“The good physician treats the disease; the great physician treats the patient who has the disease.” – Sir William Osler.
The focus of person-centered medicine is to treat people with dignity, compassion, and respect. However, we are living in a new world where there is a threat of commercialization and commodification of medicine. On the one hand, there are rapid innovations in medical technology with increasing dependence on investigations. On the other hand, most physicians are unable to find adequate time to spend with their patients or clients. How are we going to face this challenge?
Person-centered care rooted historically in both ancient eastern and western medical texts and gained further prominence in the past few decades. Of particular significance is the publication of the WHO global strategy on integrated people-centered health services 2016–2026, which garnered relevance to the need for a paradigm shift in the current models of care to a more balanced, wholistic, and person-centered approach. The power differentials are prominent in all fields of medicine, but particularly relevant to the field of psychiatry, and one would see them serving as a barrier to an effective health-care delivery, as an important factor mediating discussions around the need for such a shift. The work of Foucault and his position on biopower and biopolitics serves as an essential framework to understand these power differentials and how it serves as a barrier to an effective health-care delivery.
The Need for a Person-Centered Approach in Psychiatry
Mezzich et al., in one of their seminal publications, write “Nowhere has the tension between a reductionistic focus on disease and the consideration of the whole person been more apparent than in the mental health field.” He further speaks about the need for promotion of a psychiatry of the person (of the totality of the person’s health, including both ill and positive aspects), for the person (to assist in the fulfilment of each person’s health aspirations and life project), by the person (with high ethical aspirations), and with the person (in respectful collaboration with patient, family, and advocate constituents). The authors have further argued for the need for a faster shift to person-centered approach in psychiatry, especially in the context of a pandemic. The failure of biological reductionism, growing inequalities (and the role it plays in the predisposition, precipitation, and perpetuation of mental health problems exposed further during the COVID-19 pandemic), the shift away from approaches that focus on a meaningful therapeutic relationship, and futility of applying western models of diagnostic and therapeutic approaches to cultures where the relevance is questionable makes a strong case for these person-centered approaches to take center stage in psychiatry.
The need to tackle health inequalities must be an immediate priority for governments and public health systems across the world. The past decade has seen growing evidence for the impact of widening inequalities and its impact on health. The social determinants of health are closely linked to mental health and illness. Marmot’s work spanning many decades, and the 10-year review of his initial report throws light on the current state and interventions that governments and public health bodies need to prioritize to tackle health inequalities. The six key themes that his report suggests to tackle inequalities include developing a national strategy for action on the social determinants of health with the aim of reducing inequalities in health, ensuring proportionate universal allocation of resources and implementation of policies, early interventions to prevent health inequalities, developing the social determinants of health workforce, engaging the public and developing whole systems monitoring, and strengthening accountability for health inequalities. These strategies are rooted in the principles of person-centered care and would serve as a blueprint going forward to reduce the health inequalities.
In keeping with the theme of person-centered care, there is a need to develop strategies centered around the principle of coproduction. Coproduction is defined as an ongoing partnership between people who design, deliver, and commission services, people who use the services, and people who need them. The role and value of lived experience in shaping the policy building and service delivery are crucial. Recommendation 8 of the Five Year Forward View for Mental Health called for the development of evidence-based approaches to coproduction in commissioning in the United Kingdom. As these strategies grow in evidence base, one also needs to be aware of the barriers to effective coproduction and for these interventions to not become yet another tick-box exercise. In an article titled “Coproduction and mental health service provision: a protocol for a scoping review,” the author speaks about coproduction having the power to “create lasting organisational change as it “changes the way services view service users and family members-from passive recipients to active participants-assets to mental health services.” He also warns, however, that this “change in perspective can meet resistance from traditional service providers as they may have a different perspective of what the concept of recovery is.” There is a need to measure the outcome, sustainability, and the impact of coproduction in the long run.
A meaningful and effective therapeutic relationship is a key to any doctor–patient interaction, and particularly in mental health settings. Any intervention that takes the clinician away from establishing a meaningful therapeutic relationship is likely to have an impact on the recovery.[8–10] The essence of person-centered care revolves around establishing meaningful therapeutic relationships prioritizing the person and their culture, environment, and social milieu. The field of precision psychiatry and computational models to understand and deliver person-centered care has gained momentum in the past decade. While “precision” models offer hope in personalizing care to the individual, it is also important to contextualize and understand the ethical implications of using such models while delivering person-centered care and to not let the narrative of “precision” overrule therapeutic relationships.
