Some Discussions on Pain, Clinician and Patients …

CLINICIAN DISCOURSE WITH PERSISTENT PAIN SUFFERERS

Horst Ruthrof, FICI, FAHA, is Emeritus Professor in English and Philosophy at Murdoch University, Perth, Western Australia.

Annotations by John Quintner & Melanie Galbraith

These notes were prepared by Emeritus Professor Horst Ruthrof following a conversation (over wine) with John Quintner, retired rheumatologist, and Melanie Galbraith, physiotherapist, that took place on Friday 29th January 2016. John and Melanie have annotated them for the benefit of the broad readership of Fibromyalgia Perplex. Where necessary, they have drawn upon definitions from ‘The Philosopher’s Toolkit’ (2nd ed. 2010) by Baggini and Fosl.

Introduction

We believe that all clinicians who regularly engage with people who experience persistent pain, fibromyalgia being an example par excellence, will need to learn a “new” language in order to more meaningfully and ethically engage with them. Fortuitously, the philosophers who have pioneered the field of phenomenology have already given us the valuable language tools that we as clinicians really need.

Notes as taken by Horst Ruthrof (annotations appear in italics)

They (these notes) are amended by additional considerations, on what might be relevant to and useful for your search for an appropriate approach to a ‘third space’ narrative about the relation between clinician and sufferers of persistent pain.

The ‘third space,’ which is also known as the ‘intersubjective space,’ is a concept that can best be understood by watching how children play together. They agree to construct and then share a world for whatever purpose their play requires. When people decide to go to a concert, when they are listening attentively to the music they are all in the same (third) space. In the same way, clinicians and their patients can agree to share a ‘third space’ where all relevant issues can be raised and discussed.

Science and normativity

Beginning with a broad perspective, a distinction that appears to me to be relevant to the characterization of the two domains of the clinician, on the one hand, and of persistent pain sufferers, on the other, is that between a scientific focus and one informed by normativity.

The former can be classified traditionally as committed to the data of empirically observable evidence systematized via the testing of hypotheses and procedures of deduction and induction.

This is the essence of the scientific method upon which modern medicine is so reliant.

Normativity, in contrast, can be regarded as a summary bag containing all the sort of things that science, as science, is not designed to deal with, such as ethical, aesthetic, religious, and political values, as well as ideological dispositions. While in social practice the two domains always overlap, the principles that inform each are plainly different. It seems to me that it is the clash of those principles that make medicine an ethically highly complex arena of human endeavour.

This clash also explains why so many sufferers of persistent pain are perplexed and disappointed when their clinicians appear to be deaf to some of these important issues in their lives.

The social expectations about clinicians appear to be that they are trained primarily to apply scientific principles to the injured human body in order to return it to functional health. Persistent pain throws a big spanner in this social mechanism.

According to your descriptions, the strong case of chronic pain is typically not curable, in which case the fundamental assumption of the clinician’s task is misguided from the outset. For hardly any of our basic scientific principles appear to be relevant. For example, deduction in the strict sense is not available in this sort of medical practice since the patient is never a closed system where all data are observable for verification.

Deduction is the form of reasoning one sees acted out in classical detective fiction where all the suspects are gathered together in the drawing room awaiting the analysis of the brilliant detective. A successful deductive argument is one where if the premises are true, then the conclusion is definitely true and the murderer is revealed to one and all.

Even the process of induction by which a patient could be regarded as an open-ended system, allowing for ever more information and hence an ongoing process of falsification and corroboration of hypotheses, does not look promising. The reason for this appears to lie in the difficulties of establishing a data set that could be elicited reliably from the patient.

Often, induction involves reasoning from a limited number of observations to wider, probable generalisations. For instance, from a series of observations that a woman walks her dog by the market at 8am on Monday, it seems valid to infer that next Monday she will do the same, or that, in general, the woman walks her dog by the market every Monday. That next Monday the woman walks by the market merely adds to the series of observations, it does not prove she will walk by the market every Monday.

In the absence, then, of standard inductive procedures the clinician seems to be less in the position of a scientist as in that of the interpreter of a complex and perhaps even hermetic (i.e. closed or sealed) work of art. In which case, abduction rather than deduction or induction would be an appropriate tool of analysis, interpretation, and healing procedure.

While deduction works uncontroversially in closed systems, and induction caters well for an extended series of observed phenomena, abduction is the norm in interpretation when individual phenomena require the construction of a meaningful whole that is not specified.

Abduction is a process of reasoning used to decide which explanation of a given phenomenon we should select. Here is an example: A man is found in a cabin in a remote forest, with all the doors and windows locked from the inside, hanging dead from a noose. A suicide note in the man’s handwriting lies on the table nearby. What would best explain this set of facts? Was it an open and shut case of suicide or are there other possible explanations? This is the stuff of murder mysteries!

Much of human communication works on this wobbly principle, which seems to me to be central to the difficulties in the interpretative task confronted by the clinician facing a persistent pain sufferer.

