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"It is much more important to know what sort of patient has a disease than what sort of
disease the patient has." Sir William Osler, M.D.
The treatment of illness and disease has become a highly technical scientific endeavor.
However, beyond the mechanics, biochemical substrate, and pharmacological
interventions that make up modern medical treatment, the need to heal the patient has
changed little since the time of Dr. Osler. Unfortunately, in the current high tech and
statistically-based environments of "Evidence Based Medicine", "Managed Care", and the
specialization of medical disciplines, the heart of understanding and healing patients has
been all but lost, in favor of the focus upon the details of treatment techniques.
Sadly, this has occurred even within the field of psychiatry, where one might assume there
would be the most respect for the person – but we seem to have slowly but surely moved
from healing people to treating brains and neuroreceptors.
Beyond the specific changes which have occurred within psychiatric practice, this
phenomena has significantly impacted how non-psychiatrists understand dealing with the
emotional and psychological issues that at times accompany, complicate, and/or interfere
with attempts to provide effective treatment for somatic, non-psychiatric maladies.
There is little dispute that there is a complex interface and interaction between somatic
symptomatology, the physiological interventions of modern medicine, and the
psychological substrates of the subject patient. In common language, especially within
the non-psychiatric community, these interactions are often referred to as "stress-related
problems". However, the situation is much more complicated, as “stress” is a generic and
nonspecific term. It is not infrequent that in non-psychiatric medical records, the term
“stress reaction” is used as a diagnosis – but this is no more meaningful in describing
the actual nature or seriousness of the problems or pathology present, than it would be to
use the diagnosis of a “heat reaction” for a patient with a burn injury. Yet way too often, it
is simply assumed that if there is a “stress-related problem” arising, simply prescribing a
psychotropic medication will suffice for addressing the difficulty – when in fact, in the long
term, the addition of these agents at times only obscure, intensify and complicate the
underlying psychopathology which is present, even as psychotropic medications may
reduce some manifest neurovegetative symptomatology, and provide a modicum of acute
The interactions between physiological, psychosocial and behavioral phenomena can take
many forms. On the most basic level, if a patient is not cooperative and compliant with a
physician's instructions, treatment can be compromised, sabotaged, and on occasions,
inevitably futile. Of course, in order to be cooperative and compliant, a patient must
understand and appreciate the importance of the instructions that he or she is being given.
Even in cases which do not involve actual cognitive or developmental impairment, there
are frequently times when psychological and emotional factors may interfere with the
patient’s understanding, acceptance and cooperation – but those issues can easily be
overlooked by a practitioner who is not aware of the psychological dynamics of the
individual person being treated, beyond the issue of their simply being cognitively intact
enough to concretely understand what they are being told. Behavioral responses to pain,
life-threatening illness, loss of physical integrity or identity, etc., are complex, and are
difficult to predict and/or manage unless there is an understanding of the complexities of
the psychology of the particular individual patient.
Additionally, there is the issue of the psychophysiological responses of the body to inner
emotional experiences and affective states – responses which impact, for better or worse,
physiologically based interventions. For example, very simply, a patient who is anxious
and “uptight” will maintain a level of musculoskeletal tension which may prevent the
physiological relaxation which is necessary for optimal responsiveness to various somatic
interventions, symptomatic relief, and healing. On a much more complex level that is only
partially understood, there are complicated interactions between the immune system,
hormonal systems, autoimmune reactions, the nervous system, and even the
dermatological system, which can be triggered by "stress", emotional malaise, anxiety or
dysphoria – and which can impact the efficacy and effectiveness of physiologically based
treatments, even if overt symptoms of clinical anxiety or depression are not present, or
have been superficially contained through the use of psychotropic medications. Simply
diagnosing such a situation as involving “fibromyalgia” oversimplifies the phenomena and
obscures the need to understand and address the particular pathology is emerging and
interfering with the healing process.
