Diagnosis: What Is the Patient Really Trying to Say?

Most of today's doctors learned in medical school that when a patient makes a big thing of some minor symptom, his real complaint is not the physical ailment but an emotional problem.

Trouble is, the knowledge is all too seldom put to use. So 80 family doctors got together with a scattering of psychiatrists for a Palm Springs conference sponsored by the University of South ern California and the National Institute of Mental Health. They spent a long weekend working out means of putting into practice what everyone accepts in theory.

"Take Care of Me." Many patients, U.S.C.'s Psychiatrist Edward J. Stain-brook told the seminar, seem to be trying to say: "Nobody cares about me, so I have to take care of myself. I'd like someone to care for me in the same way that I care about myself." If the physician treats this patient's physical complaints and nothing more, said Dr. Stainbrook, he is wasting everybody's time. For the real medical truth is hid den in the patient's locked-up emotions.

The medical meaning of many so-called psychosomatic and mental illnesses, Dr. Stainbrook believes, is that people feel dependent and want to be cared for. But this is socially unacceptable: "We force people to invent symptoms, rather than letting them say simply, 'I just need help for a while.' " Such a desire to be dependent may occur naturally at any of the major crossroads in life, Dr. Stainbrook said, and should not be regarded as an emotional illness. The real trouble in today's culture, he suggested, is that although everybody obviously must have feelings and emotions, he is not supposed to let them show.

"Just Listen." The doctors agreed that the best thing they can do for such patients is to let them vent their feelings and not censure them. No one will go to a doctor and complain merely of unhappiness, because that is not acceptable, but unhappiness along with constipation is acceptable, and the doc tor must treat both. He can prescribe medication for the constipation easily enough, but for the unhappiness, said Dr. Stainbrook, he must offer the treatment recommended by British Psychiatrist Michael Balint: his time, his personality and his attention. He can do this merely by listening attentively, and thus convincing the patient that somebody cares. Often this is all that is needed—plus the confidence that the same care will be available again on another visit.

Dr. Stainbrook and others emphasized that they were not saying that every family doctor should become a part-time psychiatrist. But they agreed that family doctors should recognize that in at least half their cases the patient is using the apparent part of his illness in an effort to say something that he cannot express any other way. Only in a minority of cases is this difficulty of communication severe enough to require a psychiatrist.