Clinician-patient discourse

Viewing the topic from the narrower perspective of the kind of discourse that typically operates in exchanges between clinician and patient, two polarities suggest themselves: the medical master narrative versus a narrative informed primarily by patient needs.

While this division is hardly ever so clearly visible in actual practice, it is useful for analytically sorting the principles that underpin them.

In this theoretical opposition, three standard forms of discourse are involved, the objective discourse of factuality (science), subjective discourse (personal expressiveness), and the intersubjective discursive negotiation of meaning (social discourse).

Science deals with facts or established knowledge and medical science is no exception. Traditionally, personal beliefs and attitudes do not fall within its province. But this knowledge is not helpful to the person with chronic widespread pain who does not have a detectable lesion to explain the ongoing pain.

Medical master discourses impose messages on patients, while patient needs can be revealed only by the intersubjective negotiation of the subjective expressions between them and their clinicians.

Edmund Husserl developed a number of phenomenological insights for the characterization of what is occurring in this kind of negotiation. First, we perform acts of “introjection”, that is, tentative mental projections of the likely states of mind of persons we are communicating with, (Logical Investigations, 1900/01), followed by acts of “apresentation,” constructions of absent scenarios by way of extrapolating from observable evidence (Cartesian Meditations, 1930), which leads to intersubjective reciprocity in the social discourse of the lifeworld (Crisis, 1936).

Edmund Husserl [1859-1938] was a German philosopher associated with one of the most important philosophical revolutions of recent times. His deep influence has extended to the overall field of disciplines, which we call the humanities – psychology, sociology etc. He founded the field of study known as phenomenology (see Kockelmans, 1994).

Philosopher Thomas Nagel famously mused over the question ‘What is it like to be a bat?’ Phenomenology, by contrast, might be thought of as the project of discerning what it’s like and how it’s possible to be a human being (Baggini & Fosl, 2010: p.211).

Husserl’s phenomenological insights have recently been endorsed by empirical research conducted by Michael Tomasello, American primate and child language acquisition expert working at the Max Planck Institute at the Leipzig zoo. He talks of ‘intention-reading’ as a necessary component of early language ontogenesis (Tomasello 2006; Tomasello & Carpenter, 2007).

‘Intention reading’ is the proposition that children (and adults) acquire a mastery of language through social interaction. ‘Ontogenesis’ refers to the origin and development of an individual.

Typical examples of the medical master narrative would be the bio-behavioural story of chronic pain as conditioned response; the biomedical narrative reducing the patient to a mere organism in the hands of a techno-scientific apparatus; the brain-centred (homuncular) narrative; the stress response-survival narrative; the egotistic clinician narrative, where social standing and career goals overshadow patient needs; the ironic-sarcastic discourse, which though superficially friendly barely conceals the clinician’s contempt for the patient’s explanatory story; and, above all others, the stigmatizing narrative by which the patient is declared an immoral malade imaginaire. When considering the needs of persistent pain sufferers, all such narratives can be counted amongst unethical options for medical practice.

The homunculus refers to the idea of a “little man” inside the brain who is making decisions and generating pain.

The French playwright and actor Moliere [1622-1673] wrote ‘Malade Imaginaire’ (The Imaginary Invalid) in 1673. It concerns a hypochondriac who lives in fear of death and doctors.

What then would a discursive strategy look like that is aware of and sensitive to the needs of patients who suffer from serious chronic pain?

‘Discursive’ implies that the conversation would move from topic to topic without any order being imposed by either party.

First, what appears to be required on the part of the clinician is a conscious shift from a science dominated position to one that allows medical practice to be informed by the demands of normativity, the domain of human values. Specifically, the clinicians need to shift their professional attitude from medically curing a body to existential, pastoral care for a person. The conscious shift from focusing on a body to harkening to a person has significant, practical implications. One of which is a change of emphasis in the observation of the Hippocratic Oath (to prevent it from becoming hypocritical) towards the emotional well being of the patient.

In this context, ‘existential’ includes all matters relating to one’s existence.

The Hippocratic Oath binds new physicians to the ethos and profession of medicine, while the Western tradition of scientific medicine traces its roots to the Hippocratic writings that still shape the values of contemporary western medicine in relation to the obligations placed on clinicians to their patients and their colleagues (Bulger & Barbato 2000).

Another basic principle here appears to be a fundamental asymmetry of authority. We must ask, according to Michel Foucault (1972), who is speaking, under what conditions, with what sort of authority, and from what kind of institutional setting?

Michel Foucault [1926-1984] was an influential French philosopher who critically examined the origins and development of ideas of knowledge, punishment, madness and sexuality. His book ‘The Birth of the Clinic: An Archaeology of Medical Perception’ has become a classic in the history of human sciences.

