The Basic Models of the Doctor Patient Relationship, by Thomas Szasz and Marc Hollender

A   Contribution tothe The   Basic   Models of

the   Doctor-Patient

Philosophy of   medicine

Relationship

THOMAS S.   SZASZ,   M.D.,   Bethesda, Md.

and MARC H.  HOLLENDER,   M.D.,   Chicago

INTRODUCTION

When a person  leaves the culture  in  which he was   born and   raised and and   migrates to another, he  usually  experiences his new social   setting as something   strange\p=m-\and in some ways   threatening\p=m-\and he is   stimulated to   master it by   conscious   efforts at understanding. To   some   extent   every immigrant to the   United   States   reacts in   this manner to the   American   scene. the   American   tourist in Europe or   South Ameri America ca "scrutiniz "scrutinizes" es" the   social   setting which is   taken for  granted by the   natives. To   scrutinize\p=m-\andcriticize\p=m-\thepattern of other peoples'  lives  is  obviously  both  common and easy. It   also   happens,   however,   that people   exposed to  cross   cultural  experiences turn their  attention to  the very  customs  which formed the   social   matrix of   their   lives in the   past. to   study the   "customs" which   shape and   govern   one's life is   most   difficult of   all.1

To him the relationship  between physician and  patient—which is like a custom that is  taken for granted in  medical  practice and   which he   himself so   treated in his early history—has   become an object of study. While the precise   nature and and   extent of the influence  which  psychoanalysis and  so-called dynamic   psychiatry   have had on   modern medicine are  debatable, it   seems to us   that the   most   decisive   effect has   been   that of making   physicians   explicitly   aware of the possible  significance of   their   relationship to to  another.

patients. The  question  naturally  arises as to  "What is a doctor-patient  relationship?" It is our aim to   discuss   this   question and and to   show Similarly, that that cert certai ain n   philosophical   preconceptions associated   with the   notions of   "disease," "treatment," and   "cure"   have a profound bearing on  both the theory and the practice

  Lastly,

a

  day-to-day

In   many   ways the  psychoanalyst is   like person who has migrated  from one  culture Received for  publication   Aug. The  opinions

17,   1955.

or   assertions  contained   herein are

the   writers, and are not to be construed as   official or reflecting the   view of the Navy  Department  or the   Naval   Service at large.

the  private   ones of

Commander   (MC), U. S. N. R.;  

Department of   Psychiatry, U. S.   Naval   Hospital,   National Naval   Medical   Center  ;   Staff  Member,   Institute for

of  medicine.* WHAT

IS A   HUMAN   RELATIONSHIP?

The   concept of a relationship is a   novel one in   medicine.   Traditionally,   physicians have   been  concerned  with   "things," for ex¬ ample,   anatomical   structures,   lesions,   bac¬ teria, and the  like. In  modern  times the scope has   been   broadened to   include the concept of  "function." The  phenomenon of a  human often viewe viewed d as though it relationship is   often were a "thing'Or a  "function." It is, in  fact, neither.   Rather it is an  abstraction,   appro¬ priate for the   description and  handling of certain   observational   facts.   Moreover, it is

approach to   this   subject we   have   been influenced by   psychologic   (psychoanalytic),   sociothis logic, and   philosophic   considerations. See   in this *

In

our

Psychoanalysis,   Chicago, on   leave of  absence   (Dr. connection   References 2-4 and   Szasz, T. S. : On Szasz), and   Staff   Member,   Institute for   Psycho- the   Theory of   Psychoanalytic   Treatment,   read analysis, and   Associate   Professor of   Psychiatry, before the Annual Meeting of the American PsychoMedicine e   (Dr. analytic   Association,   Atlantic   City, N. J., May 7, University of   Illinois   College   of Medicin 1955  ;   Internat. J.   Psychoanal., to be  published. Hollender). 585

an   abstraction   which

it is  based on on   another in   such

  presupposes   concepts

the  effect of one person a way and and   under   such circumstances  that the person  acted   upon is  or is  considered unable  to  contribute to be  inanimate.  This  frame of  reference (in which the   does to the   underlies the of   some of  the  advances  of  modern  medi¬ cine (e.  g.,  anesthesia  and  surgery,  antibiotics, The is   active; the cause

