The Person with the Diagnosis

At the dawn of medicine as we know it, Hippocrates made the following observation: “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” In an era of genetics, sophisticated understanding of neural pathways, extraordinary imaging capability, detailed analysis of neurotransmitter systems, and deep brain stimulation, we have gotten somewhat distant from the point that Hippocrates tried to convey. The psychodynamic perspective is more valuable than ever. Indeed, the core of psychodynamic psychiatry is to look at each individual as a person with highly individual, even idiosyncratic features. This core principle of good psychiatric practice, and even good medical practice, may be obscured by our progress in so many areas of “hard science” in our field.

Defining exactly what we mean by the “person” can be a formidable challenge. The starting point may be the self, but unfortunately, the self is no easier to define than the person, and most would agree that the self is only an aspect of the person. To begin with, the self is both subject and object. To say “I think of myself” captures this dual function—the first half of the sentence refers to the phenomenal “I” of philosophy, while the last half of the sentence refers to the self as a representation. The self is also defined as the aggregate of personal memories and the social personas associated with them, but we are all thoroughly familiar with the selectivity of memory.

To compound things further, part of the self is conscious and part of the self is unconscious. We are masters of self-deception, and we try to avoid the full conscious awareness of all aspects of ourselves. In brief, we hide out from ourselves. Another feature of the self is that it has multiple aspects that appear based on one’s company, one’s mood, one’s experiences of the previous few hours, and one’s anticipation of what one is about to do. We regularly see in the course of psychotherapy that as one learns about the multiple facets of the self, they actually start to experience themselves as a more coherent individual.

Self-development, of course, is steeped in culture. Hence, any mention of self-definition must include the influence of the culture that shapes the self. In some Asian cultures, for example, an interdependent self is created by parenting that focuses on social context. Hence, the person is not centered in self-experience in the way that many Western cultures are.

The self is not the same thing as the person, though, because it leaves out the way that others see us. We live in a dialectic between the self as experienced versus the self as observed by others. Both perspectives have some validity. When we see ourselves on videotape, we are generally alienated by what we see and hear. We may think that we don’t look as we do on video and that our voice doesn’t sound the way it usually does. Others beg to differ while we recoil in horror. The inevitable conclusion from such experiences is that we don’t see ourselves like others see us no matter how hard we try. Nonetheless, others cannot always see how we feel inside because they have an outside perspective. So knowing who the person is requires an integration of the inside perspective of the patient and the outside perspective of the clinician. Good psychotherapy oscillates between empathic attunement with what is in the inner world of the patient and a more objective view of how the patient comes across to others.

In this brief overview of this concept, we can conclude that there are multiple determinants of the “person”: (1) the subjective experience of one’s self based on the unique historical narrative that is filtered through the lens of specific meaning; (2) a set of conscious and unconscious conflicts (reflected in defenses), representations, and self-deceptions; (3) a set of internalized interactions with others that are unconsciously reenacted, creating specific impressions in others; (4) our physical characteristics; (5) our brain as a product of the interaction of genes and environmental forces and the creation of neural networks by cumulative experiences; (6) our cultural/religious and social affiliations; and (7) our cognitive style and capacities.

What are the treatment implications of this point of view? We do not treat disorders in isolation. In fact, we treat a “person” with the disorder. Similarly, to access the “disorder,” we first need to form a relationship with the person so the patient feels comfortable and understood in a discussion about the symptoms and the distress brought about by the disorder. The “person” of the clinician must also be taken into account—specifically, that “person” interfaces with the “person” of the patient. Another implication is that treatment is not simply a series of “procedures.” The therapeutic relationship appears to be far more important than a specific technique in predicting outcome.

There are many obstacles to getting to know the “person” in psychiatric practice. There is a reason this construct is being ignored and neglected in contemporary psychiatry. Clinicians and patients alike tend to dislike complexity. We prefer simple reductionistic thinking whenever possible. Getting to know the “person” takes time, and time is money in the current health care market. Moreover, getting to know the person may be unsettling to the clinician—it may lead us into dark corners of the psyche that we are not prepared to address. Nevertheless, many of us are attracted to psychiatry because it is a specialty in which getting to know the patient is a cherished value. Let us not forget this guiding principle in an era of reductive thinking and “quick fixes.” ■