THE DOCTOR-PATIENT RELATIONSHIP ANDITS HISTORICAL CONTEXT1

THOMAS S. SZASZ, M. D., WILLIAM F. KNOFF, M. D., �MARC H. HOLLENDER, M. D.2

522

The doctor-patient relationship in itshistorical context depends on the medical(or psychiatric) situation and the socialscene. By medical situation is meant thetechnical task at hand and the availablemeans to cope with it. The physician’s andpatient’s capacity for self-reflection andcommunication, as well as their specialtechnical skills, are included in the categoryof “medical situation.” The social scenerefers to the socio-political and the in-tellectual-scientific climate of the time.

In a previous article Szasz and Hollender(12) delineated 3 basic models of the doc-tor-patient relationship. These are (a) ac-tivity-passivity, (b) guidance-cooperationand (c) mutual participation. Activity-pas-�ivity refers to those instances in which thephysician does something to a patient whois completely inactive (or passive). This isnecessary whenever the patient is un-conscious (e.g., comatose, anesthetized).Guidance-cooperation presupposes that thephysician will tell the patient what to doand the latter will comply or obey. Bothparties are “active” and contribute to therelationship. The main difference betweenthem pertains to status and power. Mutualparticipation designates a relationship inwhich ihe doctor-patient contract is es-sentially that of a parthership. The physi-cian helps the patient to help himself. Thismodel is particularly applicable to themanagement of chronic illnesses, to psy-choanalysis and to some modifications ofpsychoanalytic therapy. The models areillustrated in Table I.

Employing these conceptual models, wepropose in this essay to present an histori-cal overview of certain changes in thedoctor-patient relationship. Since our in-terest is primarily in calling attention to

1 Read at the 114th annual meeting of The Ameri-

can Psychiatric Association, San Francisco, Calif.,

May 12-16, 1958.

2 From the Department of Psychiatry, State Uni.

versity of New York, Upstate Medical Center,

Syracuse, N. Y.

correlations between social conditions andmedical practice models, we shall commentonly on a few historical periods. These willbe offered as vignettes to illustrate our

thesis. The following epochs and theirconcomitant doctor-patient patterns willbe considered: 1. Ancient Egypt (approx.4000 to 1000 B.C.). 2. Greek Enlighten-ment (approx. 600 to 100 B.C.). 3. MedievalEurope and the Inquisition (approx. 1200to 1600 A.D.). 4. The French Revolution(late 18th century). 5. Central Europe(late 19th century). 6. The contemporaryAmerican scene (post World-War II).

ANCIENT ECYPT

From earliest times, man feared helpless-ness in an unknown universe. In his owndefense he invented methods of coping withanxiety. Implicit in these methods has beenman’s belief in an ability to manipulateevents, to control and direct nature in hisown behalf.

The doctor-patient relationship, whichevolved from the priest-supplicant rela-tionship(2), retained the belief in anability of a parent-figure to manipulateevents on behalf of the patient. Fearinghelplessness, sickness and death, man hasattempted to master nature by means of1. Magic and mysticism, 2. Theology and3. Rationality (or science). Each of theseevolving belief systems, with its particulartechnology, has served the healing art.Healers have been in the past (and con-tinue to be in the present) magicians,priests and doctors. With the developmentof social organization, or civilization, thehealing role became institutionalized assorcerer, shaman, priest and physician.Each was imbued with the metaphor ofmagic. At various times, these diverse heal-ing roles have existed side by side in thesame society; they may also co-exist inthe role-functions of a single individual(e.g., the shaman). As the functions ofinstinctive self-help and mutual aid weregradually institutionalized into specialized

1958 1 THOMAS 5. SZASZ, WILLIAM F. KNOFF AND MARC H. HOLLENDER 523

TABLE 1 *

Three Basic Models of the Physician-Patient Relationship

MODELPHYSICIAN’S

ROLEPATIENT’S

ROLE

CUNICALAPPLICATION

OF MODELPROTOTYPEOF MODEL

1. ACTIVITY-PASSIVITY

2. GUIDANCE-COOPERATION

3. MUTUAL PAR-TICIPATION

DOES SOME-THING TOPATIENT

TELLS PATIENTWHAT TO DO

HELPS PATIENTTO HELP HIMSELF

RECIPIENT (UN-ABLE TO RESPONDOR INERT)

COOPERATOR(OBEYS)

PARTICIPANT IN“PARTNERSHIP”(USES EXPERTHELP)

ANESTHESIA, E.C.T.,ACUTE TRAUMA,COMA, DELIRIUM,ETC.

