Disclaimer: some doctors have excellent bedside manner and a deep and compassionate understanding of the body’s physical responses to emotions. They take care to understand their patients’ life experiences and to look beyond the purely physical. While these doctors make a point of not pathologizing anxious patients, this article is about those doctors who are lacking in this department and who, therefore, cause patients to feel invalidated.
Clinical Tunnel Vision
The medical profession likes to pinpoint: it seeks reasons that underlie symptoms, and often bristles when one is not found. When patients show up at doctor’s offices reporting vague or difficult-to-describe symptoms, many doctors’ kneejerk response is to test, rule-out, scan, and try to whittle it down to an exact answer. While this is necessary in a scientific discipline such as medicine, human experience is much more nuanced, and not everything can be easily, scientifically, or clinically defined. When some doctors cannot pinpoint a physical problem underlying reported symptoms, their immediate fallback is often to blame the symptoms on the patient’s emotional state. Many patients will be left with conclusions like “it’s just anxiety” or “I can prescribe you Xanax, Clonazepam,” or something from the well of quick-fix anti-anxiety medications. The medical profession excels at diagnosing and prescribing: “here is the problem, here is the solution.” While doctors often investigate deeply into a patient’s physical state, this is less true of the patient’s emotional state.
What is missing in the medical profession is a compassionate understanding of the range of what human beings experience and how these experiences impact their physical wellbeing. Anxious patients, for instance, often experience a slew of physical symptoms including, but not limited to, accelerated heart rate, respiratory problems, hypertension, migraines, muscle and joint pain, and gastrointestinal discomfort. The medical profession fixates on clinical answers to these symptoms, often ignoring other contributing factors, such as what is occurring in patients’ daily lives, their level of overwhelm, the traumas they have experienced, and their ongoing stressors. Treating patients through a humanistic lens can provide a holistic view of their lives and help doctors to better understand why physical symptoms of discomfort may be present beyond the easily diagnosable and identifiable. Many doctors’ unwillingness to look deeper constitutes a clinical tunnel vision that is detrimental to patients.
The “Neurosis” Label
Doctors who struggle to see through a humanistic lens and jump quickly to concluding that patients without clear physical diagnoses are “neurotic” jump from A to Z and fail to take into consideration anything in between. For some doctors, when there is no clinical answer, the only answer is that the patient is emotionally disturbed. This type of harsh labeling of anxious patients is neither reassuring nor healing. Rather, it promotes shame, humiliation, and a sense of rejection from the very professionals to whom patients go for reassurance and a sense of safety. The very idea that anxious people are “neurotic” is an antiquated notion. Freud viewed neurosis as an unusual or extreme reaction to stress, which only served to further the belief that the neurotic person was behaving in a nonsensical or “crazy” manner. And, almost a century later, some medical professionals still view anxious clients this way: they are acting “crazy,” being “extreme” or “ridiculous,” or are out of touch with reality.
The psychological literature on neurosis dates back at least a half-century. In the first half of the twentieth century, for instance, the psychoanalyst Karen Horney authored two books with neurosis in the title, and there were scores of others written by a variety of psychologists, psychiatrists, psychoanalysts and medical experts. In these texts, neurosis was described as a disorder of hysteria, attention-seeking, narcissism, and irrationality. This designation and understanding persisted for decades and, in fact, it was only in the mid-1980s that the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) officially removed the term “neurosis” from its collection of psychological disorders. At the time, this resulted in an immediate outcry from many diagnosticians, particularly those from the “old guard” and the era of Horney and her contemporaries. Doctors who maintain this outdated view of anxious patients reveal their ignorance of the nuance of human life.
A Humanistic and Existential View
While Freud and Horney were on the right track in pointing out that stress and anxiety often underlie what they termed “neurotic” behavior, they failed to connect these underlying factors to normal human experiences. Had they done so, they might have cultivated a humanistic and compassionate view rather than a harsh and pathologizing one. Stress and anxiety are experienced by all humans; the daily complexities of our lives and of the world in which we live contribute to these common human emotions. Patients who are made to feel that these responses are abnormal, ridiculous, or neurotic are bound to experience clinical invalidation. We understand now that our physical systems respond to emotional stimulus to an extent that these early psychologists did not. Read Bessel van der Kolk’s The Body Keeps the Score, Peter Levine’s Walking the Tiger, or any of the recent titles on the intersection of the emotions and the body and you will recognize this undeniable connection. But not all in the medical profession have caught up. There are still doctors who view anxious patients as neurotics and who do not devote the time or the effort to investigating the important connections between life stressors and physical symptoms. Perhaps they feel it is “unscientific” or not aligned with the medical profession’s adherence to the model of investigate>diagnose>prescribe. Whatever the reason, this approach does a grave disservice to patients and promotes continued suffering.