of both  structure and function.   comments may be   clarified The  concrete   illustrations.   Psychiatrists   often suggest to  their  medical  colleagues  that the  with his patient physician's se"  helps the  latter.  This  creates the  impres¬ sion  (whether so   intended or not)   that the is a   which   works not unlike the way   that   vitamins do in a   case of   vitamin   deficiency.   Another   idea is   that

by

 foregoing

 relationship

relationship

 actively,

 "per

  something application

physician

patient) outstanding

thing,

etc.).

 physician

 patient, passive.  This  orientation has originated in— the   doctor-patient   relationship   depends and and is entirely appropriate entirely appropriate  for—the treatment mainly on   what the   physician   does (or of  emergencies (e. g., for the  patient who thinks or feels).  Then  it is  viewed not  unlike is   severely   injured,   bleeding,   delirious, or a function. in  coma).  "Treatment"  takes  place  irrespec¬ When we  consider a relationship in  which tive of the  patient's  contribution and regard¬ there is joint participation of the two  persons less of the   outcome.   There is a similarity involved,   "relationship"   refers to   neither a here   between the   patient and a helpless Table   1.—Three  Basic  Models Model Activitypassivity

of

the  Physician-Patient

Clinical

Patient's

Physician's Role

 Relationship

Application of  Model

Role

Does  some¬ thing to

Recipient  (un¬ able  to  respond

Anesthesia,

cooperation

what  to  do

Tells patient

Cooperator

acute trauma, coma, delirium, etc. Acute  infec¬

Mutual  par¬

Helps patient

Participant  in "partnership"

illnesses, psycho¬

Guidance-

ticipation

patient

to  help  himself

or  inert)

(obeys)

tious  proc¬ esses,  etc.

Most chronic

(uses expert

Prototype of  Model

Parent-infant Parent-child (adolescent) Adult-adult

analysis, etc.

help)

structure nor  a  function  (such  as  the

"person¬ infant, on the one   hand, and   between the and a parent, on the  other. It may ality" of the   physician or patient). It is, physician and rather, an  abstraction  embodying the   activi¬ be   recalled  that psychoanalysis,   too,   evolved ties of two   interacting  systems   (persons).5 from a procedure   (hypnosis)   which was

 physical   meas¬ ures to  which  psychotics are subjected today are  another  example of the activity-passivity activity-passivity

based

THREE BASI BASIC C   MODELS OF THE   DOCTORPATIENT RELATIONSHIP

The   three   basic  models of the doctor-pa¬ tient   which we   (see   Table will  describe,   embrace  modes of  interaction ubiquitous in   human relationships and in no way  specific for the  contact  between  phy¬ sician and patient. The of the medical   situation   probably   derives   from a combination of   these   modes of   interaction with   certain  technical  procedures and and   social

  relationship

1),

  specificity

on  this   model.  Various

frame of  reference.

2. The Model of  Guidance-Cooperatio  G uidance-Cooperation.— n.— This   model  underlies  much of medical  prac¬

tice. It

is  employed in   situations   which are   men¬ less   desperate   than   those tioned (e. g.,   acute the is   ill, he is   conscious and has of his   own.   Since and feelings and he   suffers   from and   other

patient

  previously   infections).   Although

  aspirations   pain,   anxiety, settings. distressing   symptoms, he   seeks  help and is 1. The Model of Activity-Passivity.—His¬ ready and and  willing to "cooperate."   When he torically,  this is the oldest  conceptual   model. turns to a physician, he   places the   latter Psychologically, it is not an  interaction, be- (even if  only in   some   limited  ways) in a

of   power.   This   is due not  only to a   "transference   reaction" (i. e., his  regard¬ the  physician as he did his   father   when he was a but  also to the  fact .that the

This  model is  favored  by  patients  who, for various   reasons,   want to   take   care of  them¬ selves (at   least in part).   This may be an overcompensatory attempt  at mastering anxi¬

