Being a patient in a situation where other people have absolutely all the power to make decisions that can have a decisive impact on your life, that balance of power I think no one who has not really felt it on the body can imagine how it feels.

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This is some of what emerges in a new post from Nina. She writes:

 

"Terror balance"

Have you heard of the term "terror balance"? The term originates from the Cold War, where nuclear war was avoided because both parties, with the United States and the Soviet Union in the lead, had nuclear weapons that could retaliate against a possible first attack. With equal means of force, war can thus be avoided.

That's how it can be in relationships between people as well. That you "have something" equally bad to touch each other, which makes both of them keep their mouths shut about precisely this because the certainty that the other party then has no reason not to reciprocate by going out with the bad things that is to say about the one who spoke first. This can not exactly be called a good relationship. Tense, at best. But it works in such a way that what must be kept secret is kept secret precisely because both parties are an equal threat to each other.

It may sound strange, but sometimes I have wished for a situation with a "terror balance" in treatment relationships. Not often. But in periods, with individuals. Not a particularly sympathetic trait, I realize. The wish that I had something on the therapist that made the person not use what she thought she was wearing on me actively towards me. But it had at least given me a tiny sense of control. And not to completely free game without a chance.

 

Not balance in a treatment relationship

The problem is that it takes a long time before you can achieve such a balance in a treatment relationship. It is almost impossible. And such a relationship will in any case not be a good relationship or good for treatment process and progress. But it would at least protect me from being powerless as a victim of assumptions, conclusions and outright lies.

When the relationship first did not work and I was not a good enough patient, patient in the right way, was too troubled in more ways than one, it would at least have helped with such a balance of terror. When there was no other way than to stay in that relationship at the time.

The fact is that there is no balance in a treatment relationship. No matter how you twist and turn it around. What is possible, however, is to make the balance of power as small as possible. It requires a lot in many cases. But what often fails is that the therapist forgets or is not aware of how enormous that balance of power is in the first place when you meet for the first time.

As a patient, I come small, crawling, begging for help. Or you may have been forced into the situation, and then at least the imbalance is complete. How one is then met, and how the therapist chooses to both talk, relate and handle it all will be decisive for how large the imbalance will be further on.

 

Top-down

And one thing is for sure: top-down attitude with admonitions, assumptions and conclusions over the patient's head, phrases such as "people like you" or "patients with your diagnosis", and not seeing the patient as a person, as an individual, as something more than the diagnoses in the medical record and listening to what the patient actually has to say, it causes the relationship to be further disturbed out of balance, or the already established total imbalance becoming fixed.

As a patient, I can only tell you one thing about this. Such a starting point is fruitless, and the probability that we will end up in a kind of war is high. Not because I hate you or I'm angry. But because I am terrified, and that when I experience being attacked in a very vulnerable situation, then the brain and body automatically react with the fact that attack is the best defense. Hard and brutal, totally reckless. Even if in a calmer state I would know that this is extremely inappropriate.

 

Have you ever really thought ...

You who are a helper, and who have never been in the patient's shoes and situation, have you ever really reflected deeply on what it must be like to be the patient in the situation you are in, whether it is emergency hospitalization, planned hospitalization, or outpatient care? Or at the GP, for that matter. Have you ever thought that all things that are natural to you are far from always there for us who are patients? Have you ever thought about what you had felt and thought, and not least needed if you were the one sitting where I sit?

I often think about it. Both as a patient and as a professional. When professionals state that they do not understand why the patient does not progress, do not just say "well, he/she does not want to talk", etc. I often think that you have to stop from time to time and think about what you are actually saying, and what situation the patient is actually in.

I heard it myself, when I was in the extreme situation where I longed intensely for a "terror balance" with a therapist. And when I think about it, in many ways it was a reverse terror balance. The therapist had me in her hollow hand, because she, with her enormous formal power in the treatment service, also had full power over me. "Why don't you just quit?" someone asked me, and actually got pretty upset that I did not. But it was not that simple.

 

Decisions that matter to life

There was only one goal in my head: my work situation. I knew I was dependent on help. I knew that the possibilities were limited with regard to time, and not least my enormous fear of new people.

Being a patient in that situation… where other people have all the power to make decisions at any time that can be crucial to the way forward, and to your life going forward, no matter how hard you work and how hard you want and try… the balance of power where I think no one who has not really felt it on the body can imagine how it feels. How powerless, how small, how vulnerable and not least how scared you are.

Imagine having minimal influence on your own destiny going forward, beyond quitting. Which is also not necessarily a good solution. And even if you quit, the abuse of power can haunt you further in the form of diagnoses, the journal itself, or that the "rumor" follows you anyway. 

