hopkins
University
School
of
Medicine,
which,
just
over
100
years
ago,
stated
its
mission
in
three
parts:
to
provide
the
finest
patient
care;
to
seek
knowledge
to
improve
that
care;
and
to
educate
the
next
generation
to
carry
out
these
tasks
in
a
superior
fashion.12
We
can
learn
two
categories
of
material
from
patients
in
psychotherapy.
The
first
has
to
do
with
life
in
general.
The
second
has
to
do
with
the
process
of
psychotherapy
itself.
Lessons
From
Life
in
General
In
her
article
"The
psycho-‐analyst"
Ella
Freeman
Sharpe13
wrote:
...I
find
the
enrichment
of
one's
ego
through
the
experiences
of
other
people
not
the
least
of
my
satisfactions.
From
the
limited
confines
of
an
individual
life,
limited
in
time
and
space
and
environment,
I
experience
a
rich
variety
of
living
through
my
work.
I
contact
all
sorts
and
kinds
of
living,
all
imaginable
circumstances,
human
tragedy
and
human
comedy,
humour
and
dourness,
the
pathos
of
the
defeated,
the
incredible
endurances
and
victories
that
some
souls
achieve
over
human
fate.
Perhaps
for
this
I
am
personally
most
glad..,
the
rich
variety
of
human
experience
that
has
become
part
of
me,
that
never
would
have
been
mine
either
to
experience
or
to
understand
in
a
single
mortal
lift,
but
for
my
work.
It
is
not
only
that
the
psychotherapist
learns
from
the
patient
because
the
patient
has
lived
with
other
people,
often
in
other
cultures,
has
done
different
work
and
travelled
to
different
places.
It
is
also
that
the
patient
has
capacities,
skills,
creativity,
talents
and
goals
that
are
different
from
those
of
the
psychotherapist.
All
of
us
have
worked
with
patients
who
are
less
fortunate
than
ourselves:
less
educated,
less
accomplished,
more
alone.
And
we
often
work
with
patients
who
are
more
fortunate
or
more
privileged
than
ourselves:
better
educated,
more
intelligent,
more
well
to
do,
more
prominent,
more
talented.
The
therapist
can
take
various
kinds
of
satisfaction
from
working
with
a
patient
who
is
perceived
to
be
superior
in
some
way.
There
is
also
the
vicarious
gratification
that
comes
from
helping
a
patient
achieve
a
satisfactory
outcome.
This
satisfaction
is
open
to
the
therapist
whose
patient
has
gifts
or
talents
not
shared
by
the
therapist,
yet
whose
interests
may
be.14
Lessons
From
Psychotherapy
The
second
category
of
learning
is
through
the
process
of
psychotherapy.
Patients
find
it
helpful
when
psychotherapists
are
natural,
available
and
open.
Personal
attributes
assume
greater
importance
than
do
the
practical
aspects
of
qualification,
education
and
experience.15
Patients
expect
the
same
qualities
from
their
therapists
that
all
people
look
for:
qualities
that
make
them
feel
safe,
secure
and
able
to
trust.
They
expect
their
therapists
to
be
respectful,
empathic,
interested,
honest,
responsive,
realistic
and
fair.
They
do
not
need
the
therapist
always
to
agree
with
them
-‐
indeed
they
need
a
therapist
to
disagree
with
them
when
they
are
wrong,
unrealistic
or
destructive.
They
do
not
expect
therapists
to
be
all-‐knowing
or
all-‐powerful,
but
they
do
require
persistence
and
optimism
so
that
they
can
improve
their
lives.
Patients
want
to
be
treated
by
people,
not
by
someone
who
behaves
more
like
a
textbook
or
computer
than
a
human
being.
They
do
not
require
or
expect
psychotherapy
to
be
easy
or
comfortable.
Discomfort
and
pain
can
be
tolerated
within
the
context
of
an
enlightened,
caring,
professional
relationship.
