Wednesday, 17 December 2014

'Imbalance of power between patients and doctors: the price of ignoring the shadow' Christian Koeck BMJ


Christian Koeck, professor

Published 15 December 2014;  BMJ 2014;349:g7485 

The price of ignoring the shadow 

"The human capacity to understand the world is truly astonishing. What began with a taste of the fruit from the “tree of good and evil,” has developed into our unlimited capacity to separate, differentiate, define, and analyse. Consequently, the natural sciences have handed humanity previously unimaginable powers to control and shape the world. In the words of Susan Sontag, we have expanded the boundaries of the kingdom of the well and gained control of significant parts of the kingdom of the sick.1

To make this possible, society has provided vast resources to the medical sector and given physicians powers no other profession has: to open the human body, to prescribe potentially lethal substances, and to cut, pierce, and replace organs and body parts. With great powers come great responsibilities and fears. In the “Role of fear in overdiagnosis and overtreatment,” Iona Heath eloquently described the everyday inner conflicts of patients and doctors.2  I want to build on her analysis by exploring the interactions between society and medicine and between patient and doctor.

Analytical psychology teaches us that any need or feeling is balanced by a complementary quality. Early in life we learn that some behaviours are rewarded and make us successful while others are punished or provide no benefits. We develop behaviours that are related to success and suppress those that aren’t. Suppressed feelings become hidden in the unconscious, what jungian analysts call “the shadow.”3

Our ability to separate, define, and categorise underpins our scientific advances. But to survive as human beings we also need to connect and relate. While our scientific abilities make us powerful, our human needs (their shadow) limit our freedom and make us dependent. The complementary feelings to power and control are helplessness and weakness. 

Sickness and the inevitability of death trigger fears of loss of control and power. To cope with that fear, modern society has colluded with modern medicine to promise that disease can be defeated and death postponed, if not avoided. The same applies to the relationship between patient and doctor. Patients yield up power to physicians because one has knowledge and the other is apparently ignorant. Doctors decide and patients follow. Consequently, the patient-doctor interaction is unbalanced, encounters are short, and communication is replaced by diagnostic intervention. The information patients could provide is ignored, devalued, and not used in the search for treatments appropriate to that patient.

Although treatment decisions should be reached co-creatively between experts (one in medical knowledge, the other in the needs and desires of the specific person), communication often runs only from provider to patient. As a result, the disease is isolated from the patient. Separating and categorising are useful skills when analysing problems, but they are not enough when searching for the right treatment for individuals. Relatedness, empathy, and an understanding of co-dependency are necessary for this.

Both sides pay a high price for this unbalanced interaction. Patients often do not receive optimal treatment because their knowledge is never used and their needs and abilities have never been fully understood. Disconnected from their disease and care process, they may be unable to follow the treatment and are consequently labeled non-compliant.

In their turn, doctors feel overwhelmed and suffer from depression, substance misuse, and the highest rates of suicide among the academic professions.4 5 6  From a psychoanalytical perspective, this is unsurprising. Tremendous powers are being given both to the profession as a whole and to individual doctors. But with the power comes the shadow—the complementary fear of failure and feelings of loneliness, isolation, and being overwhelmed.

It is right to be impressed by what medicine can achieve, to feel soothed and calmed by its power to heal and to reduce suffering. The danger arises, however, when doctors let patients, desperate to suppress their fear of suffering and death, seduce them into taking on responsibilities they cannot bear and powers they cannot handle.

It separates patients from their care and leaves doctors in danger of isolation, exhaustion, and unbearable fears of failure. Instead patients need to be handed back the responsibility for their own bodies and diseases. Doctors can provide only help, not salvation.

Healthcare professionals need to recognise their limits and truly accept that disease and death are part of the human condition. They need to understand that successful provider-patient interaction is a co-creative process, involving two experts, interacting on the same level of hierarchy but with different skills. And they need to resist the grandiose expectation that no human can fulfill: the power to defeat suffering and death."


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