Psychology
2013. Vol.4, No.6, 506-509
Published Online June 2013 in SciRes (http://www.scirp.org/journal/psych) http://dx.doi.org/10.4236/psych.2013.46071
506
The Doctor-Patient Relationship and Self-Stigma*
Gavril Cornuțiu
Clinic of Psychiatry, University of Oradea, Oradea, Romania
Received March 8th, 2013; revised April 11th, 2013; accepted May 9th, 2013
Copyright © 2013 Gavril Cornuțiu. This is an open access article distributed under the Creative Commons At-
tribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
The text is an analysis of the relational complex in a therapeutic space. Analysis started from the need to
perform a medical act depending also on understanding these aspects. In the therapeutic process, diagno-
sis and treatment in their classical sense are just two of the aspects of a relational type interpersonal real-
ity, which is much more complex. In fact, doctor-patient relationship is part of a relational system includ-
ing the patient, his family, the physician and society. The four factors interact with each other, and the fi-
nal result, the result that has a therapeutic effect on the patient, is a synthesis of all these interactions.
Stigma is a pathological psychological product affecting all relations. Stigma is usually part of the collec-
tive mind, but also part of individual psychology. When stigma affects a patient’s mind, its effect is pro-
foundly anti-therapeutic. In psychiatry these relations are more important than in any other medical field.
The brief analysis of these relations, in the therapeutic context of a patient, is the subject of the following
text. Understanding all these aspects has a direct effect on the quality and performance of the medical act.
Keywords: Doctor; Patient; Therapeutic Relationship System; Stigma; Therapeutic Effect
Introduction
“Saluti et solatio aegrorum”. This is the slogan written on the
entrance lobby of the Psychiatric Clinic in Oradea. It means
“sooth and assist the suffering”. Outside this motto there can be
no human medicine, nor veterinary medicine, but perhaps some
cold and inhumane robots.
Therefore, the basis of any medicine is the empathetic
relationship between people and their knowledge. Only then, on
this basis, comes therapy, with its spectaculous evolution to
date. Conservatori temporibus. The things succeed one another
but the first ones give the definive tone.
Second of all, as Aristotle proves in his “Politics”, “any
society is built with a view to achieve something good”, and the
memebers of a society pair up in the leader-subject type of
relationships, in inseparable pairs. One without the other makes
no sense. The physician and his patient form such a pair (Ari-
stotle, 2005). One without the other is meaningless.
The patient is, therefore, a constitutive part of our definition
as physicians. Consequently, we have to approach him as we
approach ourselves, with the same warmth, understanding and
scrupulousness.
Third of all, after thousands of years of medical practice,
man has discovered that complete health is possible only if the
person is happy. Happiness is part of the definition of health. If
health is the only positive diagnosis, then this diagnosis cannot
be given without assessing the level of happiness. And if
getting healthy is not the ultimate goal, then medicine becomes
a series of patches. So, the discussion about happiness cannot
be avoided. This is a very unexpected and extremely delicate
consequence. If anybody would try to explain that it is possible
to draft a happiness scale, they would be considered, ab initio,
mindless persons regardless their academic status. Untamed
reason often runs wild. It would be as if somebody would state
that they can measure the intensity of a kiss with a ruler, ac-
cording to the size of the mouth.
In conclusion, three out of the five most fundamental reasons
of the medical act seem impossible to assess with the same
means as giving a diagnosis or treating a disease. If people limit
themselves to diagnosis and cure, without considering the other
fundaments, then they are Procust-like, cutting their most hu-
mane essence from their dimensions.
That is the reason why current methods of diagnosis and
treatment or the current state of profession cannot possibly be
satisfying for people as humans or as professionals. People
must not forget that before being doctors they are human beings.
And every human being has a story. The ICD or the DSM or
other scales used are Procustian tools which shape a disman-
tling, non-unitary and incoherent person. It cannot possibly be
denied their huge help when organizing the workplace and as a
work tool station, but they are not the house in which human
beings live, wanting to re-give to their own self in their full
well-being.
The scales expose the patient statically. The static approach
is for things, not for phenomena. The normal or the pathological
psyche, the human being in general, is a continuously evolving
phenomenon. A patient is a different person after his medical
history has been taken. A well-done, tactful and professional
anamnesis restructures the thoughts and feelings about the dis-
ease, about the own self and about the others. These things
must be acknowledged so that static objects are not confused
*This paper is a supplemented, revised, translated version. The previous
version was published in 2010 in Revista Romana de Sanatate Mintala,
2010, 1: 20-23. http://issuu.com/lrsm/docs/www.lrsm.ro

G. CORNUȚIU
with phenomena and realities in general.
