What do psychiatry and paediatrics have in common?

It’s a question I like to pose to medical students and junior doctors.

Sometimes I’ll point out that they obviously both start with a “p” but I’m looking for a deeper similarity. Can you think what it is? On a few occasions I’ve had a student catch it: they’re the two specialties where patients are very likely to have been brought to hospital without their having chosen to, and sometimes even against their will.

In psychiatry and paediatrics we really have to earn the patient’s trust.

That’s not to say other doctors don’t, of course. But when you choose to see a surgeon or a heart specialist, there’s a degree of trust that’s implicit in the interaction. If you very much expressly distrust them you could simply not go. And even where you go because your family are insisting on it, the doctor at least gets to benefit from the family’s trust. But that would be off the table were you to feel betrayed by said family.

Trust is essential to the doctor-patient relationship.

It has to be, given the degree of vulnerability required on the part of the patient. And in mental health, you’re invited to expose something even more intimate than your body: your secret thoughts and fears.

And yet so often the doctor offering that invitation is without the benefit of the trust required for that to happen. Not always, of course: we do often get people who choose to come to hospital because they know they need the help. But the distrust is frequent enough that one needs to be conscious of and prepared to engage it.

So how do we engage it? That’s where the therapeutic relationship comes in.

When Sigmund Freud coined the term, “therapeutic relationship”, he intended it to describe the relationship between therapist and client. And while over time it’s come to take on the broader meaning of the relationship between healthcare professionals and patients in general, it’s still used mostly in mental healthcare, where trust from our patients is not something we typically get to take for granted.

There are two ways we can think about the term. In its stricter sense (as Freud intended it) the therapeutic relationship is the foundation on which ongoing treatment is laid: it’s sort of a safe space in which the patient can trust the doctor enough to open up and be vulnerable enough for their healing to take place.

But more than being only a foundation, I’ve also come to think of the therapeutic relationship as itself treatment, just like it says in the name. This is especially more so because while relationships are a huge aspect of our support structures, they’re also often a major reason why we suffer. So the therapeutic relationship offers the patient a template for a different way of relating, or a space to practice different approaches, and they can take what they learn back into their everyday lives.

Because at the end of the day, being human is about being in relationship, and that in turn is about trust.

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My thanks to Jannis Lucas for the photo.