To Behold a Patient

As I step into the waiting room to greet a new patient, perfume or body odor, the rustle of feet or chirp of a phone, a visage similar in race, gender, and emotional expression to mine, or different, are but a few of the percepts that guide me as I proceed to get to know the person so I can try to be of help. The drama continues to unfold in the office as I respond with attraction, fear, grief, annoyance, or playfulness to the patient’s presentation and the story he tells. Most of this takes place outside my awareness.

Two weeks ago I discussed Eric Kandel’s use of neuroscientific findings about visual and emotional perception to understand how we behold works of art. This led me to wonder what neuroscience has to say about how clinicians respond to patients. Would such a perspective be useful—something clinicians could get their minds around and use in their work with patients? Or would its insights come across as trivial repackaging of familiar concepts, or impractically complex and technical?

Descriptive psychiatry, in the tradition of medicine, uses the mental status examination to observe a patient’s appearance, behavior, language, thought process, mood, affect, content of thought, and cognitive functions. Freud introduced the concepts of transference and countertransference to understand what happens in the clinical encounter. Cognitive therapists emphasize patients’ distorted thoughts, emotionally focused therapists look at feelings as they emerge in therapy, interpersonal therapists focus on relationships, and internal family systems therapists on parts of the personality. As I have discussed, the biopsychosocial model was an attempt to integrate the various domains of patients’ lives and problems, and it was reified in the multiaxial diagnostic systems of DSM-III, DSM-III-R, and DSM-IV. It has always suffered from the paucity of available biological data about patients and from its complexity; it works better as an outline or problem list than as an integrated perspective.

Nevertheless, clinicians of all persuasions build coherent images of their patients. I propose that they do this in the way Kandel describes a beholder’s experience of art, using perceptual, emotional, and relationship data to construct an ever-changing multidimensional image of the patient, which serves as the basis for the clinical alliance and therapeutic work. A patient is far more complex than any work of art, but Kandel’s approach of marshalling what neuroscience has to say about the processes involved in looking at art may be a good place to start.

I am following Kandel’s use of behold, rather than perceive, experience, relate, or empathize, since it carries meanings beyond perception, including holding, regarding, and considering.

We perceive patients with our senses of vision, hearing, smell, and touch. We may take note of our emotional responses to their appearances, behavior, and the stories they tell. We also empathize and share in their experiences on both cognitive and emotional levels. We process this information, using the conceptual models of our professional disciplines to diagnose problems, formulate histories, and assess distorted thoughts and maladaptive behaviors. But this account leaves out whole dimensions of what goes on when we evaluate a patient.

Our brains use nonconscious shortcuts to process information. Visual perception of another person focuses on the face, followed by the hands and overall posture, and very rapidly makes decisions about gender, race, and emotional state. It is likely that similar intermediate-level processing templates operate for hearing, touch, and smell.

At higher, but still nonconscious levels, basic survival circuits help evaluate the incoming sensory information. These include systems for desire (reward), fear, rage, sexual attraction, maternal nurturance, grief, and social engagement. It is easy to reflect on how some patients instantly bring out reactions in these areas. Further, conditioned learning, which involves the reward and fear systems as well as memory, leads us to associate particular patients or their attributes with pleasant or unpleasant experiences. Such associations may involve memories from our own lives, events from previous meetings with the patient, fragments of the patient’s history, or other images, including those from works of art or literature.

At every level, from the earliest stages of perceptual processing to the modifications introduced by the basic survival circuits, to learned associations, these processes are modified by “top-down” input from higher levels such as the prefrontal cortex.

Some of these responses reach our conscious awareness, which involves attention and working memory. Others are more or less available to consciousness—in statuses related to what Freud called preconscious—and can be accessed by focusing on them. These are what some therapists attend to with free-floating attention, trying to “listen” on more than one level at once.

Of what use might all this be to a clinician as she sits down with her patient? Complex neuroscience is far too much to keep in mind as she handles all the behavioral, social, and clinical tasks of meeting with a patient. In any case most of it takes place outside her awareness. Such a neurobiologically grounded model has to be expressed as a set of concepts in language and two- or three-dimensional diagrams, but to be meaningful it would have to operate at deeper levels of the clinician’s understanding of and attitude toward herself. In this sense, it is an extension of psychoanalytic training’s emphasis on in-depth self-analysis to make the clinician a effective instrument of understanding and healing the patient.

Most explications of neuroscience use descriptions of experiments to explain concepts. This is appropriate—even necessary—in science, since it makes clear the sources and limitations of the information. Kandel used works of art to illustrate visual and emotional perception, which took him away from verifiable science, but it made the concepts more understandable and applicable to my experience. Gifted clinical writers like Bessel Van der Kolk, in The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma, and Oliver Sacks in his many books have used clinical and personal examples to illustrate neurobiological concepts. I hope to follow in their footsteps as I seek to further our understanding of what goes on as we sit with our patients.

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