I often sit in on our psychiatry residents’ visits with patients. During one recently, I was reminded of reading Martin Buber when I was in college. Good doctors—certainly good psychiatrists—must establish what Buber called an I-it relationship with patients: objectively collecting, synthesizing, and hierarchically organizing data, maintaining appropriate boundaries and neutrality, formulating a working diagnosis and treatment plan. But without simultaneously establishing an I-thou relationship—involving an ineffable mélange that includes love, empathy, and spiritual connectedness with a companion soul—the clinical encounter is cold.
At a pragmatic level, cold encounters usually result in patients who don’t return, non-adherence to treatment recommendations, and little clinical benefit. Practitioners who can’t put aside checklists and allow a free flow of emotion and experience often “miss the boat” and may not help a fellow human in need.
A while back a resident was evaluating a patient. Going through his standard questions to rule in or out major depression, he asked the patient about her sleep. She said she hadn’t slept very well since a recent incident with her husband. The resident checked a box about insomnia and went on to questions about suicidal thoughts. When he had finished, I followed up and asked the patient about her marriage. The tears flowed, vital information emerged, and our formulation of the problem and treatment recommendations changed.
DSM-III, IV, and presumably V have brought reliability to psychiatric diagnoses. Someday genomics presumably will add validity to our nosology. We should follow the rules of the DSM to ensure clear communication and fidelity with best-practice treatment guidelines. Measurement-based care and evidence-based medicine are watchwords of modern practice and to be honored every day.
But there is a vital role for I-thou, which in no way conflicts with a scientific and objective approach. It’s the human part of the complex equation of two people sitting with one another. In his daily physician’s prayer, the twelfth-century physician and philosopher Moses Maimonides wrote, “In the sufferer let me see only the human being.” Amen.
-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry