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Rationality and Relation

Practical medicine as well as psychiatry as a craft have always been based on two cornerstones. The rational cornerstone is the hallmark of a medicine that aspires to be scientific. This cornerstone has produced spectacular, partly specific therapies (the so-called magic bullets, pharmaceutical or other interventions which specifically attack a disease or its cause, such as antibiotics). It became the foundation of scientific medicine and scientific psychiatry.

The other cornerstone is the relational. I will briefly expound on this one, as it is extraordinarily significant in psychiatry. In the first place, to determine symptoms, the psychiatrist is almost totally dependent on the patient’s willingness to talk about his symptoms. So the quality of the relationship has a direct influence on the diagnosis and therapy. Secondly, thanks to this relationship, the psychiatrist can perform useful work even when no (effective) therapies are available. Further, through this relationship the psychiatrist can support his patient, offer a prospect, and evoke a feeling of cooperation and identification. Other relational elements are offering dependable information, providing insight into the disorder, discussing possible courses of action, and helping to weigh the advantages and disadvantages of various itineraries. In addition, during therapy, mutual trust, discussion on how things are going along, and the possible desirability of a change in itinerary are important for optimal cooperation. Such cooperation increases the effectiveness of the treatment. A satisfactory relationship with the patient is paramount to the healing process. It can shorten the stay in the hospital, boost motivation, and optimalize the patient’s cooperation. Many psychiatric disorders are chronic or tend to keep returning, making a maximally cooperative relationship even more important. In short, the relational cornerstone is of great significance in psychiatry. Of course this applies to medicine in general as well. The significance of the relational element has not abated now that the nature and number of treatments have augmented.

The neopositivistic direction may, in this respect, have some damaging side-effects. Physicians have become technical experts who are poorly accessible to their patients.* Patients complain a great deal more about today’s technologically perfected medicine than they complained about the powerless physicians of former times.

Illness does not strike only, nor in the first place, the body, but the entire person. “Doctoring” is much more than applying medicines or conducting operations. In practice, in somatic medicine as well, the biomedical disease concept is too reductionistic, too simplistic.

*In 2002 a national commission on mental health instituted by the ministry of health published its report in the Hague. One of its conclusions is that family physicians, the pillar around which the Dutch health care system revolves, are less willing than in the past to discuss all sorts of problems related to health care that can occur in the daily lives of their patients with them. Cardiologists often do not take the time to discuss the importance of not smoking with their patients after they have had a heart attack. Specialists report lacking the time to discuss organ donation with the family following the brain death of a patient. The suspicion is raised that they may lack the motivation and the skills to conduct a discussion with the family in such emotionally difficult circumstances. The report suggests hiring special hospital doctors, whose job will be to facilitate communication between the specialists and the patients, “relieving” the specialists of this load. Nurses are to assist family physicians in cases which require extra communication, such as chronic or terminal illness. These are only some examples of how inaccessible physicians have become to their patients.
It seems to me not unlikely that the growing popularity of alternative medicine may be related to this. – J.P.

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