ACUTE INFEC-TIOUS PROC-ESSES, ETC.

MOST CHRONICILLNESSES, PSYCHO-ANALYSIS, ETC.

.

PARENT-iNFANT

PARENT-CHILD(ADOLESCENT)

ADULT-ADULT

�

* A slightly altered version of a table which appeared originally in Szasz, T. S., and Hollender, M. H.:

A Contribution to the Philosophy of Medicine. The Basic Models of the Doctor-Patient Relationship.

A.M.A. Archives of Internal Medicine, 97: 585-592, 1956.

healer roles, status-role differences betweenhealer and sufferer appeared for the firsttime.

Describing the treatment process, Siger-

ist stated:

The magician came or the patient was broughtto him. After some preparation, some purifica-tions, the magic words were spoken, some riteswere performed, and all was over. In manycases this was probably enough for the pa-tient who was under great nervous tension tofeel suddenly improved or even cured (6).

Even ancient Egyptian medicine, how-ever, was not devoid of empirico-rationalfeatures. These were largely limited to thetreatment of externally visible disorders,such as fractures. Problems of “internal”medicine-like those of psychiatry-presentcertain observational difficulties in the faceof a “naive” (culturally unsophisticated orchildish) approach. Thus an infusion ofmagic in connection with these medicalendeavors has persisted much longer thanin relation to external and visible parts ofthe body. Even today, children-and peoplegenerally-have many more fantasies (and

“fantastic” ideas) about the insides oftheir bodies than they do, for instance,about their hands or feet.

It seems unlikely-and this is largely anassumption, since we possess little informa-

tion on this subject-that in ancient Egyp-tian medicine the activity-passivity type ofrelationship was ever altered. Neither thesocial circumstances nor the technical tasksand tools available were such as to require

a modification of this relationship.

CREEK ENLICHTENMENT

As Zilboorg noted, “Hippocrates lived inan age unique in history. . . It was theage of Hellenic enlightenment”( 13).

In about the fifth century, B.C., theGreeks developed a system of �medicinebased on an empirico-rational approach.By this it is meant that they relied in-creasingly on naturalistic observation, sup-

plemented by practical trial and errorexperience, abandoning, as much as theycould(2) magical and religious explana-

tions of bodily disorders. Singer, forexample, described the Hippocratic writersas

clear-eyed observers, unmoved in theirpursuit of truth by any preconceived view ofits nature, uncorrupted by the jargon of theschools, naked heroes of science facing theworld as it is and not as it may be thoughtto be(7).

Hippocrates’ rationalistic orientation canbe best illustrated by the famous statementattributed to him concerning epilepsy:

524 THE DOCTOR-PATIENT RELATIONSHIP 1 December

As for this disease called divine, surely it toohas its nature and causes whence it orginates,Just like other diseases, and is curable bymeans comparable to their cure (7).

In carrying empirical medicine to newheights, the Greeks were among the first

to �emphasize and develop what has be-come an historically important schism,namely, the separation of medicine (andscience) from religion (and ethics). Po-litically, too, they were among the firstnations to evolve toward a democraticform of social organization. They recog-nized the desirability of equality, at leastamong the elect (i.e., among the nobility

or “non-slaves”). Guidance-cooperation,and to a lesser extent, mutual participa-tion, were the characteristic patterns ofthe doctor-patient relationship. The Hip-pocratic oath, while overfly a code ofethics for the physician, is, in a less obvioussense, also a “Bill of Rights” for the pa-tient. The rules of the game (as it were),codifying the physician’s prescribed atti-tude toward his patient, were defined, inpart, as follows:

The regimen I adopt shall be for the benefitof my patients according to my ability andjudgment, and not for their hurt or for any

wrong . . . Whatsoever house I enter, therewill I go for the benefit of the sick, refrainingfrom all wrongdoing or corruption, and es-pecially from any act of seduction, of male orfemale, of bond or free. Whatsoever things Isee or hear concerning the life of men, in myattendanae on the sick or even apart there-from, which ought not to be noised abroad, Iwill keep silence thereon, counting such thingsto be as sacred secrets(8). (italics added).

