In the first two posts in this series, Part I and Part II, I tried to show that the change from patient to client or consumer is meaningful on many levels and has systemic consequences. I pointed out, with the help of several commenters, that the most salient difference between a client or consumer and a patient is that patients come to Doctors when they are in pain and distress. This makes all the difference.
When a person is in pain, they regress from their typical level of functioning to an earlier, psychologically less mature level of functioning.
A couple of illustrations might help clarify how this works. Consider a young child, a 5 year old, running around the house. He is carrying on his typical 5 year old activity, without a care in the world, with no need for close supervision or much more than an occasional moment to "touch base" with his Mother. Now imagine that child tripping and skinning his knee; what happens next? There is the initial shock that the previously benign world has suddenly risen up and struck him; if there is blood, there is the additional anxiety that such bodily leakage always evokes in young children whose grasp of inside and outside is not as solid as it will be later in development. Tears and wailing ensue; he wants his Mommy. The previously robust youngster, reveling in his musculature and his movement, enjoying the freedom of the young, has instantly regressed to a needy, frightened baby who needs to be comforted and held by his mommy; only her (or her "stand-in" replacement's) kisses and reassurances can restore him to his previous level of functioning. A kiss, a band aid (often necessary even when there is no blood), and a short time later, the child is a 5 year old dynamo once again.
Now consider an adult, a grown man, making a living, functioning in the world. Consider what happens to so many grown men when they have a cold.
The caricature of the man who needs TLC from his wife because he has a mild viral syndrome has enough truth to it to be recognizable in innumerable jokes and cartoons. He needs his wife (in her incarnation as a maternal caretaker) to make him chicken soup, to offer soothing words of sympathy for his fever of 100, to be understanding and take care of him. Obviously, this is not a universal situation but it occurs often enough to suggest the regression that occurs in adults who feel, and are, sick.
Now consider an adult who has a truly frightening medical situation. A woman discovers a lump in her breast or a man develops chest pain which travels down his left arm. These are frightening situations that have the potential to become terrifying, life threatening, and life altering. In a state of high anxiety the person looks for the Doctor to perform certain technical procedures (which in fact most Doctors don't perform; X-rays, CAT scans, etc are done by high tech machines, run by technicians) with the child-like wish for reassurance that everything will be all right. When the worst occurs, the person is likely to become even more needy, frightened, and distressed. This is where the person is most in need of a Doctor as a source of strength, hope, and comfort, and this has been lost in most of medicine by turning Doctors into mere providers.
When a person regresses, and less mature emotional states surface, what is also activated in their dependence on others, are wishes for archaic relationships (the early mother, "mommy", for example) which are known as "transference reactions." I have written about transference in the past; in Changes: Part I I described the way in which our minds develop "templates" for objects; when such templates, in much more complex forms, develop of the important people in our lives, we refer to these templates as "transference objects." When patients express such feelings and (unconsciously) recreate such relationships within therapy, we treat these as transference reactions. Much of the work in Psychoanalysis is devoted toward resolving transference. In PC & Defects in Reality Testing: Part VI I described a particular case in which a man's transference reactions were replicated in his therapy in ways which were identifiable; once he became conscious of how his transference reactions were distorting his perceptions, it allowed him to begin the difficult process of addressing his damaged relationships.
Transference is an extremely powerful tool which can be a valuable ally in the curative process. This is, of course, most clear in Psychotherapy, but even in purely medical illnesses (and one can question whether there is ever an illness that affects the body without affecting the mind) the transference wishes and fears that are activated can either be used to enhance healing or to interfere. All of these concerns are ignored under a system which treats Doctors as interchangeable "providers" and patients as clients and consumers.
On the most basic level, consider a patient who has conflicts over caring for himself and difficulty tolerating deprivation (for example, an overweight man with high cholesterol and cardiac disease who needs to be put on a diet and exercise regimen.) Skillfully using the transference to a somewhat idealized Doctor may prove to make the difference between a patient's compliance with a difficult regimen in order to please his Doctor (and improve his health) and that same patient's avoidance of follow-up appointments and the life changes necessary for better health.
Finally, there is a further significant problem that arises from the change I am discussing. Obviously, not every medical intervention has a happy outcome; none of us get out of this life alive. That being said, once Doctors are turned into providers, and patients are taught to see themselves as consumers and clients, a fundamental defining aspect of the relationship shifts. Consumers have an interest in receiving something of value in their arrangement with a provider. If you purchase a new car and it is a lemon, you are likely to demand a refund or a replacement car; if you are left unsatisfied, you not only are likely to become rather angry but you also will have a tendency to sue the providers of the defective product. Medical care is now often approached in the same, potentially adversarial, manner. When patients have poor outcomes, it is terribly discouraging, but because there is now a provider who has fundamentally failed to provide the service you have requested, or demanded, you are now entitled to feel anger and disdain for their failure. Doctors often complain that most law suits are generated by poor outcomes rather than by overt malpractice. We end up with the worst of all possible situations. Doctors are afraid of being sued (a legal assault) and order unnecessary and expensive tests and procedures (which can and often do increase risks to patients) in order to protect themselves from the John Edwards of the world. Most Doctors realize that on a witness stand a good lawyer can force complex situations with poor outcomes to look like malpractice. Juries in many places have bought into the idea of "providers" and "consumers" and in areas like New York, with an overabundance of entitlement thinking, wealthy Doctors and Insurance companies are seen as "fair game" by too many people. One of the greatest injustices of the system is that often the best Doctors, the ones who take on the most difficult cases, are the ones most likely to be sued and most malpractice, some of it quite egregious, ends up being missed. Perhaps an even worse systemic outcome is the pressure on everyone and the loss of healing power which occurs from forcing Doctors and patients to see each other as adversaries.
My next post will look at the collusion of the Mental Health professions in the dehumanization of Psychotherapy. A good Psychotherapist does not provide consumables to his consumers, nor does he provide advice to his clients, he helps his patients discover the sources of their pain and distress and discover the abilities within themselves that can address and resolve their mental pain.
Recent Comments