 

No black paint

Now it sounds like I'm painting the whole psychiatry black. And that is far from the intention. For there are many who master this role who have taken over very well in terms of power, and still others who master it mostly well or well to varying degrees. And often it is not intentional when the balance is shifted towards greater imbalance. It is often about lack of understanding, lack of own experience, it's about prejudice, professional controversies, haste, follow-up errors from others, or even lack of knowledge.

And for me, that kind of thing can be forgiven if there is only room to be able to speak out and be taken seriously, instead of ending up with new stamps. The need for a certain predictability, for example, is not the same as having a huge need for control. From the outside, the need for predictability may seem totally exaggerated.

Try a few weeks in my shoes, like me in my life, and I think you will look at that matter a little differently. Actually. Resistance to a therapist is not necessarily due to the a patient dividing helpers into the good and the evil ones. It might simply be a terrified patient who does not trust that particular person without perhaps being able to put his finger on why. It's not always because the patient is apparently just twisted.

 

Abuse of power

One thing is the unintended balance of power, which can be corrected regularly if the therapist is willing to be responsive and take feedback and take it seriously as the patient's experience. It can be straightened out again without ending up with any winner or loser. Only minor imbalance left, until next time. Because that's how it is. The power imbalance in the treatment relationship is absolutely dynamic and not static.

Unfortunately, there are also situations where there is a deliberate abuse of power on the part of the therapist, even though the therapist probably will not admit it, or is willing to see it for himself at all. The power imbalance is exploited, and in any case the patient is the loser, and that must be brought to life. I know myself what it can lead to. I also know that you can end up being branded as paranoid if you dare to tell facts and experiences to a third party later. Or there and then for that matter.

As a patient, you are always inferior, no matter what. In psychiatry, it is mainly word for word. The journal weighs heaviest. The therapist writes the journal. Case closed. In meeting with this type of therapist, the wisest thing to do is to keep your mouth shut and do as you are told or as expected. Do not bother, do not make noise. I failed there, so the problems in this relationship lasted. 

 

The therapist's responsibility

It should not be like that. We as patients have a personal responsibility when it comes to following up plans, working to get better, make choices, take initiative, show up, and do what we can. No one can make us healthy, without our active involvement.

However, the responsibility to ensure that the balance of power is as small as possible at all times, and that the communication, involvement and information flow in the relationship goes as it should, and which is most appropriate for the patient and the treatment process, it is ALWAYS the health personnel who have, if it is in the municipality or in the specialist health service.

There is a difference between making the patient responsible for everything that does not work and what goes wrong, and making certain demands on the patient. There is also a difference between closing the ears, refusing to listen and believing the patient, and not "letting the patient have the say" in one and all.

I want two things:

One is that the health service, and health professionals who stand around the patients, recognize that there are professionals who should never have had the job they have, and who abuse the power they have in their overall position in relation to patients both calculated and extensively. Whether it applies in one way or another. Acknowledge it, and dare to warn. And leaders who are actually notified must take it seriously. One can not automatically assume that the patient version is wrong and without root in reality, only based on one's own misconceptions. It is not the case that it is always the patient who is to blame, or is most "crazy" even if we are in psychiatry.

The second is that health professionals acknowledge that they have no idea at all what it is like to be a patient, and how inferior, small and out of control over how much you feel, unless you have actually been in the situation yourself. And that one considers how one would experience it oneself, and is humble that reactions that may seem silly, unnecessary, inappropriate and exaggerated on the part of the patient in given situations may be about the very fact that you are in two parallel universes, where you sit safely and have power, while the patient is scared, insecure and ultimately has little to say. That you could actually react in exactly the same way if you were just as inferior and powerless, at least if you felt that way.

 

To me, this is deadly serious

There are so many good people who work in psychiatry. Nobody is perfect. But if more people stop for a moment and think about the balance of power that is actually there and acknowledge it, then it may lead to much less frustration and potential conflicts and petty wars in treatment relationships that may actually have the potential to be very good.

Are you a psychiatric assistant, or a health assistant in general, then stop for a moment and simply ask yourself the following questions: "What would I have needed and appreciated if I was the one who sat there in the patient chair and was dependent on help to get the days to go around? How would I possibly react to the situation? How small would I feel if the roles were reversed?” Because you know? I will promise you that the experience, and the way of thinking, and how you react and handle things, it is diametrically different whether you are on the professional side or the patient side of the table.

I am on both sides several times every single week, and I will promise you that both experience, way of thinking and reaction pattern are very different. On the medical workers side, it's about other people's lives. On the patient side, it's about my life. On the medical workers side, someone is dependent on me. On the patient side, I am dependent on others. Lots of power versus little power. And that professional power, we as health professionals are obliged to take it seriously in the meeting with the patients. That professional power, I expect it as a patient that you take me seriously. Because for me this is deadly serious.

- Written by Nina