Patients as Friends: Lessons From History

September 1, 2006

Friendship with patients, particularly those with serious mental illness, may seem anathema for a psychiatric ethicist, yet there is a long and rich history of physician-patient friendship in medical ethics.

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.

Rather, I was sad that the conversations about Buddhism with the brain-injured man who struggled to apply its sublime tenets to his own trauma had ended. I regretted that I would not hear about how several of my higher-functioning patients with schizophrenia were doing with their returns to school. I mourned that I would no longer be able to share the parenting successes and struggles of the many patients with bipolar disorder whom I was privileged to treat. These are feelings of one friend for another, borne of the most secret confidences of tragedies and terrors and the most common conversations about dogs and books.

The chair next to my desk somehow seemed emptier despite a steady procession of consultants and earnest residents. And in this emptiness I saw, perhaps for the first time, the incredible privilege of being invited into patients' lives, the enormous trust they show in inserting our interpretations into their histories, and the daunting risk they assume in placing their vulnerabilities to our safekeeping. There could be no doubt that my care for these patients had not been a one-way street but rather a road toward their recovery that we traveled together.

Dangers and missteps

I have described a number of positive exchanges with my patients that are sadly overshadowed by a contemporaneous negative incident that brought into sharp relief the dangers and missteps inherent in relating to patients as friends. An elderly man with an agitated depression and chronic suicidality had made considerable progress over the years I had been seeing him. A major factor in his response to treatment was the strength of our therapeutic alliance. Once he was stabilized medically, one of our goals in supportive therapy was for him to buy a recreational vehicle, which he had previously owned and much enjoyed but had sold when he became seriously depressed. Right around the time of my leaving the clinic, he had bought the RV and brought me a picture of it. As both therapist and human being, I shared his obvious joy in the purchase and somewhat too casually said, "well bring it by and show it to me some time." Later that day, he had left me a message trying to make arrangements to show me the camper. I dismissed this as his wonted obsessive perfectionism; had I been more attuned, I would have recognized that my well-meaning remark had destabilized the man.

Several weeks later, he saw another psychiatrist in the clinic acutely with a fixed idea that he had been responsible for my departure. Then I received a strange, angry, and anguished letter claiming I had called him at home inquiring about our "trip together" and used my first name. I immediately phoned the veteran and asked him to come in right away. He arrived several hours later severely regressed with romantic, even erotic, delusions about my feelings and intent toward him, despite partial insight that these were his own projections. Processing the episode, including my apology and explanation, relieved the suicidal feelings and acute confusion, yet the damage was not wholly reparable. His fantasies and the associated guilt continued to plague him, and I transferred him to a colleague at his request and my recommendation. I sought supervision on the case from our most gifted psychotherapist and while absolved that I had not truly crossed a boundary, I came away from the termination with a renewed respect for the unpredictability and contingencies of psychiatrist-patient friendships.

Mishaps such as mine reinforce Illingworth's3 argument in Bioethics that the friendship model may violate the autonomy of patients and can be a form of "psychological oppression" stemming from internalization of inferiority. This is the underbelly of the inequality Erasmus praised. James,4 in a response to Illingworth, argued that the trust that many psychiatric physicians build with their patients is a moral good in the therapeutic relationship. It is this form of fiduciary friendship that I would advocate is of vital importance in psychiatry precisely because of the intense alienation of the mentally ill both from their soundest selves and from an often cold and rejecting society.

The very vulnerability of the psychotic, despondent, and addicted patients we treat, which renders them so easily wounded and exploited, is paradoxically the source of our ethical duty to befriend those most bereft. While reverencing the strict codes of conduct that rightly govern our interventions in the fragile constitutions of psychiatrically ill men and women, we must not become so detached and separate that we are unable to comfort and connect. Nor should we allow the creeping constraints of economics, the pressures of time management, or the specter of legal intimidation to stifle our natural instincts to hold the hand of a patient whose parent has died, answer a sincere question about our own family life, or accept a simple gift of appreciation. Our measured affection and temperate kindness may be the only sun lighting what is often a chilled and forlorn existence.

Historians of psychiatry may wonder why I did not focus on Freud in this essay, since surely it is his revolutionary work in transference that writes the cautionary tale for friendship in our profession. Yet such a contention misunderstands and misrepresents the master of psychoanalysis, who actually was closer to the humanists in counseling his disciples to benevolently manipulate the inevitable emotions of childhood from both sides of the couch toward the health of the patient. The threat to friendship in psychiatry today comes not from our psychotherapeutic wing but from our biologic camp, which in a headlong rush to be seen as legitimately scientific may have failed to notice that most of medicine, realizing the bankruptcy of this reductionism, is already moving back to the patient-centered medicine of old.5

Dr Geppert is chief of behavioral care consultation and medical director of the substance abuse residential rehabilitation treatment program at New Mexico Veterans Affairs Health Care System in Albuquerque. She is also assistant professor in the department of psychiatry and associate director of religious studies at the University of New Mexico in Albuquerque. This column was formerly entitled "Starting Out" and focused on issues of the psychiatrist newly in practice. Now that Dr Geppert is moving out of the early career phase, her new column, "Windows," will take a wider view of the world of ethics and meaning in psychiatry.

References:

References

1. Drane JF. Becoming a Good Doctor: The Place of Virtue and Character in Medical Ethics. Kansas City, Mo: Sheed & Ward; 1988.
2. Albury WR, Weisz GM. The medical ethics of Erasmus and the physician-patient relationship. Med Humanit. 2001;27:35-41.
3. Illingworth PM. The friendship model of physician/patient relationship and patient autonomy. Bioethics.1988;2:23-36.
4. James DN. The friendship model: a reply to Illingworth. Bioethics.1989;3:142-146.
5. Curlin FA, Hall DE. Strangers or friends? A proposal for a new spirituality-in-medicine ethic. J Gen Intern Med. 2005;20:370-374.