Thursday, 14 May 2015

Pushing Explanations

Clinicians of my temperament get worried about forcing our explanatory views on the people with whom we work. Whatever explanatory frameworks we may have encountered during our training (medical, cognitive, psychodynamic models), however helpful we may have found them, we have a basic reluctance about regarding them as the explanation, and are more comfortable drawing on the idiom an individual uses to explain their life. One way to accommodate this kind of reluctance is to adapt a form of explanatory pluralism, where multiple models are held in mind, sitting comfortably alongside one another.

This approach is useful because it not only allows us to think in terms of multiple philosophical models, but also leaves space for the language used naturally by individuals whose experiences we are trying to discuss.

Much of the time this approach is relatively trouble free. That is to say, most of the time there is no benefit in substantially disagreeing with a person about how they account for their experience (I am thinking of an individual I knew who heard voices and was perfectly clear there was nothing wrong; who was I to disagree?) .

However, despite my basic sympathy with explanatory pluralism (what I could call my conviction that, when it comes to talk of "mental illness" there is basically no fact of the matter) I realise that I can cook up some uncomfortable cases for myself, which make the approach less satisfactory. Sometimes simply going along with an individual's account of themselves won't be sufficient.

Here is one problem case:
A parent approaches you, the clinician. Their child is causing problems at school. These are not insubstantial problems. The child is disruptive and, on the face of it, unpleasant to teachers and making it difficult for the classroom learning to proceed. You do a school visit and discover things are just as bad as you were told. The teachers are at their wits end. The parent knows the nature of the problem and implores you to help by providing an official diagnosis: according to them the child has a disorder called ADHD and your help is needed. If you can test the child and affirm that yes, they do meet the criteria for ADHD, you can ensure necessary accommodations at school. The child is absolutely certain too, that they have ADHD. They feel like they are not in control of themselves, that they are not to blame for the trouble they are caught up in, that a "disorder" is the only possible explanation. 
You are uncomfortable. Yes the child meets the DSM criteria for ADHD, but you worry about this construal. You note that the child has recently had to deal with some life events which anyone would find emotionally disruptive (let's say a close relative recently died, or they moved school, or they are being bullied). You have a sense that if the family system was able to address this emotional disruption in some way (with help from a systemically inclined clinician for example), the "ADHD" might be substantially resolved. Further, you have worries about the use of the diagnosis ADHD. Sure you could oblige and diagnose, but you feel if you do that then the parent will be less inclined to view the child's problems in a way that might be helpful. In short, you feel it is incumbent upon you to try and discourage them from the explanatory framework (my child has a disorder) that they have adopted. This is not because you think they are straightforwardly wrong (you can see their point) but because you think their metaphor will encourage damaging courses of action like the prescription of avoidable stimulant drugs and the neglect of the child's emotional life. 
Here's another:
An individual you know lives in the community. They have suffered several episodes of disorganization and confusion before and these have tended to lead to dangerous and self destructive behaviour. At best the individual has had sustained periods of self-neglect. Now they are becoming disorganized again. You are worried about them. If they could be persuaded to allow themselves to be looked after (temporarily in a caring inpatient respite center you could refer them to) then they would be safe while they recovered. But although they are frightened they do not feel they need any extra care as there is nothing the matter. As far as they are concerned they are fine.
You disagree. You feel they are being overcome by some psychological change, that they are becoming unwell. You don't buy a "chemical imbalance" theory of their problems, but you can see they are not themselves, and the idea that they have succumbed to an illness would be a useful metaphor. You don't think they will always have this illness, nor be defined by this illness, but that characterisation seems a powerful way of accounting for the need they now have for extra care. 
What both of these stories have in common is a narrative brought to bear on them by the people whose lives they primarily concern. The acquiescent part of you wants to go along with these stories (they are the account that makes most sense to the person), but a concerned part of you does not. Let's not take away the easy way out; the optimistic proposal that you can always construct a joint understanding. In both these cases the person resists your interpretation, some degree of conflict is unavoidable. Even without saying the other person is "wrong", you are trying to give life to an explanatory framework which is at odds with their view of how their situation is functioning. In these cases, are you doing something beneficent or are you enacting a failure of mutual understanding? I would suggest the former. Helpful though it is to try and adopt language that "makes sense" to an individual, it won't always fit with our best image to how to help people.

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