Naturally, nature sciences (of a series) require quantifications.
These quantifications are impossible in the sciences of singu-
larities (for instance, history). The psyche, besides the aspects
of its generalities, is also a singularity. The generalities are
derived from and consequences of its biological under-layer
and are quantifiable. The singularity of the psychic derives
from heredity and its ontogeny; that is why each phenotype is
unique. It may be compared to the light which is both quant and
wave at the same time. To regard the psychic only through its
generality (quant) would be a pitiful reduction and it would lead
to errors of approach and understanding.
So far, psychology (the science of the healthy mind) and
psychiatry (the science of the ill mind) have approached the
psychic either in its generality or in its singularity. There is a
need for a synthesis which would give unity to the two aspects
of the psyche. This is not possible unless the genetic heritage
and the ontogeny are systemically integrated. For the time be-
ing, this is only possible at the level of sums. The synthetic
unity remains a dream, but, at least, one more step is taken
towards fulfilling it.
Every generation restated, sometimes loudly, that the mo-
ment had arrived for a quality leap, for a synthesis which would
use all good discoveries of the minds and hearts of the previous
generations of physicists, and then, step by step, all was aban-
doned in the exclusive favor of novelty. A state of accumula-
tion has been reached which should enable people to become
wise.
Historical Data about Reflection These
Principles in the Medical Practice
There is a tendency for the current generation to proudly and
stupidly pretend that they have an undeniable superiority in
thinking compared to other generations. This pride has its ori-
gins in ignorance, partly. But if one examines carefully the
older or the ancient, one may have surprises which warn us to
be modest. Thus, 2049 years ago (Ösler, 1921), Varro in De Re
Rustica was talking about “tiny organisms which cannot be
perceived by the naked eye and which get inside the body and
cause diseases”. Or, in 16th century Venice, Fracastorius was
talking about “contagious germs passing from one person to
another”. Of course, the techno-scientific complex of the time
could not capitalize such thoughts, but the performance of
thinking in a sector of (series) nature allows people to trust the
performance of the thinking back then, especially when it re-
ferred to singularities.
In this context, R. Iftomovici (2009), remarks that, before
medicine, the shamans based their therapeutic exercise on the
valence of uniqueness. Their discourse, addressed to Sprits or
Secluded or Malefic Forces, was often imploring: “Help him”,
“Make him stronger” etc. or imperative: “Go away!” or “Get
out” etc.
Of course, the extra religious awareness must not be attrib-
uted to the shaman act, but the intuition of the role of the va-
lence of uniqueness must be noted.
In a papyrus dating from Ramses I times (1314 BC), it is said
that “the incantations are excellent in boosting the effect of the
medicine, and the medicine does the same for the incantations”
(Iftimovici, 2009).
Approximately one thousand years later, in the Hippocratic
Corpus, in the book about proper behavior (ibidem), there is the
concept of thenai, which stated that medicine is both science
and art. The science addressed the human generalities and the
art referred to human uniqueness. The art implied talent to
“know how to ally with the patient’s soul in the healing act. For
this, the doctor must not offend the family”, “to accept the
consultation from other colleagues” etc. The Hippocratic Oath
in itself makes reference to the moral aspect and to the relation
of uniqueness in the medical practice (Cornuţiu, 2004).
Aristotle makes a very profound remark: “... and we notice
that the doctor in general does not heal even though he pos-
sesses the medicine but there is another principle which urges
him to act according to science, but not because of science”.
The more direct explanation of this statement is to be found in
Plato, who says: “I would earn people’s respect but I would sin
against the gods” (Plato, 1993). In a different culture, Confu-
cius’, this truth sounds as follows: “The philosopher says: the
one who knows the principles of right reason does not equal the
one who loves them; the one who likes them does not equal the
one who makes them his own pleasures and practices them”
(Confucius, 1994). This is the same duality in unity: quant and
wave, series generality of nature and uniqueness of phenotype.
The necessity of synthesis and the respect for the harmony
between the two aspects of the same unique reality was also
noticed by Albert the Great, who wrote: “there seems to be a
unique nature of things whose essential act is one” (Albert the
Great, 2001). Saint Augustus was also preoccupied by these
relations and he emphasized the characteristic of the human
uniqueness grained in affectivity. He said: “for those, it is
enough to believe, to hope and to love” (St. Augustus, 1992).
