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11
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
2
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.
3
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.
4
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 .
5
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.
6
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.
7
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.
8
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,
9
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 ?
10
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.
11
I think it is a good understanding to say about this
case that a true psychotic disorder can express a
true human feeling.
12
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.
13
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.
14
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 ?
16
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
17
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 »
18
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)
1919
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.
2020
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.
21
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».
22
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.
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