Fears about disease, physical decline, and death are so common to the human experience that they hold a continued place in literature, art, film, song, and other expressions of our stories. There is an existential component to physical health that cannot be ignored. Disease and death are great unknowns: we know neither when they will happen nor what they will feel like. To deny fears related to illness and non-existence or to view them as “silly” is to invalidate the larger experience of being human. Yet some in the medical profession often do just that: those patients who are labeled as “just being anxious” are made to feel that this is abnormal; but seen existentially, feeling anxious is anything but abnormal. The medical profession’s rigid focus on the scientific method leaves little room for viewing patients’ lives and circumstances through an existential lens and connecting life experience to physical and somatic experience. This is not to suggest that doctors should double as therapists or philosophers but, rather, that a little understanding of how existential concerns impact peoples’ physical functioning can go a long way toward creating a validating environment.
Pathology vs. Humanism
Pathologizing normal and commonly-experienced human emotions should be considered a form of harm to patients and a direct violation of the Hippocratic Oath. While not as blatant as botching a surgery or missing a cancer marker, the psychological and emotional damage of rigidly defining and labeling human experience through harsh clinical and medical terminology can last a lifetime. Once branded a “hypochondriac,” a “phobic,” or a “neurotic,” a patient may become averse to necessary medical treatment or to dealing with doctors and live with lingering feelings of shame. Does this mean that all doctors should be required to take courses on humanism and existentialism? Not necessarily, but they should, in the interest of holistic and compassionate treatment, be aware of how these factors influence and affect physical functioning.
When medical professionals make a concerted effort to understand their patients’ life experiences and current circumstances deeply and compassionately rather than focusing only on physical symptoms, they are writing the most valuable prescription, one that says, “you are understood, you are heard, and I do not judge you for your body responding to your experiences in this uncomfortable way.” It is time that the clinical intersects with the human in the medical profession. If doctors can recognize that no patient wants or choose to feel anxious, overwhelmed, worried, or panicked, or to suffer the physical responses to these emotions, they might think twice before they rush to medicalization of commonly experienced problems.
Beyond “Diagnose and Prescribe”
Rigid adherence to the model of “investigate, diagnose, prescribe” limits patients’ treatment options to those that are mainly pharmaceutical. This is not to say that there is never occasion when a medicine intervention is helpful but, rather, that the frequent medicalization of commonly experienced problems can limit other interventions and be detrimental to patients. Patients who are hesitant to begin medications, particularly antidepressants, benzodiazepines, or anxiolytics are often viewed as being “difficult” or non-compliant. Doctors rarely investigate underlying reasons why patients might be medication-hesitant. And many do not mask their frustration with these patients. Further, some doctors balk at the idea that anything but medication can be helpful to patients. In truth, however, a number of other evidence-based interventions and therapeutic modalities such as Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, Mindfulness-Based Cognitive Therapy, Rational-Emotive Behavioral Therapy, and others can be as effective in the treatment of anxiety as traditionally prescribed antianxiety medications or can work successfully in tandem with these medications. But some doctors’ unwillingness to take this type of integrative approach, and their inflexibility in terms of their long-accepted diagnostic model can severely limit patients’ sense of autonomy in their own treatment.
The anxious patient is often unwittingly caught between the clinical and the humanistic. They are often immediately pathologized for self-reporting very human challenges, such as anxiety or panic, and backed into a diagnostic corner of being labeled and medicated. As a clinical social worker and psychotherapist, I have found throughout my career that, in many cases, it is challenging to consult with medication prescribers on patients’ behalf. Some are simply unwilling to cross their knowledge base with mine; others choose to view medication and psychotherapy as completely separate entities that cannot not work in concert; still others reject the idea that talk therapy can be as helpful as medication. Whatever their reasoning, these prescribers ignore an important opportunity to view their patients’ treatment options holistically and creatively.
Integrating the Clinical and the Human
A sea change is needed in the medical professions’ tendency to pathologize everything and anything that comes into a medical setting. For the sake of this article, let us assume that the opposite of pathologization is humanization. Pathology assumes and concludes whereas humanism seeks to understand and takes a curious approach. If doctors can work towards integrating both a patient’s unique life experiences and situations with a clinical understanding, patients will be left feeling validated and treatment can be designed with their best interests in mind.
While this type of integration might be an idealistic notion, sometimes a paradigm shift is necessary to realign the incongruencies in longstanding and rarely-questioned systems. Primary care and psychiatry have taken on an institutional stature in the United States, to such an extent that they are rarely, if ever, questioned or challenged to adapt. But, as our lives and experiences become ever more complex, the medical profession must honor this reality by continuously seeking adaptive means of treating patients with dignity, respect, and in the interest of support and healing rather than of labeling and pathologizing.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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