summary response

© 2010 by The Johns Hopkins University Press

Conflicting Values and Disparate

Epistemologies: The Ethical Necessity

of Engagement

Mohammed Abouelleil Rashed

Keywords: communication, harm, psychiatry, lan- guage

I am delighted for the occasion to respond to Verhagen’s insightful commentary and Gupta’s important critique of my paper. In the

process, I hope to further clarify my thesis and the proposal that stems from it. I start by attending to Verhagen’s commentary, because in many ways we are in substantial agreement and, if anything, his observations help to further elucidate many of the ideas I propose. After that I turn to Gupta, who disagrees with me on several important points.

Verhagen’s four levels of analysis of psychiatric knowledge bring in to focus the fault lines, or the points in psychiatric practice and theory that require critical attention if we are not to inadver- tently bring harm upon patients. It is already at the junction of the first level (experience of the patient as incorporated in to a narrative) and the second level (the clinician’s formulation of the story), as Verhagen observes, that there is a risk of losing the uniqueness of the patient’s story, and with it the values she attaches to her experiences and current predicament. Diagnostic devices like

‘criterion B’ and ‘cultural congruence’ may have been introduced to safe guard against patholo- gizing normality, but as I have demonstrated throughout section 3 of my paper, that cannot be guaranteed, and these devices may in fact be part of the problem.

The problems between the second and third levels of analysis really start at the second level when the story is reformulated in to a ‘case’ with a specific ‘diagnosis.’ Once that is done, clinicians inevitably appeal to the known explanations for the diagnosed disorder, whether psychological or biological. The problem here is that other pos- sible explanatory frameworks, such as spiritual/ religious, are eliminated as possibilities, partly because the patient’s story has been redescribed in the language of disorder thereby losing the essential characteristics that make it her story. Redescribing the patient’s experiences hampers further attempts at meaning seeking (which in- cludes a search for explanation), especially if that occurs in a coercive context (I address this again in my response to Gupta). Finally, it is the fourth level where the epistemological foundation for psychiatry stands. The psychiatric commitment to a positivist/empiricist approach to experience and

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belief feeds in to the other two levels; it limits the availability of alternative explanatory models in the third and the legitimacy of subjective narrative in the second.

I am in agreement with Verhagen that psychia- trists “need to understand how they are related to their knowledge,” and they also need to be aware what could go wrong at the fault lines, and how that can be rectified. Gupta’s comments are impor- tant, and indeed she agrees that clinicians “need to think more deeply and critically about their epistemological stance” (2010, 207) and should try “harder to understand and accommodate the world views of their patients”(2010, 207). But we need a far more critical attitude toward the psychiatric contribution to these fault lines, and a willingness for mental health professionals to modify their practices, and perhaps their beliefs for a more coherent and ethical psychiatry. Below, I attend in detail to Gupta’s comments, but first a summary of her critique is due.

Gupta questions whether in proposing an open-ended process of communication with pa- tients I have sufficiently taken in to account the values, languages, and epistemologies of mental health practitioners, in the same way that I am “appropriately attuned” to those of the patients. She then questions why it is the case that we must prioritize patients’ languages and epistemologies. Following from that, she makes the more explicit point: why do we have to ‘believe’ patients’ ac- counts and explanations of their experiences? In opposition to my proposal for an open debate (that includes patients/families and not just profession- als) over the epistemologies brought to the clini- cal encounter, Gupta argues that clinicians must remain committed to their epistemologies and the explanatory frameworks that stem from them for two reasons: the first is that the “the commitment to the explanatory framework informs the clinical treatment and as such, the commitment is essential to the clinical service being offered” (2010, 206). The second is that these commitments—by virtue of allowing clinicians to offer medical care that they honestly believe would be effective—inform clinical ethics (like the duty to do no harm); as such being in a state of negotiation about them “opens up the potential for abandoning not only

one’s epistemology but the ethical duties that flow from it”(2010, 206). She asks, “Do we really want physicians to be willing to recommend treatments they do not believe will help—such as attending a spiritual advisor—in the service of finding com- mon linguistic ground with patients?” (2010, 206). Finally, Gupta argues that in Femi’s case no harm would have been done had he not been involuntarily detained in hospital, which leads her to the conclusion that what I am really objecting to “are the legal powers retained by psychia- trists in many legal jurisdictions to involuntarily detain and treat patient which, when executed, necessarily impose psychiatric values, language and epistemology on patients” (2010, 206). The solution, then, is to limit psychiatrists’ power to detain people, something that would eliminate the harms I describe in my paper and would alleviate the need for psychiatrists to “be in a constant state of negotiation about the explanatory framework they use to understand patients’ problems” (2010, 207), or, in other words, to keep religious and psychiatric beliefs apart, as Gupta wrote in the title of her response. I respond to these points in the order they arose.

