When I was training to become a clinical psychologist, my supervisors gave me several pieces of great advice. One told me that the psychologist or therapist is the expert on mental health treatment and research but the patient or client is the expert on their own experience and symptoms. I didn’t realize it then, but this supervisor was preparing me to practice participatory medicine. Psychotherapy is ideally a collaboration between the patient, who brings their knowledge of their mental health concern, and the clinician, who brings expertise on effective therapies. Together, they figure out which therapies are going to work in this particular situation and for this particular problem.
I often explicitly communicate this approach at the beginning of therapy. I will sometimes tell patients that while I may be the expert on effective therapies for depression and anxiety, they are the experts on what they are feeling. And I need to hear about their experience and when the therapies need to be adapted or changed based on that experience. This encourages patients to share their feelings and concerns and disagree with me if that is what is true for them. Sharing experiences of mental health symptoms can be hard for patients due to stigma, disbelief from friends and family and bad experiences with previous providers. Directly encouraging them to share their feelings and concerns can both validate their experience and promote a more open clinician-patient relationship.
Sometimes this collaborative approach can be difficult for providers. Most go through more than a decade of specialized training and think of themselves as experts in their area of practice. It can be scary to approach the relationship as one of two experts working together. It can be even scarier to think about proposing a therapy or treatment plan the patient disagrees with, adding some additional information about why that plan will not work. I try to view these situations, where a patient disagrees or provides new information that counteracts my treatment plan, as providing important information. For example, if I validate a patient’s anxiety and the patient says they shouldn’t feel anxious, that tells me something important about the patient’s experience. Maybe their family is not understanding about their anxiety. Maybe they feel ashamed about their anxiety because they cannot do everything they want to do. Regardless, when a patient disagrees with me, I realize that there is something important I need to know to help this patient that I do not yet know.
Once I was working with a client on anxiety from panic disorder. Panic disorder is when panic attacks are triggered by changes in bodily sensations like an increase in heart rate or breathing rate. I took this client through the usual, evidence-based therapy for panic disorder, but she did not improve and frequently did not complete homework assignments between therapy sessions. I had a conversation with this client and encouraged her to describe what she was feeling and what she felt was not working in therapy. She described the anxiety in greater detail. Eventually it became clear that while this client might have panic disorder, she also had Generalized Anxiety Disorder. And she reported the worry from the Generalized Anxiety Disorder was actually the greater problem. We discussed possible treatment plans and decided to switch the focus of therapy to Generalized Anxiety Disorder.
This idea of the healthcare provider and patient as two experts may seem more applicable to psychotherapy but can be relevant to all medical disciplines. If a patient responds to a yes or no question with a long answer or a “kind of,” that gives the provider important information. Maybe the patient has another concern that hasn’t been addressed yet, or that they are scared to bring up. Maybe the questions are not getting to the root of the patient’s problem. Regardless, the patient is the expert of their experience and any response–or non-response–can help the healthcare provider understand that experience.
Dr. Salene Jones is a clinical psychologist and behavioral scientist. She studies how financial hardship affects health as well as policy changes to address financial hardship. She also is a psychometrician who creates patient-centered measures of quality of life.
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