This oath is of considerable interest fromthe point of view of the doctor-patientrelationship and its connections with theprevalent socio-political pattern of its time.Not only does the Oath reflect the con-temporary ethical ideal of democracy for-and equality among-the free citizens ofthe state, but it rises above it and com-mands a higher level of humanism. Webase this inference on the Hippocraticinjunction to accord the same humanprivileges to the “bonded” patient, forslave, as accorded to free citizens of thestate. Hippocratic tradition raised medicalethics above the self-interests of class and,

by implication, nation. This supranationalconcept of health as an ethical value per-sists to this day, but it has undergoneimportant reverses during practically everymajor war and social upheaval.

MEDIEVAL EUROPE AND THE INQUISITION

The revival of religious and mysticalworld views following the fall of theRoman Empire, and culminating in theCrusades and witch-hunts of the middleages, brought with it a regression in bothpolitical and medical relationships. A ma-jor historical event worthy of special men-tion occurred in 1484, when Pope InnocentVIII issued a papal bull in support of thepopular medieval belief in witches.

The Inquisition now shifted into highgear. Two inquisitional theologians, Spreng-er and Kraemer, authored that medievaltextbook of clinical psychiatry entitledMalleus Male/icarum-The Witches’ Ham-mer-which fanned a smouldering demon-ology into a flame which engulfed Europeand eventually spread to the shores ofthe New World.8 In regard to this period,Zilboorg observed:

Galen’s humoral theory is pushed into thebackground and the devil is elevated [again]to the role of causative agent of melancholy.Sin and mental disease have become equatedin the mind of man; the major sin of man andwoman and the major preoccupation of thedevil is sex(13).

Thus the primitive, magico-religious be-liefs embodied in the Old and New Testa-ments were revitalized and charged withpower. Social relations, too, drifted towardsever-increasing depths of inequality andexploitation. While feudal monarchiesdominated the political scene, medievalCatholicism rose to achieve a level ofsecular power unmatched in its history.The political dominance of feudal royaltywas paralleled by the moral dominance ofcontemporary religion. The divine rightof kings had as its corollary the subjugationof the masses. Magic, mysticism and super-stition were rampart. Good and evil were

3 Although Massachusetts reversed most of itswitchcraft convictions in 1711, it was as recentlyas August, 1957 that the names of 6 women, ex-ecuted in Salem, and branded as witches for 265years, were cleared by legislative resolve.

1958 1 THOMAS 5. SZASZ, WILLIAM F. KNOFF AND MARC H. HOLLENDER 52�

God-given and sharply and indeliblyetched. This was the tenor of the time. Aswould be expected, medicine and religionwere inextricably entwined. The physician,imbued with magical powers shared bythe priests, was in an exalted position. Hispatient, unless of the nobility, was re-garded as a helpless infant. The model ofthe doctor-patient relationship, like thatof lord-serf, was activity-passivity.

Mental disorders, too, it should be noted,were regarded in the religious frame ofreference. People were, so to speak, eitherpossessed by God, and therefore saints, orpossessed by the Devil, and hence witches.Neither fell within a category which couldbe called “medical” or “psychiatric.”

It is interesting to note, in this connec-tion, that while in our time there has beena widespread desire to exonerate, as itwere, the witches either as innocent victimsof their time, or as “mentally ill” ratherthan “bewitched,” there has been no simi-lar clamor for revising the diagnosticcategory of “saint” (e.g., Joan of Arc). Yetit would seem that if logic rather thansentimentality governs the up-grading of“witches” to “patients,” an analogous down-

grading of “saints” to “patients” wouldfollow( 10).

It is consistent with the “human atmos-phere” sketched above that it was duringthis period that the insane asylums, whichwere nothing but dungeons in which mentalpatients were chained until they died, cameinto being. Such were the historical-andfrom the point of view of the evolution ofman’s struggle for freedom, logical-ante-cedents of the French Revolution.

