2.3 Changing notions of the therapeutic relationship and responsibility
The shift in practitioner-patient relationships in the last 30 years was described earlier in this book. In addition, Budd and Sharma note that in industrialised societies the nature of the majority of illnesses presented to doctors has changed from acute to chronic and, along with this, the nature of the healing relationship has also changed (1994, p. 11). For many long-term conditions, orthodox treatment can provide only short-term gains. Instead, the key issue is the management of symptoms. In many cases, a person takes on the role of being an expert in that they direct and know the best ways of dealing with episodes of ill health. This type of person is what the government terms ‘the expert patient’ (DoH, 1999, 2001). At the same time, everyone is presented in health policy ideology as a new consumer of health care services under the NHS, whether they are chronically ill or not. People have rights about their own health and obligations to look after it, while state-provided health services claim to be more patient-centred.
Changes in the therapeutic relationship can be seen in the way in which the training of doctors, nurses and the professions allied to medicine now pays more attention to social and psychological aspects of care. The shift from paternalism to shared decision making is perhaps most apparent in primary care services and is witnessed by the growing interest in narrative-based medicine, which puts the patient's story centre stage (see, for example, Greenhalgh and Hurwitz, 1998). Despite the rhetoric of patient-centredness, change is slow because of entrenched attitudes about the appropriate roles of practitioners and patients. For patients to gain greater power and control, professionals have to relinquish their power and control. Real change requires a complete restructuring of health services and health roles. However, in theory, if not fully in practice, there is a definite shift towards sharing therapeutic responsibility (for a discussion of this, see Coulter, 1999). This includes giving people the information they need to make decisions and be an active partner in the therapeutic alliance. To what extent this idea of partnerships of responsibility is a reality depends on both the individuals (users and practitioners) and the settings, situations and health matters involved.