A
patient
[of
S.E.G.],
who
also
happens
to
be
a
librarian,
was
asked
if
she
could
find
the
precise
reference
for
the
quotation
with
which
this
paper
begins.
She
was
successful
in
doing
so
and
volunteered
her
opinion
of
the
quote.
[This
passage
from
The
Talmud]
is
appropriate,
for
it
expresses
the
essence
of
what
I
have
experienced
in
psychotherapy.
In
the
beginning
I
was
surprised,
because
you
didn't
presume
to
know
who
I
was
and
what
was
best
for
me.
No
one
can
know
for
another
person.
That
attitude
left
us
free
to
try
to
understand
together
ft
allowed
me
to
have
power
in
the
relationship,
and
we
were
on
a
journey
together
I
was
the
captain,
you
weren't.
You
didn't
presume
to
know
what
was
best
-‐
how
could
you?
it
gave
me
the
chance
to
contribute
to
my
own
healing.
She
was
stating
that
a
most
important
feature
of
the
therapeutic
alliance
was
mutuality
-‐the
therapist
listened
and
wanted
to
understand,
and
the
patient
then
felt
free
to
explain,
and
eventually
learn,
about
herself
and
her
inner
world.
Summary
and
Conclusions
In
this
paper
we
have
described
and
recommended
an
attitude
that
we
consider
essential
to
all
good
medical
care.
Why
have
we
felt
called
upon
to
do
so?
Modern
tools
of
investigation,
providing
objectified
measures
of
the
patient's
systems
and
symptoms,
offer
opportunities
that
did
not
exist
in
the
past.
However,
these
same
opportunities
bring
with
them
the
risk
that
clinicians
will
lose
their
well-‐developed
skills.
The
practice
of
medicine
may
therefore
become
less
effective.
All
medicine
benefits
from
the
physician's
observations
of
the
patient.
Of
cardinal
significance
are
the
data
gathered
through
history-‐taking.
Experienced
clinicians
make
a
diagnosis,
at
least
provisionally,
in
large
part
through
the
information
provided
by
the
patient.
Other
sources
of
information,
of
course,
are
required
to
amplify
the
understanding.
Our
experience
in
psychiatry,
most
particularly
in
psychotherapy,
has
confirmed
the
continued
relevance
of
history-‐taking,
including
the
patient's
view
of
which
therapeutic
efforts
were
injurious
and
which
ones
were
helpful.
We
suggest
that:
*
listening
to
the
patient
will
provide
important
information
that
is
not
otherwise
available;
*
an
appropriate
medical
posture
is
one
of
a
respectful,
cooperative
interrelationship
with
the
patient,
not
one
of
unilateral
omnipotence;
*
these
attitudes
must
be
encouraged
in
students
and
residents,
not
only
by
explicit
explanation,
but
by
implicit
example;
*
this
position
will
protect
the
physician
from
the
danger
of
becoming
a
technician
who
only
interprets
data
from
tests
and
examinations
and
who
therefore
sacrifices
the
opportunity
for
a
meaningful
relationship
with
the
patient.
We
are
grateful
for
what
our
patients
have
taught
us.
Our
lives
have
been
enriched,
and
we
believe
that
patients
and
students
of
psychiatry
have
profited
from
our
lessons.
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*This
paper
is
the
revised
version
of
a
presentation
to
Grand
Rounds,
Department
of
Psychiatry,
Mount
Sinai
Hospital,
Toronto,
Ont.,
Oct.
4,
1991.
†Professor
emeritus
of
psychiatry,
University
of
Toronto,
Toronto,
Out.
‡Professor
of
psychiatry,
University
of
Toronto
Correspondence
and
reprint
requests
to:
Dr.
Stanley
F.
Greben,
Department
of
Psychiatry,
University
of
Toronto,
933-‐600
University
Ave.,
Toronto,
ON
M5G
1X5
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