THE FRENCH REVOLUTION

The spirit of liberalism initiated by theRenaissance, fostered by nascent Pro-testantism and brought to a high pitch bythe French Revolution re-animated man’ssearch for equality, dignity and empiricalscience as opposed to dogma. The suc-cessful Protestant “protest”-the originalmeaning of this word is probably rarelyremembered now-against the unopposedmight of the Roman Catholic Church wasfollowed by America’s successful overthrowof English dominance, and then by that

momentous social upheaval, the FrenchRevolution.

There are striking illustrations of theeffects of the dominant socio-politicalevents on medical behavior during thisperiod. As we noted, the pre-revolutionary

dungeon which served as a mental hospitalwas the appropriate place of confinementfor socially undesirable elements in asociety which viewed life and the deviantpeople in it only in two colors: black andwhite-witch and saint. The French Revolu-tion-and the events which led to it-brought this period to a socio-politicalend. Pinel’s effort to free mental patients

was equally dramatic, but it would seem,much less effective. Today, we look uponthe “open hospital” and so-called milieu-therapy as if they constituted moderndynamic-psychiatric innovations. Yet, theirrelevance seems to lie mainly in thatmental patients were until recently-andare today still-locked up” (committed)(11). Relieving them from this social andiatrogenic trauma may then seem like aform of “therapy.” How different is thisphenomenon from the well-known witticismabout the man beating his head against

the wall, because-as he said-it felt sogood when he stopped it?

The effect of Pinel’s efforts, however,should not be minimized. Certainly thestatus of the patient and the attitude of thephysician were altered. The model of thisrelationship, accordingly, changed (al-though not completely) from act1�rity-pas-sivity to guidance-cooperation. It should berecalled that more than 200 years earlier,Weyer had advocated reforms in the treat-ment of the “insane.” His pleas, how-ever, fell on deaf ears. He was, so tospeak, ahead of his time. By this it ismeant that he advocated an altered doctor-

patient relationship which was premature

in terms of the social scene.

LATE NINETEENTH CENTURY CENTRAL EUROPE

The rapid growth of science during the18th and 19th centuries led to the develop-ment of the physician as the expert engi-neer of the body as a machine. This stateof affairs favored, as we know, develop-ments principally in microbiology andsurgery. Concurrently, patterns of the doc-

526 THE DOCTOR-PATIENT RELATIONSHIP [December

tor-patient relationship stressed the latter’sdependency and inferiority. In medicineproper, the development of anesthesiastimulated progress in surgery. The mainnon-surgical illnesses of the time were, ofcourse, syphilis, tuberculosis and typhoidfever. In treatment, the activity-passivity,or at most the guidance-cooperation, typeof doctor-patient relationship prevailed.

In the late 19th century two majorpsychiatric trends developed. One was theKraepelinian, or “organic” approach; theother, originated by Breuer and Freud,was the psychoanalytic-and in a broad,contemporary sense, the psycho-social-approach. Both, as we well know, are stillvery much with us and constitute, in fact,the principal conceptual and methodologi-cal viewpoints of present-day psychiatrists.

Commenting on this phase of psychiatrichistory, Szasz stated:

Xraepelin’s chief objects of observation wereinmates of mental hospitals[4]. He studiedthem by direct common-sense observation. Theunderlying assumption was first that theysuffered from diseases much the same as otherdiseases with which physicians were familiar,

and second that society and the physicianswho studied them were “normal” and consti-tuted the standards with which their be-havior was compared. Accordingly, patientswere subsumed under categories (“diagnoses”)based on the behavioral phenomena (“symp-toms”) that were judged to be dominant. Thespirit of the inquiry precluded emphasis onspecifically individualistic features and deter-minants; Kraepelin’s approach, as Zilboorg[13] noted, was therefore at once humane andinhuman. He was interested in man, but wasnot interested in the patient as an individual(9).

The Kraepelinian or “organic” approachto psychiatry thus rests on the premisethat the patient “has”-in the sense thathe “possesses” something-a “disease.” Theeradication of the disease is thus picturedon the model of ridding the body of patho-genic bacteria. In a way this is a scientifical-ly updated analogue of exorcising thedevil(5). Adherence to this orientationpredisposes to continued espousal of the

activity-passivity or the guidance-coopera-tion models as the appropriate types ofdoctor-patient relationships in psychiatrictreatment.