The history of science comprises a consistent blend of gener-
ality and singular subjectivity. In 1927, the famous science
philosopher (Calvin, 2007) Bertrand Russel remarked, banter-
ing in an English manner the psychology and the psychophar-
macology laboratory research: “the animals studied by the
Americans swoop, hectically almost, with unbelievable agita-
tion and energy, and, in the end, almost by chance, they get the
desired result. The animals observed by the Germans sit still
and think and, in the end, they develop the solution in their
inner conscience”.
All these are connected with understanding diseases and pa-
tients and they determine the attitude towards patients. In order
to limit the subject, return to the partiality stated in the title is
needed. It is remarked what J. Z. Sadler (2005) concluded as
historical evolution: “in the western medical practice, the ideal
of the doctor-patient relationship has evolved since the second
half of the 20th century towards equality as the ethical ideal”.
All these are supported by the presence of the informed consent,
by the necessity of discussing the therapeutic options with pa-
tient, by the recommendation of reaching a therapeutic decision
together, etc.
This evolution of the contractual and relational content of the
medical act is not merely the translation of the evolution of the
general (theoretical) conception in reality, but also an evolution
of the collective thought, which differs from geography to an-
other, in spite of the homogeneity imposed by globalization.
Thus, this attitude is natural for the Anglo-Saxon population,
but in Hispanics it may signify insecurity on behalf of the doc-
tor who emphasizes these aspects, or even incompetence, as they
prefer the authoritarian attitude, which they associate with com-
petence and confidence. These are reflexes of the two cultures
and are impossible to abolish, the catholic shadowing a strict
hierarchical order from God downwards and the protestant

G. CORNUȚIU
leveling the humans.
The spiritual level of the human being must not be over-
looked (the human being is bio-psycho-socio-spiritual, with
four levels). According to psychoanalysis, in the western cul-
ture, the self is governed by internalized believes. In Asian
cultures, the self is determined by social relations and responsi-
bilities.
These cultural differences of the historical state must be
pointed out because they determine the degree of inner freedom
of a person. Moreover, they ingrain in the collective thought of
a group and, as is well known, the placebo or anti-placebo ef-
fect is not dependant only on the patient or physician but also
on other people’s (the patients’ social groups) opinion about the
treatment. In front of every patient these generalities must be
shaded for personal success and the well-being of the patient.
Medical and Psychological Outlooks
According to O’Brien and Houston (2007) “a big part of
what a therapist does could be called research”. This fact could
also be set in relation to the current medical paradigm: “person
centered medicine” (Mezzich, 2008), because each case must
be examined (investigated) in its domestic, professional, social
and cultural context. Therefore, the patient’s truth is expressed
by every specialist attending the case, but every specialist no-
tices the part of the truth belonging to his specialty. General
medical practice states: “interpersonal relationship and infor-
mation are inter-twined as essential cornerstones of healthcare”
(Tonang, 2006). This is confirmed by daily practice: “Lower
use of medication treatment, poorer doctor-patient communica-
tion, and depression stigma are key contributors to mental
healthcare disparities among Latinos with depression” (Interian,
Ang, Gara, Rodriguez, & Vega, 2011). The patient, his convic-
tions and emotions are seen in the center of the relational com-
plex: “Patient trust has an impact on patient satisfaction, ad-
herence to medical prescription, and continued enrollment”
(Holbeck, 2011). In this relationship: “Patients seek doctors
who can provide treatment and cures to allow them to return to
their daily routines. Physicians practice medicine hoping to
successfully diagnose and treat people with illnesses” (Rabin,
2010). Family and social settings of the patient-therapist rela-
tionship are set. Brought to the gates of reason are the four
instances of the therapeutic relational complex: patient, doctor,
family and society. By saying society, the overall society
framework and everyone else, closer or more distant to the
patient is understood.
The Psychiatric Particularities
From the things mentioned above it can be infered that the
accurate diagnosis and an accurate “technical” approach of the
treatment are not enough to maximize the effectiveness of
therapy. The maximum of the therapeutic effectiveness regards
the entire rational complex of a disease. This complex is a syn-
thetic combination of the relation between four factors: patient,
doctor, society and family, each interacting with the others (the
relational complex consists of 12 types of relations as seen in
Figure 1).
As presented in the diagram above the accurate “technical”
approach of the treatment regards only the patient and the doc-
tor in the direction doctor-patient and less on the direction pa-
tient-doctor, which is already a different relation with a differ-
ent content.
Patient Doctor
Family Society
Figure 1.
The therapeutic relationship system.