While understanding the underlying molecular and biochemical neurophysiological
interactions which form the substrate of these interactions is beyond the scope of this
discussion, it should be self-evident that recognizing the impact of the interaction between
somatic, psychophysiological and psychological factors is important to any practitioner
who seeks to achieve optimal results with a patient, and that this is especially germane to
the practitioner of primary care medicine, and those addressing orthopedic/neurological
In essence, a differentiation must be drawn between medical “treatment”, and “healing”.
When a patient is suffering from an illness or injury, obviously, more often than not,
modern medicine offers a plethora of interventions which can hasten the patient's
physiological recovery. Understanding the physiological disease process can be useful (if
not essential) in devising specific mechanical and/or biochemical/pharmacological
interventions to reduce or even resolve the pathological process present. Simplistically,
surgical intervention can mechanically repair damaged organs, provide for improved integrity of the physical body, support the musculoskeletal system, and excise diseased
tissues; physical cleansing and the use of antibiotics can address infectious processes
and related complications; pharmacological intervention can correct malfunctioning bodily
systems. However, while any or all of these interventions may be absolutely necessary (if
not at least strongly indicated) in the treatment of a disease process or injury – while the
disease may be “treated”, that is no guarantee that the patient will be “healed”.
There is much involved in "healing" which the physician cannot directly control, even on a
purely physiological basis. The actual process of the healing of a wound, the restitution of
healthy tissue, and the regaining of functioning is essentially a natural process which no
physician can completely control. The healing process can be interrupted or disrupted by
a lack of appropriate medical care; and the healing process may be strongly supported,
enhanced, and improved through provision of appropriate medical care – but the actual
healing itself remains a natural, extremely complex, and still rather mysterious process.
However, beyond the objective somatic pathology present, in all but a few cases of illness,
disease, or injury, there are also subjective aspects which come into play. Most
commonly, the subjective aspect of disease is experienced as physical pain, and with
treatment of the illness/injury, pain usually subsides – but that is not always the case.
Subjective responses to illness, disease or injury are not limited to physical pain. A person
may be “improving” or even “fully treated” or “cured” according to objective laboratory and
clinical tests, but he or she still may not appreciate themselves as being in a normal state
of health, i.e., they have not been “healed”. Yet the technical aspects of modern medicine
are largely focused upon treating objective symptoms of illness, disease and injury
through “Evidence Based” modalities, with little or no focus upon promoting the patient to
“heal” in the full sense of the term – which includes not only restoration of physiological
integrity and health, but also a subjective sense of well-being.
Obviously, in emergency or life-threatening situations, the subjective experience of the
patient (beyond adequately controlling pain, and obtaining what basic compliance is
necessary) are of secondary importance to the physiological interventions which are
indicated. However, once the emergent or life-threatening status has been resolved or is
sufficiently reduced, if a physician does not understand the patient in whom the disease or
injury has occurred, the treatments provided may be far less than optimally effective, may
be significantly sabotaged, may be rendered essentially futile, or in the most severe
cases, may even turn dangerously counterproductive.
The question then presents as to how the treating physician, whatever his or her specialty,
can take into account an understanding of the patient in anticipating the possible problems
that may occur in providing optimal treatment, thereby reducing the impact of potentially
disruptive problems, while optimizing and maximizing the chances for therapeutic success
– both in terms of a physiological resolution of pathology, and in regards to “healing the
At the bottom line, after all appropriate treatment is rendered, the basis for the evaluation
of the success of the medical intervention in the perception of the person who has been treated rests in the subjective sense of relief from distress and a return to a subjective
sense of well-being, personal integrity, and hopefulness.
It is in this area where a comprehensive understanding of psychopathology, as provided
by a mental health practitioner, who has performed a complete and sophisticated
psychiatric/psychological evaluation, can be most useful to the treating non-psychiatric
practitioner – especially when communicated in a clear, jargon-free, understandable
manner. This information must go beyond a simple recommendation for prescription of
psychotropic medications, and must convey to the non-psychiatric practitioner a sense of
the person whom he or she is treating; and recommendations for how to best approach
the patient as a person who requires medical treatment. However, in providing only
superficial support to our non-psychiatric colleagues, we are failing them, we are failing
our patients, and we our failing ourselves as mental health professionals who seek to heal
people, rather than simply treat disorders.
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