To come across this phenomenon of worth is to learn something very significant about ourselves. We are enabled to be what we are only within these complex and mutual relationships with others, relationships which voice that complex and often troubled imperative." --Richard Zaner, PhD
Recently I assumed a new role in which most of my clinical time is spent consulting or teaching. My former position was as an attending psychiatrist in a primary care clinic where I had worked since fellowship. When I left, I was either supervising or directly clinically responsible for over 400 patients with serious mental illness. Many of these individuals had been my patients for nearly 4 years and some I had even cared for in residency. While the change represented a promotion for me in professional terms, I experienced the move as a poignant personal loss of friends.
Speaking of friendship with patients, particularly those with serious mental illness, may seem anathema for a psychiatric ethicist who is supposed to be the guardian of boundaries and monitor of countertransference. Yet there is a long and rich history of physician-patient friendship in medical ethics that can illuminate not only my own transitional grief but also the often-neglected affective dimension of most therapeutic relationships in mental health. In this month's column, I will briefly explore this historical perspective and its relevance for modern psychiatric practice, examine the very prudent concerns about the friendship model of the physician-patient relationship for psychiatry, and finally offer a tentative formulation of an ethically viable approach to patients as friends.
Historical perspective
Hippocrates, Seneca, Erasmus, and Paracelsus are among the illustrious proponents of friendship between doctor and patient. The hippocratic school and Plato conceived the affection in the physician-patient relationship as an example of philanthropic love. Drane,1 in one of the few books on modern medical ethics to discuss friendship, quotes a striking passage from Paracelsus, the 15th-century physician and philosopher, that if written today might well result in the writer being brought before his state medical board or local psychiatric association on charges of boundary violations: "The very deepest foundation of medicine is love. . . . If our love is great, the fruits derived from it in medicine will also be great; and if it is weak, the medical fruits, too, will be weak. It is love that leads us to learn the medical art and without love, no one becomes a real physician."
Seneca, the Roman Stoic philosopher, probably thought more deeply about friendship, including that with his doctor, than any other ancient author. For Seneca, the doctor demonstrated his friendship through empathy for the patient's suffering, his personal interest in the patient's well-being above other priorities, and his caring attention to therapeutic interventions no matter how arduous. Drane argues that physicians have an ethical obligation to friendship, grounded in the need and illness of the patient. Only a physician--no family, friends, or even clergy--can bring to the clinical encounter this positive parenting, this authoritative comfort, which possesses such healing power for sick, fearful, and lonely patients.1 If you doubt the force of your own present presence, just reflect on the emotion underlying a patient's response to the end of even a medication management visit, "is the time up already, when can I see you again?"
Leaving friends
Our patients' dependence on us as inspirers of hope was painfully brought home to me in the month after my departure from the clinic. I had informed patients individually that I would likely be leaving the clinic, but the reality did not dawn on them until they began receiving letters of transfer to different psychiatrists. My voice mail was then filled with entreaties and tears to which I finally had to ask the patient advocate to respond because my own emotions were so overwhelming as to be unhealthy for patients and their new providers. The protestations of my patients are not the result of any special talents I have as a therapist or even my personal warmth as a human being; rather, they express the meliorative strength of the virtue of friendliness in a therapeutic relationship.
This friendship is, of course, unequal, based as it is on the mental illness of the patient and the psychiatrist's ability to meet this need with compassion and competence. Erasmus, drawing on classical sources, conceived this inequality as a form of moral reciprocity,2 and it was the loss of this reciprocal emotional give-and-take that I was grieving. Most of my patients were psychiatrically stabilized. They were being transferred to very qualified colleagues, and they would in all probability eventually develop beneficial attachments to these now-unknown doctors. So it was not worry for their well-being that caused me to lie awake at night thinking about them.
