As a clinician, I believe strongly in the patient-centered approach to behavioral health. This strategy has shifted the power dynamics in treatment, away from the expert telling a patient what’s wrong with them and what the patient needs to do to fix it. Instead, the patient-centered approach focuses treatment on the patients’ identified needs and treats individuals as autonomous self-experts who know themselves best.
It’s important to note that the patient-centered model was largely pioneered in the field of treatment of those with intellectual disabilities. For decades, these services included inhumane treatment of such patients. Lawsuits and reform forced the field to become much more adept at seeking out and identifying a patient’s needs, rather than treating all patients as the same, and simply making decisions for and about them.
But even in the field of treating individuals with intellectual disabilities, a patient-centered clinician must sometimes find ways to meet a patient’s needs, recognizing limitations and abilities. I was recently asked to consult on a case of a patient with cognitive impairments, who desperately and obsessively wanted to drive a car. Unfortunately, legal limitations and this patient’s abilities made this illegal and impractical. I encouraged the clinical team to work with the patient in a different manner, responding, validating and affirming his desire, but working within limits. I suggested they explore things such as driving video games, driving simulators, driving go-karts in a closed course, and so on, working to support and affirm the patient’s needs, but not supporting something which was or would be impossible.
As I challenge the field of sex addiction, I’m often accused of being rejecting of patient’s experiences, as they walk in the door and state that they feel addicted to sex or porn. A naïve, simplistic patient-centered approach would assert that in this case, the patient’s belief in addiction is all that’s needed for diagnosis. Essentially, this strategy is based on an aspect of post-modern thought, wherein a person’s experience or truth, is inherently valid, and more valuable than larger, systemic theories. Post-truth politics is a related modern political culture, wherein debate is based on appeals to emotion and personal conviction, and where facts or data are discounted.
"We often illustrate this dilemma with a medical parallel. A patient walks into his doctor’s office and says “Doc, I have cancer.” And the doctor says, “Well, at least we don’t have to run all those tests. Let’s start treatment.” —Braun-Harvey and Vigorito (p. 57)
The “trust your patient’s self-diagnosis” model is rooted in modern social trends. But, is this good medicine? Is it ethical, and effective clinical care? I once went to my doctor, convinced that I had developed pneumonia. I’d had it before, and knew what it felt like, I’d researched the symptoms. (Thanks, WebMD.) "Just give me the antibiotics!" I said. My doctor examined me, informed me that my symptoms were the result of allergies, and sent me home to rest. I humbly accepted her expertise. A recent study from Sweden found that only 50% of people who self-identified as having “hypersexual disorder” actually met the criteria which were developed for this disorder, which was itself ultimately rejected by the DSM 5. Research on the self-identification of sex or porn addict consistently finds that this self-identity emerges from a moral or religious conflict over sexual behaviors, and that these individuals are not on average having more sex or watching more porn than anyone else – they just feel worse about it. Though individuals and therapists commonly report that self-identified sex addicts have problems with impulsivity and executive function (planning and self-control), multiple studies find that in actual testing, this just isn't true.
“These are among the most challenging patients seen in urology practice today: a young, healthy man with neither systemic disease nor a history of trauma, who has complaints of ED. These men often have co-morbid diagnoses, such as anxiety, depression, or mood disorders, which make the issue of ED more complex for both the patient and the urologist. The psychological burden of ED in these young men is more pronounced than it might be in older men as this is the phase of life during which many men expect to be highly sexually active. These young men are usually technologically savvy and may have scrutinized much of the readily available information on the internet regarding ED. Often they arrive to clinic armed with an understanding of the diagnostic evaluation that may be offered to further investigate the etiology of their concerns. This makes the evaluation and treatment of these men more challenging since additional diagnostic testing is often not indicated after a thorough history and physical examination. In many cases, they may have self-diagnosed and self-treated based on the information that they obtained prior to seeing a physician. Many of these men will see multiple urologists on their quest to find a pathophysiology that they can accept, and many have unrealistic expectations of a rapid cure or a surgical cure….It may also be beneficial to refer the patient to a sex therapist or counselor though many young men will reject the idea that there is a psychosocial element to their ED and may refuse to consider therapy.” —Reed-Maldonado & Lue (2016)
Clinical care today has the challenge of potentially dealing with upset patients who have access to the Internet. Online, we can educate ourselves about what we think our problems are, and their cause, and what the right treatment is. But a Google search doesn’t equate to advanced clinical training. An online bulletin board discussion isn’t the same as a second opinion. Sadly, these resources can be misused, leading to some people being described as “cyberchondriacs,” and many doctors reporting that it is challenging to treat patients who believe they know more than their doctors. This is why the field of medicine exists, as opposed to the pharmacy and medical field being a “self-help” and self-prescription aisle at Walgreens. We need more skepticism in the clinical field, from both patients and clinicians, so long as it is framed within a caring, empathic and supportive framework.