Both   persons are   "active" in   that  they   con¬ tribute to the relationship and and   what   ensues from  it. The  main  difference  between  the two participants   pertains to   power, and to its actual or potential   use. The   more  powerful of the two   (parent,   physician,   employer, etc.)   will speak of guidance or  leadership and   will   expect   cooperation of the   other member of the  pair  (child, patient,  (child,  patient,  employee, The etc.).  patient is   expected to   "look up to" and to his doctor. his  doctor.   Moreover, he is   neither to  question nor to   argue or   disa¬ gree  with the  orders he  receives.  This  model has its prototype in the  relationship of the and his   (adolescent)   child.   Often, parent and threats and   other   undisguised   weapons of

patient's own experiences   provide   reliable and  important   clues for  therapy.   Moreover, the   treatment   program   itself is  principally carried out by the patient. patient. Essentially, Essentially, the physician  helps the patient to  help  himself. In an evolutionary   sense, the   pattern of mutual participation  is  more highly  developed

 I t is  fundamental  to ings is  desirable.  It

scope of  this   essay.   Yet, it   must be   empha¬ sized   that as long as   this   subject is ap¬ proached with the sentimental  viewpoint  that a physician is  simply  motivated by a  wish to

position ing

child)

of his  bodily eties   associated   with   helplessness and   pas¬ processes   which he   does not  have. In   some sivity. It may  also be   "realistic" and   neces¬ ways it may   seem   that   this,   like the   first sary, as, for  example, in the management of model, is an active-passive   phenomenon. most   chronic   illnesses (e. g.,   diabetes   melliActually,   this is   more  apparent   than   real. tus,   chronic   heart   disease,  etc.).   Here the

physician   possesses  knowledge

than the   other two   mode models ls of the the   doctor-

patient  relationship. It  requires a   more   com¬ and  social  organization on plex psychological and the  part  of  both participants.   Accordingly,  it  "obey"  o r for  those is  rarely appropriate  for  children or persons who are mentally   deficient,   very poorly   educated, or profoundly   immature. On the   other  hand, the greater the   intellec¬ tual,   educational, and   general   experiential force are employed,   even though  presumably similarity   between  physician and and  patient the these are for the patient's   "own   good." It more appropriate and necessary this  model of should be   added   that the   possibility of the therapy  becomes. exploitation of the  situation—as in any re¬ THE   BASIC   MODELS AND THE   PSYCHOLOGY lationship  between  persons of  unequal  power OF THE   PHYSICIAN —for  the  sole  benefit  of  the  physician,  albeit under the guise of  altruism, is   ever  present. Consideration of why  physicians  seek one 3. The Model of  Mutual  Participation.— or  another  type of relationship  with  patients a particular Philosophically,   this   model is  predicated on (or   seek  patients who fit   into the postulate  that  equality  among  human be¬ relationship)   would   carry us beyond the the

so¬

cial  structure  of  democracy  and  has a crucial  role  in  occidental civilization  for  more than two   hundred   years.   rests on complex   processes of identification—which   facilitate of others in   terms of   with and the   discrete in¬  of the  observer  and the  observed. It is   crucial to   this  type of   interaction   that the ( 1 )   have

 played

mutuality

maintaining dividuality

  Psychologically,

 conceiving oneself—together   tolerating

help   others (not  that

we

porarily,

  scrutiny

deny  this  wish), no scientific  study of the  subject can be  under¬ taken.   Scientific investigation investigation is possible only if value judgment  is  subrogated,  at  least  tem¬ to

a   candid

of

the   phy¬

sician's actual   behavior  with his  patients.   model   places the The  in   absolute  control of  the  situation. In  this  way  it  needs for  needs  for  mastery and At the contributes to feelings of

  activity-passivity   participants   approximately physician equal power, (2) be  mutually interdependent  gratifies (i. e.,   need  each  other), and (3)   engage in  superiority.f activity  that will be  in   some ways  satisfying to  both.

 \s=d\ References

6 and 7.