The doctor-patient relationship has a consistent and neces-
sary scientific and rational content. It may become a failure
unless this is taken into consideration. The patient does not only
expect competence from his doctor, but, according to his struc-
ture, human sympathy, sometimes peer-like, other times par-
ent-like and affective warmth for his security and comfort and
especially for his protection of dignity as a creature “fallen to
the ground”. From a therapeutic perspective this means patients
have unconditional trust in their doctor, which is a primordial
premise for the placebo effect, which translates into therapeutic
compliance. If the non-compliance rises to 40% - 50% in
cardio-vascular diseases, in psychic patients (especially schiz-
ophrenics) it rises up to 70%.
In addition, comfort, security, self-esteem and dignity re-
statement are the four factors which allow the recovery of the
reality function in psychotic patients. This is the long term ef-
fect of the seriousness of the relation doctor-patient taken the
other way around—patient-doctor.
Therefore, doctors are just one of the factors that influence
the therapeutic evolution of a patient. Another rational category
is the doctor-family and its other-way-around—family-doctor
relationship. The five types of families must be mentioned:
harmonious, overprotective, the family of double signal, the
cold family and the overemotional family, each type having a
specific impact on the emotional evolution of the patient, on his
existential and future security, on his comfort and degree of
solicitude (Cornuţiu, 2004). All five types of families require a
different approach in order to understand the disease and they
must be trained specifically for the future relationship with the
psychic patient among them. The indirect psycho-therapeutic
contribution is essential. It must be mentioned that, for instance,
within the same time unit, 15% of schizophrenics decompen-
sate in a harmonious family, while in an overemotional one
50% do so. The counseling and training of these families has a
direct effect on the patient-family relationship, harmonizing the
patient’s primary group affectively. It is pivotal to his social
insertion. Without it, the patient’s social insertion may be
scarce because the family is the barest and the most representa-
tive image of the world he lives in. All this means that the pa-
tient cannot be approached only as a patient because he has
increased affective psychological needs which are different
from the needs of a psychologically healthy person, who is self-
confident.
As Sadler remarked (Sadler, 2005), “any disease is an ethical
public case” which leads to a social redefinition of the person
who became ill. The diagnosis therefore establishes a new ratio
individual-society. This is extremely important because “not
every psychotic crisis evolves into schizophrenia” (Calvin,
2007) and if schizophrenia is tempestuously diagnosed (no
matter how right it may seem) it becomes a contribution to the
psychotic patient’s definitive disconnection from the reality.
Schizophrenia is nothing more than an evolving subtype of the
508

G. CORNUȚIU
first psychotic episode. This thing does not only depend only on
diagnosis but also on the limitation to a set of “bare necessities”
of the treatment (according to vulnerabilities). Nothing is more
devastating for the patient’s self esteem and his hopes than the
diagnosis of schizophrenia. The psychotherapeutic preparation
of giving this diagnosis has an immense therapeutic effect as it
annihilates self stigma.
This may make the patient understand—through dignity,
self-esteem and hope—that his disease is a natural one among
other diseases, which all have their “ailments”, and should walk
tall in society. If “stigma may spring from lack of understand-
ing” (Radden, 2004), self stigma springs from the same lack of
understanding. All these are necessary because “psychic dis-
turbance rarely lead to total and definitive inability of auton-
omy, most of the times there is only an intermittent inability”
(ibidem). Annulling self stigma allows the psychic patient a
reasonable social functioning, according to the completeness of
the remission, which validates him socially, thus altering his
perception of the disease and lowering his stigma.
In this direction, the norms of good medical conduct: the pa-
tient’s right to choose his therapist, his right to an explanation
of disease and treatment, his right to consent internment and
treatment, his right to refuse treatment, etc. all have the pur-
pose not only to protect the patient from a juridical point of
view, but also to reduce self stigma with all its consequences
previously mentioned.
These are the ribs of an adequate doctor-patient relationship
in general and doctor-psychiatric patient in psychiatry in par-
ticular, which can be defined as indirect psychotherapy in case
of adequate medical practice and as failed psychotherapeutic
act in case of neglecting the good practices. They can be given
different meanings in psychiatry, considering each type of psy-
chiatric suffering and their enriching connotations, but they do
not alter the central topic of the general rules generated on the
12 types of contextual relationships in case of disease, in which
the doctor is only one of the four factors in the relation.
Conclusion
Developing a rating scale for self stigma is needed. It could
bring benefits in understanding and optimizing therapeutic
steps through evolutionary studies on pathological groups be-
tween minimal self stigma groups and maximum self stigma
groups. A third step could be the development of means to fight
self stigma.
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