From the standpoint of our presentinterest, one of the most significant fea-tures of Breuer’s psychological discoverieslies in the great attention which he wasable to pay to his patient as a human being.In terms of the doctor-patient relationship,the cathartic method meant that it wasworth while to listen to the patient at greatlength. While this may seem like a minorpoint today, it should be remembered thatthe listening role, extended over a periodof time, was a radical departure in themedical and psychiatric practice of the19th century.

Breuer’s personal qualities and interestsmade it possible for him to develop whatmust be judged as the first genuinely

communicative relationship (in a medicalsetting) between doctor and patient. As aresult of it, as Breuer reported, the pa-tient’s “. . . life became known to me toan extent to which one person’s life isseldom known to another. . .“( 1).

Breuer’s relationship with his patientsmust, for proper emphasis, be contrastedwith that of Charcot. Charcot, no doubt,may have divined some of his patients’secrets such as unfulfilled (sexual) longings.We submit, however, that he never knewhis patients in the sense in which Breuerand Freud came to know theirs. According-ly, Breuer and Freud’s historical role lies(among others) in having reintroduced, asit were, the patient into the medical arenaas an active, cooperative-and indeed, col-laborative-participant in illness and inhealth. The early cathartic method openedthe way not only to the psychoanalyticmethod but-from the point of view of thedoctor-patient relationship-also to the de-velopment and broad implementation ofthe model of mutual participation.

It is apparent that while in the Krae-pelinian viewpoint “mental diseases” areregarded as entities located in the patient’sbody, and usually in his brain, according tothe psychoanalytic approach-as it is

generally understood today-the samephenomena are considered as problems orconflicts in human relationships. The full

effect of these divergent views on the natureof the doctor-patient relationship has beenappreciated only recently.

There is the danger of over-psychologiz-

1958 1 THOMAS S.. SZASZ, WILLIAM F. KNOFF AND MARC H. HOLLENDER 527

ing Breuer and Freud’s early ideas con-cerning the nature of their own work. Itseems to us that while they were wellaware of the “human problems,” so tospeak, with which they dealt, they never-theless continued to formulate their workin the traditional theoretical frameworkof their time (i.e., “disease-and-health”).The alleged diseases simply were regardedas belonging to a special group, namelythose due to the damming up of libido.Moreover, according to Strachey,

To the end of his life, Freud continued toadhere to the chemical aetiology of the “actual”neuroses and to believe that a physical basisfor all mental phenomena might ultimatelybe found(1).

THE CONTEMPORARY AMERICAN SCENE

The development of our current ideasand practices, both in medicine and inpsychiatry, reflect the influences of 3 mainfactors: 1. From psychoanalysis specifical-

ly, and more generally from modern Ameri-can psychiatry (Meyer, Sullivan), stemsan increasing appreciation of the impor-tance of the patient’s role as that of a self-determinate partner in the therapeuticrelationship. 2. Increasing medical andsocial emphasis on chronic illnesses (e.g.,diabetes, arthritis, cardio-renal diseases,etc.) during the firsthalf of this centurymade it necessary for physicians to enlisttheir patients’ collaboration as medicalassistants, as it were, in the managementof their own health problems.4 Since “com-plete cure” is not a meaningful conceptin most of these medical situations, it isfor technical reasons usually impossiblefor the physician to rely on active-passivetechniques. The guidance-cooperation mod-el is therefore feasible but falls short ofbeing desirable. 3. The steady drift insocial relations (in America as well as inmost parts of the world) toward increasingacceptance of, and often insistence on,“democratic” or “socialistic” (equalitarian)patterns of behavior exerts-we assume-a

4 In this connection it is interesting to recall theHippocratic aphorism, “Life is short, art is long,opportunity fugitive, experimenting dangerous, reason�ing difficult: it is necessary not only to do oneselfwhat is right, but also to be seconded by the patient,by those who attend him, by external circumstances”(3, p. 96; italics added).

pressure on medical relations to conform toa similar pattern, whenever possible.