In my paper, I wrote that “we need to adopt the patient’s own language, and frame the problem in terms that would meet her approval” (Rashed 2010, 200). This is not a prioritization of the patients’ epistemologies as such, but recognition that if we are to have any chance of grasping the emotional and intentional worlds of those who are in distress then we must try understanding them from within, embracing the descriptions they bear for the person. We must remember that in disclos- ing their subjectivity, individuals (whether you call them patients or not) are by definition more able to convey their experiences than any one else, not that they are necessarily immune to error about the probable explanations of their experiences, but that this cannot yet be our primary concern. In other words, when Femi said that he had been in communion with God, it would seem absurd for us to open the process of negotiation by claiming oth- erwise. We must take his assertions at face value, whether we believe that that is possible or not. As I argued in section 3 of my paper, it is one thing to disagree on explanation, and quite another to

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redescribe the experiences in a language alien to the patient. What we need to work with is precisely the experience of hearing the voice of God, and not that experience reduced beyond recognition to the psychiatrist’s language of hallucination, delusion, biopsychological disturbance, and so on. This seems to me to be the first step in preserving the values the patient attaches to their experiences and to avoid imposing the negative values associ- ated with the psychiatric terms on the patient. From that point onward, we can engage in what I called an open-ended process of communication, a process that may indeed involve educating the patient as to the social problems that may arise from insisting on adopting a certain language to talk about their experiences (secondary insight), and a process where agreement could be reached that a nosological/medical framework is the most appropriate approach to deal with the problem. Adopting patients’ languages and epistemologies is therefore an important first step in the quest for agreement that should characterize a noncoercive clinical encounter.

We must also be aware that the subject posi- tions in the patient–doctor encounter are unequal, which immediately places the doctor’s linguistic practices and epistemology in a position superior to those of the patient, something that initiates the very familiar situation where the patient would be talking about their experiences while the doctor is silently translating the patient’s report in to the language of disorder. By the end of the interview, the patient’s report of her experiences has already lost all the characteristics that make it about those experiences and is stripped of all the values it holds for her, becoming instead an alien formulation or a list of symptoms (Verhagen’s second level). It is precisely because of the unequal positions both parties occupy, and the risk of invalidation, that doctors must be sensitive to patients’ accounts, and engage with their language and epistemologies. From this perspective, the question of whether we should ‘believe’ the patient seems to be ir- relevant: the moment of the clinical encounter is not about who is right and who is wrong. It is certainly not about arriving at the ‘truth,’ but rather at finding some common ground that would unite the involved parties in agreeing on a course

of noncoercive, respectful intervention. In Femi’s case, for example, we need not believe that God can talk to people, or indeed that He exists at all, but it is one thing to appreciate that our episte- mologies (the doctor’s and the patient’s) may be incommensurable, and quite another to sabotage a person’s account of her experiences for it to fit our framework.

Gupta raises important concerns regarding the risks involved if clinicians abandon their profes- sional epistemological stances and explanatory frameworks. I would like to clarify that I am not urging psychiatrists to abandon their commitment to a particular framework; after all, as Gupta says, this is a commitment fostered through years of training and ‘belonging’ to a certain group of professionals. But it is important for clinicians to appreciate that they represent just one possible framework, and that spiritual, religious, psycho- logical, and other frameworks and avenues of care exist, and the process of negotiating which would be the most appropriate in a certain case must start by framing the problem in terms that would meet the patient’s approval, to be followed by a process of communication that involves the patient, members of the relevant social group, and mental health professionals.

We do, of course, want clinicians to recommend treatments they believe would work, but we also want clinicians to be sensitive to the possibility that in faithfully executing their duty to ‘do no harm’ they may be inadvertently bringing harm upon the patient, under the illusion that that is what the patient needs. We must, however, draw a distinction here between the domain of psychiatry and other medical specialties. Gupta’s argument would hold if, say, the issue under consideration is the management of diseased coronary arteries. The professional opinion may be that the patient requires immediate coronary artery bypass graft surgery. In this case, it would be negligent to the highest degree for the professional to adopt the patient’s perspective and send them—according to their wishes—to a spiritual healer. But the situ- ation with psychiatry is different. As I argued at length in section 3, psychotic phenomena are not pathological in themselves, and it is within the sub- sequent process of evaluation of these experiences,

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a process that implicates the values and beliefs of the patient and all those involved, that pathology is determined; in other words, pathology is in the outcome, not the symptom. It follows from this that clinicians must be attuned to the possibil- ity that their contribution—through diagnosis and hospital treatment—may impose negative values on the process of evaluation of psychotic experience, generating harm and eliminating the potential for a positive outcome. It wouldn’t do to hide behind the justifications offered by the use of ‘criterion b’ and ‘cultural congruence’; I argued at length the problems with these devices in section 3. An unexamined use of these devices within an unreflective clinical practice would amount to a violation of the ethical principles Gupta mentions in that we would in fact be doing harm, only not seeing it that way. I take it then that our ethical duty to the patient is to engage in an exploration of what Gupta in summarizing my paper has termed “linguistic, moral, and explanatory terrain” (2010, 205), and my proposal for an open-ended process of communication is an attempt to do that. The question of what will help should be answered within this process, and not be assumed before hand. It may be the case, for example, that seeing a spiritual adviser is what the patient needs, as it is within a religious framework that the patient’s values will be accommodated and they would be guided through their crisis.