In the clinical situation, the clinician always has the greater authority, leaving the patient in the inferior position of utterance. Even the most sensitive and sympathetic approach to patient needs cannot eliminate this asymmetry. Therefore it needs to be acknowledged by the clinician and built into the interpretive process. A similar, theoretically relevant point about discourse is made by Jean-Francois Lyotard (1989) via his theorization of the differend, a discursive injustice resulting from inequality in speech situations.

Jean-Francois Lyotard [1924-1998] was a French philosopher, sociologist and literary theorist, who developed the concept of ‘differend’ as a powerful analytical tool. For example, in the legal world, the ‘differend’ relates to the case where the means to argue is taken away from the plaintiff or when adjudication of a dispute is conducted only in the language of one party.

Fundamental too is the establishment of trust between clinician and patient, to be initiated and sustained by the medical expert. The establishment of mutual trust in itself is a complex process, in which felicity conditions play an important role (Cf. John Langshaw Austin, 1962; Paul Grice, 1989).

In this case, the most important of the felicity conditions is sincerity. The sincerity condition specifies that the clinician must have the requisite thoughts, feelings and intentions to successfully undertake this important task of establishing trust.

Likewise important are a genuine interest in the patient as a person by the facilitation of a genuine dialogue (cf. the principle of dialogism in the work of Michael Bahktin (1963, 1992) with a goal towards directing patients towards coming to terms with their fundamental existential situation.

From a dialogical standpoint, listening is the capacity to share what makes someone’s story worth telling and worth hearing. This is in contrast to a monologic discourse, which pretends to be the ultimate word, is finalized and deaf to the other’s response.

Patients require gentle guidance to reveal their deepest fears and learn to accept their condition without falling into despair. Persistent pain, not unlike terminal illness, can be regarded as ‘limit situations’ or ‘boundary situations’ in the sense in which they were theorized by Karl Jaspers (1954).

Karl Jaspers [1883-1969] was a German-Swiss psychiatrist who later became a leading philosopher. ‘Boundary situations’ are those that cause us to be aware of our own weakness and helplessness. These situations are usually unalterable.

Against this background, and taking practicalities of time constraints and other limitations into account, the clinician should be able to achieve a satisfactory ‘validation’ of the patient narrative in the sense of being able to accept patient utterance as felicitous and truthful.

Sad to say, as the demand for medical diagnostic skills has increased, as has the influence of insurers and systems of managed care, (Bieber et al. 2007) the precarious balance between available clinical resources – reducible to time and money – and the possibility of individual patient benefit has been tilted towards ever shortening consultation times.

The term ‘validate’ is being used here in relation to its Latin root ‘validus’ – to strengthen. It highlights an ethical obligation for the clinician, which is to “strengthen” the person in pain.

References:

Austin JL. How to Do Things with Words. In: Urmson JO, Sbisā M (eds). Clarendon Press, Oxford, 1962.

Baggini J, Fosl PS. The Philosopher’s Toolkit. 2nd ed. Chichester: Wiley-Blackwell, 2010.

Bakhtin M (1963) Problems of Dostoyevsky’s Poetics. Moscow: Khudozhestvennaja literatura. English edition: Emerson C (1984) Minneapolis: University of Minnesota Press, Minnesota.

Bakhtin M. The Dialogic Imagination: Four Essays. Austin: University of Texas Press, 1992.

Bieber C, Müller KG, Blumenstiel K, et al. Long-term effects of a shared decision-making intervention on physician-patient interaction and outcome in fibromyalgia: A qualitative and quantitative 1 year follow-up of a randomized controlled trial. Patient Educ Couns 2006; 63: 357-366.

Bulger RJ, Barbato AL. On the Hippocratic source of Western medical practice. Hastings Center Report 2000; 30(4): S4-S7.

Foucault M. The Archaeology of Knowledge. London: Tavistok, 1986.

Grice P. Studies in the Way of Words. Oxford: Clarendon Press, 1989.

Jaspers K. Way to Wisdom: An Introduction to Philosophy. Manheim R (trans). New Haven: Yale University Press, 1954: 7.

Kockelmans JJ. Edmund Husserl’s Phenomenology. Lafayette, Indiana: Purdue University Press, 1994.

Lyotard J-F. The Differend: Phrases in Dispute. Bennington G & Massumi B (trans). Manchester: Manchester University Press, 1988.

Tomasello M. Why Don’t Apes Point? In: N. J. Enfield & S. C. Levinson (eds.), Roots of Human Sociality: Culture, Cognition and Interaction. Oxford & New York: Berg, 2006: 506-524.

Tomasello M, Carpenter M. Shared Intentionality. Developmental Science 2007;10 (1):121-125.

 

 

2 Comments

  1. Thank you so much for this wonderfully insightful article. Having studied Physiotherapy, then Psychotherapy I am well aware that the language we use, and even the stance we take is significant to patient outcome. This article is the validation I have been looking for in terms of my recent return to Physiotherapy and the delicate position that this is.

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