In (non-psychiatric) medicine, all thesefactors tend to favor the increasing utiliza-tion of mutual participation in the doctor-patient relationship. At the same time, thedoctor is involved, probably more oftenthan ever before, in the task of educatinghis patient in matters of health, illness

or treatment.In psychoanalysis and psycho-socially

oriented psychiatry, the same factors haveled to two major developments. One is therelatively widespread acceptance of, indeeddemand for, psychotherapy. Thus, thesocial and economic success of psycho-analysis, which has been greater in theUnited States than in any other country,probably has resulted-as has been sug-gested by others too-from the political andsocio-economic climate of this country. Thesecond development, in which psycho-analysis again has pointed the way, is theneed in many situations for both doctorand patient to scrutinize the very relation-ship in which they are engaged. Freud’sfundamental concept of “transference” wasthe first step in this direction. Inquiryalong this line received great impetus,however, also from the work and findingsof sociologists and cultural anthropologists.

All this is not to say that the psycho-analytic method of treatment rests whollyon, or employs only, the model of mutualparticipation. There is controversy overcertain important variables in this regard,for example concerning how much regres-sion is fostered by the analyst in theanalytic situation. Since we are not con-cerned now with a discussion of the precisedetails of a particular mode of psychiatricor medical treatment, it should suffice tonote that the scrutiny of diverse therapeuticinteractions in terms of their characteristicdoctor-patient relationships would consti-tute an important means of clarifyingdissimilar operations, now subsumed by asingle name (e.g., “psychotherapy”).

SUMMARY

The doctor-patient relationship whichcharacterizes a given situation depends ontwo principal categories of variables: themedical situation and the social scene.

528 THE DOCTOR-PATIENT RELATIONSHiP [December

The cultural matrix impinges on the in-dividual characteristics of both physicianand patient in the form of learned orienta-tions to disease, treatment, cure and to thedoctor-patient relationship itself.

We have briefly reviewed and com-mented on the probable connections be-tween the socio-historical and intellectual-scientific circumstances of 6 historicalepochs and the prevalent type(s) of doctor-patient relationship.

It is our thesis that the value of aspecific pattern of the doctor-patient rela-tionship can be established only by evaluat-ing all the relevant and pertinent variables.We would suggest, however, that awarenessof the cultural relativity of the doctor-patient relationship should make us skepti-cal of the assumption that our currentpi�r�s are “good” or the “best possible.”

Probably more often than not, they areneither, but simply reflect the congruenceof social expectations and socially shared

ethical orientations of physicians. In thisconnection, physicians, and perhaps psy-chiatrists particularly, explicitly may con-sider which of the following 3 alternativesthey favor: 1. That they reflect the pre-

valent social values and expectations oftheir culture; 2. That they lag behind thesocial changes of the time and representthe values of the immediate past; or 3.That they join with those forces in societywhich lead to its modification (whether to“progress” or “regress”). Critical examina-

tion of the doctor-patient relationshipusually predisposes to change, while non-

scrutiny of human social relations favorsthe status quo.

BIBLIOGRAPHY

1. Breuer, J., and Freud, S.: Studies onHysteria (1893-95), in The Standard Editionof the Complete Psychological Works of Sig-mund Freud. London: Hogarth Press, Ltd.,1955, Vol. II.

2. Edelstein, Ludwig: Bull. Hist. Med. 5:201, 1937.

3. Anon. Aphorism. Encyc. Britann. 2: 96.4. Kraepelin, E.: Manic-Depressive Insani-

ty and Paranoia. Edinburgh: E. and S. Living-stone, 1921.

5. Reider, N.: Am. J. Psychiat., 111: 851,1955.

6. Sigerist, H. E.: A History of Medicine,Vol. I, New York: Oxford University Press,1951.

7. Singer, C.: Hippocrates and the Hip-pocratic Collection. Encyc. Britann. 11 :583.

8. Singer, C.: Medicine, History of. Encyc.Britann. 15: 196.

9. Szasz, T. S.: Am. J. Psychiat. 114:405, 1957.

10. Szasz, T; S.: A.M.A. Arch. Neurol.and Psychiat., 76: 432, 1956.

11. Szasz, T. S.: J. Nerv. and Ment. Dis.,125: 293, 1957.

12. Szasz, T. S., and Hollender, M. H.:A.M.A. Archives of Internal Medicine, 97:585, 1958.

13. Zilboorg, G.: A History of MedicalPsychology, New York: W. W. Norton andCo., Inc., 1941.