The Psychotherapy of Hope: The Legacy of Persuasion and Healing

9 Psychotherapeutic Communication in Medical Settings

CHAPTER 9 Psychotherapeutic Communication in Medical Settings Arthur M. Freeman III, M.D. . . . hopelessness can retard recovery or even hasten death, while the mobilization of hope plays an important part in many forms of healing in both nonindustrialized societies and our own. —persuasion and healing, 1991, p. 132 The conceptual blueprint for psychotherapy outlined in Persuasion and Healing has particular relevance for those who provide psychotherapy in medical settings (Frank and Frank 1991). This chapter explores how Jerome and Julia Frank’s emphasis on the power of therapists’ conceptual orientation, the commonalities of all psychotherapies, and the role of demoralization as a final, clinical pathway applies to the care of hospitalized patients who are medically ill (see also chapters 4, 7, 8, and 15 in this volume). As Jerome Frank proposed, disciplines related to the persuasive arts—specifically, rhetoric—also contribute substantially to the relief of distress for patients of all kinds, including those who have serious medical conditions (Frank and Frank 1991). Beyond medical psychotherapy as a clinical and technical intervention, psychosomatic medicine in general and consultation-liaison psychiatry in particular would benefit from further application of Frank’s ideas, as discussed at the conclusion of this chapter. “Take care!” cried Alice. “You’re holding it all crooked!” And she caught at the brooch; but it was too late: the pin had slipped, and the Queen had pricked her finger. “That accounts for the bleeding, you see,” she said to Alice with a smile. “Now you understand the way things happen here.” —Through the Looking Glass Psychotherapeutic Communication in Medical Settings 179 Justifying Therapy: Medical History as Apologia Medical care typically begins with a patient’s account of symptoms, which the examiner scrutinizes primarily for clues to an underlying disease process. This “history of the present illness” is, in Frank’s terms, an “apologia.” Patients’ accounts provide an essential but imprecise guide to diagnosis, necessarily limited by the ambiguity of language. As the patient adapts to the clinical setting, the apologia may shift in response to the examiner’s questions. For example, the patient who first describes a distressing, band-like pain in the head after an argument will be prompted to clarify whether the pain is better or worse in particular positions, associated with visual changes, and so on, until the examiner can decide between it most likely being a tension headache or a brain tumor. While the medical questioner follows the logic of pathophysiology, many patients either lack a “coherent plot that explains why the experience occurred” or offer a story based on personal factors that have little specific medical relevance . A medical encounter that leaves patient and doctor in alignment involves closing the “hermeneutic circle” by the construction of a mutually satisfactory story, be it medical, personal, or both. When some objective test explains the story, the physician, at least, feels gratified. When, as often happens, definitive resolution proves impossible, validation of the story becomes an ongoing process without a clear end point. If the physician and patient negotiate a common understanding—for example, “being upset makes your neck muscles tense, and that causes pain”—the story seems at least partly validated, though for the patient the meaning of the pain may have many other dimensions. Thus, even in medical encounters, truth resides in plausibility rather than in objectivity. Truth can be an interpretation that “is the most satisfying or makes the most sense” to the patient. Psychotherapy in any setting requires the mutual construction of a new clinical history (Frank and Frank 1991, pp. 24–39). As implied in the simple example above, psychotherapy applies as well to medically ill patients as to those with belief-related, emotional or behavioral problems. Stress is a foundational concept for understanding psychotherapy in the context of medical care. Stress typically structures the plot of the stories that patients recount. Psychotherapy may play a useful role when patients either seek relief for physical symptoms related to stress or are unsuccessful in adapting to the stress of physical ailments. 180 Arthur M. Freeman III Psychotherapy cannot treat organic illness directly, but it does restore patients ’ morale in the face of disease. The corresponding concept of stamina, or resilience, in the face of stress varies across patients, conditions, and treatment settings. At one extreme, most people require moderate stress to promote good health. Excessive, uncontrollable stress, by contrast, may make mild disease worse and serious disease fatal. Stress, moreover...