Acta Psychiatr Scand 1999: 100: 319-320 Printed in UK AN rights reserved

Copyright 0 Munksgaard 1999 A CTA PS YCHIA TMCA

SCANDINA VICA ISSN 0902-4441

Editorial

‘Yes doctor, no want from you?

doctor’:

The first part of the title of the article ‘What do patients want and do we want to know? A review of patients’ requests of psychiatric services’, published in this issue of Acta Psychiatrica Scandinavica (l), may be regarded as blasphemy at a time when a client-centred approach is the leading principle. Who would dare to say that we don’t want to know what patients want? So in a way the answer is simple - yes, we want to know what our patients want.

But here the problems start. What does the patient want from whom - his or her individual doctor/(psycho)therapist, the institute or the mental health services as a whole? Is it the individual patient, the family or the patient organization who want things?

In the article by Noble, Douglas and Newman, 28 studies involving versions of the Patient Request Form (PRF) are (critically) reviewed (1). The 17 items of this form mainly deal with how the patients expect to be ‘cured’. The top three requests of patients attending (primarily out-patient) services in Europe and the USA are ‘clarification’, ‘psycholo- gical expertise’ and ‘psychodynamic insight’.

This is an interesting finding which raises many questions.

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What are requests? ‘Patients’ expressed desires and wishes should be termed requests’. It is unclear and even doubtful whether this is the same concept of request as used by Lazare et al. (2) in the development of the PRF as part of a ‘negotiated approach’ towards patient requests. Specifically in psychotherapeutic literature various overlapping notions are used, including patients’ frame of reference (3), preferences (4) or expectancies (5) . This overlapping of theory and notion may be one reason why the results in this area of research remain inconclusive.

Is the PRF a proper instrument for defining request? Probably not, but there appears to be no real alternative that has a minimum standard of validity, reliability, etc. The results of the review of Noble et al. (1) may be seen as a sign of poverty in this area of research and

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what do patients

also a call for better and more thorough research. It is interesting that in the 28 studies reviewed, a relative similar ranking order of request was found. This may also be a reflection of the (western) cultural background of the populations studied, and it would be interesting to test the PRF in different cultures, or to add other more culturally specific items to the PRF.

Are there practical consequences of the outcome of studies regarding requests? In our institute (Parnassia Psychomedical Centre, Den Haag, The Netherlands) the PRF has been studied for more than 10 years and we found, for instance, a clear difference in requests bet-ween different patient groups (as defined by the DSM-I11 and SCL-90 score). But how can these findings be translated into practical consequences? One simple way to use the PRF (completed at intake by all of our out-patients) is to discuss their remarks with them. In that way it can function as a simple but effective tool as well in the training of residents.

Is it relevant to know what the patients want (or request)? Although, as mentioned earlier, many methodological questions remain, research in recent decades seems to confirm that when the expectations of the patient/client are not met, this may lead to ‘expecting dysconfirmation’ (5) that (negatively) influ- ences the therapeutic relationship, satisfac- tion, drop-out and ultimately the outcome of the treatment. This does not mean that to follow the patient’s perspective and offer a ‘tailor-made’ therapy leads to a better result, as the studies of Schulte et al. (6) and Emmelkamp et al. (7) show. However, future research should take much more account of what the patient’s expectations and request are in relation to outcome. For instance, this may be relevant in studies comparing psycho- therapy and medication in the treatment of

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depression. What would the influence on outcome be if randomization included the patient’s preference for a particular treatment?

The question of what patients ‘want’ has probably entered a whole new arena. The patient may have obtained through the internet or his or her patient association or bookshop a book, based on the latest guidelines expertly written by one of your colleagues (e.g. on the bookstall of the American Psychiatric Association meetings!). For instance, what if the patient asks for 12 sessions of cognitive behavioural therapy for the treatment of his depression and the therapist (or institute) only works with interpersonal psychotherapy and/or antidepressants? Or supposing a patient wants an antipsychotic ‘A’, because he has heard that it has less side-effects, but the doctor has to say that they must have ‘B’ because that is in the hospital pre- scribing guidelines? ‘Doctor knows best’ may certainly not apply in this situation.

Perhaps more than ever the individual doctor, the institute and all third parties involved will have to ask the patient what they ‘want’, but they will also have to tell them what they can and are able to offer them in this period with restrictive financial budgets and an ongoing search for the ‘true’ evidence-based psychiatric therapy. In a way we shall indeed have to ‘negotiate’ whether there is a ‘cure’ and by what

available means this ‘cure’ may be achieved, and whether these means are available. Yet what the patient wants, as in the rest of human life, must be treated with respect and taken seriously.

Acta Psychiatrica Scandinavica Erik Hoencamp

invited Guest Editor

References 1.

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NOBLE LM, DOUGLAS BC. What do patients want and do we want to know? A review of patients’ requests of psychiatric services. Acta Psychiatr Scand 1999;100:321-327. LAZARE A, EISENTHAL S, WASSERMAN L. The customer approach to patienthood: attending to patient requests in a walk-in clinic. Arch Gen Psychiatry 1915;32:553-558. DUNCAN BL, MOYNIHAN DW. Applying outcome research. Intentional utilization of the client’s frame of reference. Psychotherapy 1994;31:294-301. BENBENISHTY R, SCHUL Y. Discrepancies between therapists’ role preferences and role expectations. J Clin Psychol 1986;

GOLDSTEIN AP. Therapist-patient expectancies in psycho- therapy. Oxford: Pergamon Press, 1962. SCHULTE D, KUNZEL R, PEPPING G. Tailor-made versus standardized therapy of phobic patients. Adv Behav Res Ther 199&’14:67-92. EMMELKAMP PMG, BOUMAN TK, BLAAUW E. Individualized versus standardized therapy: a comparative evaluation with obsessive-compulsive patients. Clin Psychol Psychother

421 19-721.

1993;1:95-100.

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