Is It Right For Physicians To Take A Parental Role With Patients?

A pair of recent studies looked at different modalities for following patients on weight loss programs. One study compared patients who received  in person follow up from primary care providers versus those who received telephone and web based follow up to those who got nothing at all.  Patients in either follow up group experienced twice as much weight loss after one year than those who had no follow up at all (there was no difference between either follow up intervention).  The other study looked at the effectiveness of in-person “life coaching” on weight loss results and also found it to be significant. 

While the impact of this in terms of weight loss indeed could be huge I also believe this study raises an interesting question about doctor patient relationships and boundaries that is worth exploring.

The overall message of the studies was that patients in both groups who had any kind of follow up with their primary care providers (be it in person, on the phone or web based) experienced better results in losing and maintaining weight than those who did not.  With 2/3’s of Americans overweight or obese, any intervention that can help patients maintain weight loss has the ability to improve millions of lives and should therefore be utilized. The authors hailed the study as a breakthrough in helping patients battle obesity.

“It could be considered something of a breakthrough in weight loss,” said Dr. Frank Sacks, a professor of Cardiovascular Epidemiology at the Harvard School of Public Health who participated in the second study.

While this intervention may be effective in the laboratory the question remains about how this impacts doctor patient relationships in the clinic and if this impact is ethical or fair?  If adult patients are reporting their weight loss to physicians does this not place the physician in a paternalistic or parental role to the patient and if so is it appropriate for doctors to take advantage of this role in clinical practice?   

The hidden dynamic among all human relationships, and especially those between doctors and patients, is a phenomenon called transference.  Transference is the process whereby one individuals unconscious emotional perceptions influences their participation and behavior in a relationship.  The perceptions are usually very powerfully influenced by early childhood influences.

For example a person who had a poor relationship with little verbal communication with a male caretaker early in life may have a difficult time communicating with other male authority figures later in adulthood.  

Transference is classically thought of as a part of psychiatry and psychotherapy, but all doctor patient relationships (and all human relationships) are deeply influenced by the unconscious subjective perceptions of the participants. 

In my coursework with the New England Society of Clinical Hypnosis I will never forget the words of the brilliant hypnotist  and former NESCH president Dr. Max Shapiro who surprised me in a seminar many years ago when he said: “If a patient comes to you with a deific or mystical transference  about hypnosis don’t be afraid to use that in your work with them.”  

Shapiro felt that using the patients unconscious feelings of awe or mysticism around hypnosis (which is often held in such mystical esteem) to their  advantage could be a useful intervention towards reducing symptoms and improving their lives.  Could the same be argued in this situation regarding a patients parental transference to the physician? 

The doctor patient relationship already intrinsically has a parent child tinge to it by it’s inherent nature.  Consider the things that physicians typically provide to patients.  Empathy.  Nurturing.  Moral, emotional and physical guidance.  The very essence of the relationship evokes a parent-child dynamic between the doctor and provider that is unavoidable.

When patients report their progress in weight loss to the doctors does this not place the physician even more in a parental role with the patient?   The physician becomes the source of praise and approval or of disappointment and disapproval like a parent around a critical issue in the patient’s life.  This takes advantage of the parental transference-countertransference between the doctor and the patient and may produce results but is it appropriate?.  Consider that patients with serious behavioral health problems often lack psychological maturity in some way.

There are no right or wrong answers to this question but it is worth thinking about: Should physicians be placing themselves in a position where they can take advantage of the parental transference countertransference dynamic that exists between them and their patients?    It could produce results but is it ethical and fair to adult patients who ultimately would be best served by empowering themselves to ensure their own wellness without reliance on a professional’s praise or approval?  Could taking on a parental role with a patient eventually provoke feelings of rebellion and disobedience (often a part of parent-child relationships) that may undermine the purpose of the intervention eventually?   Should doctors dare to take advantage of this mechanism in patients who lack psychological maturity?

It is likely that right or wrong these interventions will become more widely used because of the results they showed in these studies but I believe these are important questions to ask.  

A Fundamental Flaw In Modern Psychiatry?

There is no question that as modern psychiatry has evolved it has become a powerful force in the United States.

The field underwent a major shift in paradigm the past 30 years.  Psychiatrists used to work mainly with behavioral modalities like different kinds of therapy to encourage self exploration and change, but modern psychiatry has focused on the use of powerful psychoactive drugs to alter behavior.  Psychiatrists previously spent hours in therapy with their patients but today most psychiatrists get less training in therapy in residency and in clinical practice usually only do 15 minute medication visits with patients.  In these visits they prescribe powerful medicines and inquire about side effects from drugs and leave the therapy to psychologists and social workers.  

Psychiatrists have left the therapy couch behind and transitioned mostly to drug based therapies based on the idea of biological psychiatry.  This is the basic concept that a "chemical imbalance in the brain" can be treated with a "precisely tailored" medicine.  While this concept sounds great in advertisements and commercials a closer look shows that the science is behind these "chemical imbalances" is not well defined and the drugs used are hardly precise and often have bad side effects.

The true causes of psychiatric illness goes beyond a simplified chemical imbalance and remains a nebulous combination of psychological, environmental and biological factors that probably varies tremendously among individuals.   The danger is that in actual clinical practice the treatment option most individuals get now from doctors is a drug that alters brain chemistry in a very imprecise way, but mental problems happen on many different levels.

These underlying chemical imbalances may not be well defined in mental illness, but psychiatric drugs have a place in medicine and if a doctor prescribes one a patient should NEVER stop taking it until they have an in depth conversation with the prescriber.   

As this paradigm shift has happened physicians are confronted with the danger of not considering the depth and complexity of most behavioral problems for the individual.  Advertisements and commercials make these drugs sound simple and many doctors place patients on these drugs without much thought, but be advised: Psychiatric drugs are complicated and have serious pros and cons that must be carefully considered.  The decision to start one should never be taken lightly or glanced over.

There is no doubt that part of mental illness is biology.  There are clearly functional, physiological and anatomical changes in the biology of the brain that are associated with different acute and chronic mental and emotional states.  Yet there is murky evidence that any of the biological mechanisms altered by psychoactive drugs actually cause  the "diseases" these drugs treat.  Altering these mechanisms may help change symptoms much like tylenol helps a back ache but that doesn't mean deficiency or disorder in these areas cause clinical disease.  After all, no one would argue that a lack of Tylenol causes backache. 

As Modern Psychiatry has become overly reliant and focused on drug therapy it has lost sight of the human side of behavior. It has stopped seeing the "forest for the trees" and forgotten that every illness occurs in the context of social, cultural, behavioral and psycho-spiritual factors, not simply biology.    Medicine and Psychiatry often try to drug people to meet our arbitrary cultural standards of normal and abnormal (and disease and health), when often the emotional and behavioral states of individuals are natural to that individual, appropriate based on circumstances and have potential for positive change through non-pharmacologial, human centered modalities.   

In a perfect world much thought would be given to the decision to start high functioning adults on any psychoactive medicine.  These drugs would not be routinely handed out with minimal consideration of the whole person's body, mind and spirit.   And the paradigms that doctors use to view behavioral problems would address the existential roots of human problems.


 Over the next few weeks we will present a series of topics in modern psychiatry where we look specifically at the pro and cons of drugs, investigate the science behind behavior and hopefully provide useful information to help people understand modern psychiatry better. The first topic is going to be on antidepressant use so stay tuned!