The Patient-Therapist Relationship: Secret of the Care

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“…Time, sympathy, and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”  

 – Francis Peabody, MD

 Therapists (e.g. advanced practice psychiatric nurse, psychiatrist, and psychologist) should initially make sure that they know a patient’s name and that the patient knows the therapist’s name.  They should introduce themselves to other people who have come with the patient and should find out whether the patient wants another person present during the initial interview.

 Qualities of the caregiver:

  • Imperturbability: the ability to maintain extreme calm and steadiness
  • Presence of mind: self-control in emergency
  • Clear judgment: the ability to make an informed opinion that is free of ambiguity
  • Ability to endure frustration: the capacity to remain firm and deal with insecurity
  • Infinite patience: unlimited ability to hear pain
  • Charity towards others: to be generous especially to the needy and suffering
  • The search for absolute truth: investigate facts and pursue reality
  • Composure: calmness of mind and bearing
  • Bravery: the capacity to face or endure events with courage
  • Charity towards others: to be generous especially to the needy and suffering
  • The search for absolute truth: investigate facts and pursue reality
  • Composure: calmness of mind and bearing
  • Bravery: the capacity to face or endure events with courage

Confidentiality:

As much as physicians must legally and ethically respect patients’ confidentiality, it may be wholly or partially broken in patients’ situations. If a patient makes clear that he or she intends to harm someone, the therapist has a responsibility to notify the victim.

Countertransference:

Emotions breed countermotions. For example, if the care giver is hostile, the patient becomes hostile; the care giver then becomes even angrier than before and the relationship deteriorates rapidly. Rising above such emotions involves being able to step back from the intense countertransferential reactions and explore why the patient is reacting in a self-defeating way. If the therapist can understand that the patient’s antagonism is in some ways defensive or self-protective and most likely reflects transferential fears of disrespect, abuse, and disappointment, the doctor may be less angry and more empathetic.

Empathy:

Empathy is a way of increasing rapport. An empathetic therapist may anticipate what is felt before it is spoken and can often help patients articulate what they are feeling. Patients sometimes say “How can you understand me if you haven’t gone through what I’m going through?” Clinical psychiatry, however, is predicated on the belief that it is not necessary to have other people’s literal experiences to understand them. The shared experience of being human is often sufficient.

While much early work on this subject was generated from a psychodynamic perspective, researchers from other orientations have since investigated this area. It has been found to predict treatment adherence (compliance) and concordance and outcome across a range of client/patient diagnoses and treatment settings. Research on the statistical power of the therapeutic relationship now reflects more than 1,000 findings.

Schizophrenia Spectrum and Other Psychotic Disorders, DSM-5

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To make it easy on psych students.

A diagnosis of Schizophrenia is quite debilitating on the patient and his/her family, that’s why it is crucial to distinguish between Schizophrenic patient and other disorders on its spectrum.

Schizophrenia diagnosis is made when you have at least one of the following: delusions, hallucinations, or disorganised speech in addition to catatonic behavior or negative symptoms (e.g., diminished emotions expression). the latter symptoms must persist for at least 1 month, and continuous signs of the disturbance must persist for at least 6 months.
Brief Psychotic disorder is relatively easy to distinguish from Schizophrenia since the symptoms must be present for less than 1 month.
Delusional disorder on the other hand, can be diagnosed when the criteria mentioned above in schizophrenia are never met, and the functioning of the patient is not as impaired as in schizophrenia.
Schizoaffective disorder can be considered as schizophrenia coupled with severe mood disturbances, and the clinician can specify whether its bipolar type or depressive type.
Last but not least, the schizophreniform disorder is similar to schizophrenia but with lesser impairment in functioning. Research shows that patients with schizophreniform disorder are more receptive to treatment and report less remission rates compared to those with schizophrenia.

Always make sure that the psychotic disorder is not substance induced and is not due to another medical condition (e.g. brain tumor, multiple sclerosis)