by Marc Gérald CHOUKROUN – Éditions Glyphe June 2012, 206 p.
The history of medicine is marked by two philosophical currents that intersect, complement, or contradict each other. Sometimes authors lean toward a very materialistic perception of illness and the patient. This approach explains technological advances, whose advantages are undeniable and which improve medicine's therapeutic capabilities. However, materialistic perspectives can also incite certain culpable temptations, of which patients become victims. This has led to abuses, cheating, and financial greed, some used to feign innovation, others simply to profit without providing any real benefit. And now, practitioners themselves are becoming victims: materialism and objectivity have led directly to profitability.
Furthermore, the pursuit of objectivity has the perverse effect of denying the patient's subjective dimension, a dimension directly linked to their emotional roots and their vulnerability, already weakened by the illness itself. This is why some practitioners and patients have complained of being mistreated in terms of their humanity.
The second approach is the opposite. These religious, philosophical, and psychological currents have been able to develop conceptions closer to human sensibility, beliefs that humankind has cherished since the dawn of time. The subjective approach to human beings, far from representing a caricature of humanity, touches upon its richness and depth, and learned individuals are often surprised to discover that even the humblest human being possesses thought, insight, and a wealth of knowledge inherent in their very nature.
Having grown up in both dental and psychology faculties, I have been repeatedly challenged throughout my professional career by the complementarity
and contradiction of these two approaches. It seems clear to me now that practitioners are regularly confronted by an unavoidable dialectic in diagnosis and treatment: the logic of the body versus the subjectivity of the mind. The enigmatic title of this work expressly aims not to suggest that practitioners should be champions of their art in every category, but rather, with humility and in the face of the magnitude of the problem, to present a patient exploration of reconciling this dialectic. It will be readily understood that this dialectic constantly pushes us toward each of these inclinations, prompting ongoing questioning. I believe I can now offer some insights.
So, what exactly happens within this subjectivity? It's a genuine epistemological journey, because our culture tends to position us on a unidirectional axis: the patient is sick, the practitioner treats them. However, as we read on, another perspective emerges: the management of care depends on both actors. No, no, you haven't understood; it's not about the patient's free and voluntary cooperation so that the practitioner can implement their treatment…
This still remains within the realm of objectivity. To improve cooperation, one simply needs to understand the effects of communication and behaviors: information leaflets, courtesy, reception staff, decor… All of this, again, is the school of technology.
What strikes us, for example, is language: how is it that after talking for half an hour with my patient about the need for extractions, listening to him, leaving him with a smile, I receive a letter two days later indicating
that he will consult another colleague? And what about the patient who came every morning without an appointment to a colleague's office, complaining of real pain? And the patient who gives flowers to my colleague and then sues her a month later? And the child who loses his appliance in his room and can't find it? No, this book deals with observations that have led some thinkers to believe in magic… and yet. There's no question of avoiding a certain
strangeness, without, however, lapsing into belief. Freud was always against mystical attitudes, and that's why he had to imagine another hypothesis: transference. No, it's not the doctor who hypnotizes the patient and magically cures them, but neither is it the patient alone who decides whether they remain ill or move towards a different destiny. Yes, deep within us, there exists a construction of our reality that took shape in the depths of the
womb, and it would be foolish to believe that organogenesis occurred as it did in a car factory! What is the body? Vesalius offered us a very useful vision for healing, but is it sufficient? How does the placebo effect work? Is it the patient's delusion? Then why can they develop side effects they are unaware of? (nocebo). Does medicine possess the power to heal? In that case, why is he only given an obligation of means?
So what does healing depend on? Chance? The patient's perversity, whether they want it or not? We can clearly see from these questions that, no matter how much the practitioner trains and improves, there are clinical situations that leave them questioning, or even confused.
Faced with these difficulties, it's important to know that authors, researchers, and clinicians have attempted to provide answers. It's difficult, or perhaps a shame, to continue feigning ignorance, because what I've found beyond these answers, beyond a vast superiority complex, is that excellence is a tenderness in the practice of daily life. Beyond caregiving, there are things happening on an emotional level, and we must stop
being like a wall, and stop being afraid of our reactions.
The analysis of transference shows us that the practitioner's reactions, or countertransference, are a source of misunderstandings, misinterpretations, and rejection of treatment by the patient, who feels unaccepted and does not trust us. Conversely, the practitioner, who learns to live with and accept their sensitivity, becomes stronger, more humane, and shares their vulnerability with the patient.
Just because one is very strong intellectually and physically does not mean one should be emotionally strong; quite the opposite, in fact, the strongest practitioners are threatened by psychorigidity and prevent the patient from surrendering their body and stimulating their immune responses.
This book reveals that a patient may or may not want to get better; if they don't, even the best treatments will fail. At the same time, they may be indifferent to their own well-being but still undergo treatment to please the doctor. This is how many athletes win gold medals to please their coaches, even more so when the coach of the Irish boxing champion is her father!
It's important to understand, within this technocratic evolution, that love remains one of the driving forces of life. Most children who stop sucking their thumbs after a consultation with their orthodontist do so out of love—love that has been tainted within their families by hatred, rivalries, fears, and failures, but which resurfaces in its purest form with the practitioner.
Of course, we must learn that this relationship is fictitious, temporary, and without commitment.
Frustrating perhaps, but at the same time an opportunity to experience a relationship in its fullness, whereas in reality, daily life and personal history often break down relationships. The doctor-patient relationship is a unique chance for a patient to fully experience the bio-energizing effect of a brief, localized encounter within the treatment setting. This is why Freud so aptly warns us that the essential condition for
producing a therapeutic effect is that these emotions do not extend beyond the consulting room and remain confined to verbal expression. Nevertheless, in certain cases, the practitioner must consciously engage in extra-relational activities: attending a patient's procedure, accepting an invitation to an exhibition, or checking in on a patient who has experienced a significant life event.
It is this support that constitutes the power of care.
It is within the faculty's rights to limit itself to the transmission of objective knowledge, but it is crucial to point out today that clinical practice cannot be confined to this knowledge alone. It is not even a deliberate choice on my part to address this subject; it stems from lived experience, both as a practitioner who has witnessed the impact of the patient-patient relationship on therapeutic efficacy, and as a patient whose failing body was misunderstood and distressed by practitioners untrained in the science of medical psychology.