I agree with Gupta that involuntary hospital- ization is directly implicated in the generation of harm, and this is one of the things I object to. But her suggestion that the solution is to limit psychiatrists’ legal powers to detain people rests on the assumption that the practice of psychiatry and the legal powers of detention are separate issues. Although we can obviously separate these issues conceptually, Femi’s case illustrates that in practice they remain closely intertwined. In Femi’s case, involuntary hospitalization was justified through the application of psychiatric procedures as they currently stand: the discernment of symp- toms within the context of social/occupational dysfunction, the absence of cultural congruence, and the presence of risk to self. The profession- als conducting the assessment were therefore discharging their duties in accordance with the

diagnostic principles of psychiatry. As I argued in more detail in the original paper, the problem of misplaced hospitalization seems to be embedded in psychiatric practice itself and not a matter of clinicians’ competence. In other words, and all things being equal, we could expect the outcome of Femi’s assessment to have resulted in hospital detention regardless of who was conducting the as- sessment. The problem then is in psychiatry itself. I agree with Gupta that less harm would be done if we “place a premium on patient autonomy and stringently limit psychiatrists’ powers to involun- tarily hospitalize and treat” (2010, 206), but how are we to do that without having a substantially different kind of psychiatry? My proposal for an open-ended process of communication is intended as a sketch of what that psychiatry might look like. The immediate problem in Femi’s case was, therefore, involuntary hospitalization, but the foundation for this problem lies in the assumptions and procedures of psychiatric practice, and it is those that we must try to change. Appealing for legislative change to limit psychiatrists’ powers of detention is of course a laudable endeavor, but it is hardly in clinicians’ immediate powers to bring about such a change. Yet the adoption of a more critical attitude toward the theoretical assump- tions underlying psychiatric practice is of great potential benefit to the clinical encounter.

Notwithstanding the above, and if we do find a way of limiting the powers of detention that psychiatrists hold, there are more insidious kinds of harm that may be inflicted on patients without the necessity of them being detained in hospital. These stem from the invalidation that individuals in distress may experience when confronted with a biomedical discourse that pathologizes their experiences, leaving them with nowhere to seek help. In Gupta’s alternative scenario, Femi is not detained in hospital and ends up going his own way after refusing to agree with the clinicians’ explanations and treatment recommendations. Although Gupta’s suggestion clearly illustrates the point that less harm would have been done had he not been detained, we can still ask, why should we accept either of these extreme positions: involun- tary hospitalization or complete non-engagement? Individuals who end up presenting before psy-

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chiatry are frequently in some form of distress, and because psychiatry remains the authority on unusual experience and belief, clinicians have a crucial role to play. They no doubt have their professional expertise to offer, but over and above that they are in a position to play a mediating role in the open-ended process of communication that I propose. This role involves respecting and engaging with the patient’s values and epistemol- ogy, the acknowledgment of the values implicit in psychiatric models, the negotiation of alternative explanations, and the arrangement of alternative care if that is deemed necessary.

Keeping religious and psychiatric beliefs apart, as Gupta proposes in the title of her commentary, is a call for non-engagement. Yet this risks per- petuating the already unequal positions patients and doctors occupy in the clinical encounter, to the detriment of those who find themselves with psychiatry at times of distress. Furthermore, non- engagement can no longer be maintained in a

world that is becoming increasing multicultural, yet no less heterogeneous for that. If psychiatrists are to be able to offer care and support for indi- viduals with diverse epistemologies and beliefs, the clinical encounter must be based on an open-ended process of communication. To be sure, that would mean that psychiatrists may need to relax their professional orthodoxy and this indeed is a dif- ficult endeavor, but one that is no longer a purely academic interest, but an ethical imperative.

References Gupta, M. 2010. Religious beliefs and psychiatric

beliefs: Worlds apart and perhaps best left that way. Philosophy, Psychiatry, & Psychology 17, no. 3:205–207.

Rashed, M. A. 2010. Religious experience and psychia- try: Analysis of the conflict and proposal for a way forward. Philosophy, Psychiatry, & Psychology 17, no. 3:185–204.

Verhagen, P. 2010. Evocative. Philosophy, Psychiatry, & Psychology 17, no. 3:209–211.