Kleinman talks about the role of culture in cross-cultural research on illness and the relevance particularly to mental health. He also draws the reader’s attention to some of the pitfalls of the highly influential WHO studies from earlier years that paved the way for the development of some of the categorical classificatory systems. The concerns Kleinman raised about these studies in this paper are still largely unaddressed. He speaks about the “tacit professional ideology which functions to exaggerate what is universal in psychiatric disorder and de-emphasis on what is culturally particular.” He further explains the relevance of anthropological approaches to clinical and research in mental health and how it offers hope over the “controlled cross-cultural comparisons.” Kleinman draws your attention on how categorical fallacies operate in the popular classificatory systems further demonstrating the need for anthropological inquisitiveness in psychiatrists. The role of ethnography and reflexivity in person-centered care is well established.[13,14] Anthropological and cultural curiosity serve as tools to implement meaningful person-centered care. The shift to understand the person as a whole, including the social, cultural, political, and spiritual milieu, and not just as a part will make this medicine more adapted to the current times.
The Open Dialogue approach and interventions based on this approach have garnered some momentum in the past decade. In this article, authors talk about what in inherent to the Open Dialogue approach as an approach which “emphasizes the practitioners’ capacity for empathy, presence and listening. It avoids interpreting others’ experience through symptom-focused diagnoses.” The key component of Open Dialogue approach is “network meetings” involving the family and social networks and listening to their experience. The transparency of the approach and the joint decision-making “recognizing diversity” and “mitigating power differentials” align with the pillars of person-centered care. There is a focus on the need to shift our narratives from “risks” to “relationships” in such approaches. The evidence base of Open Dialogue approach for the first-episode psychosis in adolescent age group in Finland is well established, and evidence from other parts of the world is still emerging.[16–20] Most studies have demonstrated encouraging outcomes. At the heart of this approach are person-centeredness and the need for fundamental shift in the way we view therapeutic relationships in medicine, and particularly psychiatry.
A shift to person-centered care would have implications on training and curriculums around the world. There is a need for curriculums to evolve from the “one-size-fits-all” approach to personalized programs focusing on developing key skills that are relevant to the current times. The shift to focus on the person more than the illness is a key to that evolution. An article published in 2020 highlights some of the training implications for the Royal College of Psychiatrists. Decolonizing movements have garnered momentum in certain pockets, and the challenges it face are highlighted in this article. To quote the authors, “we must acknowledge the way in which psychiatry has played a role in the suppression of indigenous healing systems around the world, how it was complicit in the justification of slavery and colonisation and how profoundly a particularly ‘Western’ mind-set underscores its deepest assumptions and theories.”
Medical specialties cannot exist as independent entities outside of the events that shape human life and suffering. The key events in the past decade and political turmoil around the world have shifted the focus to inequalities operating in our societies. The impact of this on medicine, and particularly psychiatry, is significant. There is an opportunity to introspect, improve, and fix the identity crisis that has plagued physicians, and particularly psychiatrists. The key is to move away from the futility of biological reductionism that has defined psychiatry and also to introduce criticality into our science and practice. To quote the authors from this article, “Rather than contracting in an exclusive focus on biologic structure, the field needs to expand if we are to meet the needs of real people in the clinic, on medical wards, and out in the community who require comprehensive, relational care to address their suffering effectively and humanly.” At the heart of all these is a shift to relationships and person-centered care. With huge treatment gap, which is as high as 80% in many low- and middle-income countries, we have to reorganize mental health services to make it more person-centered. We need a shift from hospital-based care to care in the community and mental health integrated in primary care. Most clinicians are content with a bio-medical explanatory model, but this is insufficient in many instances. Spiritual orientation and religious faith are important to many people, and they may emerge as key factors in healing. Person-centered care also involves prevention of illness and promotion of physical and mental health. Enabling people to recognize their strengths and potentialities will help them lead a more fulfilling life. As we move forward in these challenging times, we must never forget to remain respectful to patient’s beliefs and values!
Note: This paper was presented with the Venkoba Rao Oration Award at the XXIX National Conference of Indian Association for Social Psychiatry, Agra, 18–20 November 2022.
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Conflicts of interest
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