Abstract
Objective
Personal narratives of lived experience with psychiatric illness and distress remain central in the epistemology of mental illness. We provide a commentary on this potential bridging of patient narrative-based epistemology, and medico-scientific epistemology used by psychiatrists used for diagnosis, formulation, prognosis and treatment.
Conclusion
Discussion and planning of psychiatric care can be framed by understanding the narrative-based epistemology of a patient’s illness as highlighted by five key questions to explore the patient’s illness explanatory models. We propose five key questions for the psychiatrist’s complementary consideration of medico-scientific epistemology that frame conceptual models of aetiology, pathophysiology, diagnosis, formulation, prognosis and treatment, which are embedded in the predominant socio-cultural environment. These questions assist in bridging patient narrative and medico-scientific explanatory models to facilitate more effective collaborative care planning.
“There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy” – William Shakespeare, Hamlet
Humans usually communicate through stories, and patients seeking psychiatric care present narratives of their illness, and accounts from family and carers. These narratives are likely to be culturally specific. They involve personal stories of the patient’s illness, expressed through idioms of distress, the specific words, phrases and actions that people in different cultures use to express suffering. 1 Patients and their family/carers will also describe their narrative in terms of their explanatory illness models, which are socio-culturally embedded, and vary across the culturally diverse communities in Australia and New Zealand. 2 These explanatory models may also have been influenced by symptom and treatment experiences during previous episodes of illness and recovery, either of the index patient, or some acquaintance with a similar illness. These stories may present a combination of the positive aspects of previous treatment and the negative experiences of care and poor outcomes. Accordingly, it is essential that psychiatrists understand patient, family and carer perspectives and explanatory illness models. This patient narrative-based explanatory model is the key epistemology of mental illness. Explanatory models of psychiatric illness can thus be adapted to enhance empathy, and an understanding and alignment of aetiology, diagnosis, prognosis and treatment. 2 This involves tailoring diagnosis and treatment in a constructive manner in collaboration with patients, based on ongoing dialogue regarding patient and doctor explanatory models, which are each located in a given socio-cultural context. In many countries, there exists mental health legislation that endorses involuntary treatment of patients in circumstances when patients do not agree to, or cannot provide appropriate consent to, treatment, but are at risk to themselves or others, where patient and doctor narratives are clearly opposed – this is not our focus here.
In parallel, psychiatrists, use epistemology based upon medico-scientific explanatory models to understand the aetiology, classification, diagnosis, treatment and prognosis of mental illness.
From the above, there are two parallel epistemological underpinnings to understanding mental illness: the partially socio-culturally constructed personal narrative of the illness, and medico-scientific models that may also incorporate socio-cultural, as well as biological and psychological knowledge. Psychiatrists can and should bridge these epistemologies. For these reasons, we focus on the flexible application of patient, medico-scientific and psycho-socio-cultural explanatory models in conceptualising aetiology, diagnosis, prognosis, and collaborative care. Psychiatric care is dynamically tailored to ongoing evaluation of the patient’s illness, including the understanding of patient explanatory models and goals.
Patient explanatory models
Kleinman and colleagues pioneered the epistemology of patient explanatory models
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: 1. There is an important distinction between the medical disease and the illness that a patient suffers. 2. Patients’ illness experiences are determined by their socio-cultural context and disease explanatory model. 3. If only disease is addressed, treatment will be less effective than if the broader concept of illness is encompassed in discussion of aetiology, diagnosis and treatment. 4. Traditional biomedical science tends to blind health professionals to socially constructed illness and differing explanatory models underpinning effective patient engagement.
There is an essential iterative transaction between patient and doctor explanatory models. Patient and family explanatory models are influenced by socioeconomic status, culture, education, religion, occupation and past interactions with illness and healthcare. Five questions to explore patient explanatory models were recommended by Kleinman et al.
2
:
1. What do you think has caused your problem?
2. Why did it start when it did?
3. What do you think your sickness does to you?
4. How severe is your illness? How do you think it will progress?
5. What kind of treatment do you think you need?
Psychiatric diagnosis is primarily based on pattern-matching of constellations of symptoms, signs, cognitive and other investigations by psychiatrists, with limited exceptions. In psychiatry, there is often no consensus as to a diagnosis arising from a unitary biomedical disease, compared to, for example, Huntington’s disease as a genetically determined neuropathologic disorder.
There are also patient- and carer-centred explanatory models such as trauma-informed care 3 and recovery narratives, 4 which have transformed mental health policy by focusing on consumer and carer perspectives. There are ethnocultural contexts, including culture-specific syndromes that arise from different cultural idioms of distress, 1 for example, amok, hikikomori, ataque de nervios. 5
Medico-scientific and psycho-socio-cultural explanatory models
Psychiatrists draw upon a wide range of evidence-based medico-scientific explanatory models, in understanding disease and illness, including biomedical science, psychology, sociology and anthropology. 6 Medico-scientific epistemology, and associated explanatory models for many psychiatric illnesses, continues to evolve. Some disorders, such as schizophrenia, may be highly variable in clinical manifestations, pathophysiology and trajectory. Sub-specialisation occurs in psychiatric care, such as neurostimulation, psychodynamic psychotherapy and/or child and adolescent psychiatry. However, with sub-specialisation, particular medico-scientific explanatory models may predominate, in contrast to eclectic generalist psychiatric practice. A range of medico-scientific explanatory models may be required for effective engagement with patient explanatory models.
In Australia and New Zealand, modern medico-scientific explanatory models are also embedded in a Westernised, Educated, Industrialised, Rich and Democratic (WEIRD) partially globalised ethnoculture that embraces individualism, as well as reputationally based and impersonal, as opposed to kinship-based networks. 7 This ethnoculture underpins much of the existing medical and psychological research upon which a significant proportion of medico-scientific epistemology is based. Consequently, what might be regarded as nomothetic theories related to research conducted in WEIRD cultures are at least partially idiographic (i.e. specific) to those cultures in terms of values, meaning, narratives, as well as to health and illness explanatory models, rather than universally generalisable. WEIRD ethnoculture needs to be recalibrated with patient explanatory models, which may differ due to cultural, linguistic and first nations diversity. Some forms of psychotherapy may be difficult to translate cross-culturally due to psychosocial differences. Perhaps, the therapeutic discourse may be challenged by the differences in the idiomatic expression of distress as well as different conceptualisations of mentalisation, health and illness. 1 For example, psychodynamic psychotherapy, such as self-psychology, may rely upon a WEIRD individualistic psycho-socio-cultural context that differs from kinship-based Asian societies. Another example might be the patient and carer acceptability of neurostimulation treatment. Similarly, patient and carer centred models such as recovery and trauma-informed care also require consideration in calibration of explanatory models. As a final example, patients and their treating doctor may both view phototherapy as less intrusive than ECT for the treatment of depression, yet have very different conceptualisations of how depression arises and is treated.
Psychiatrists therefore need to reflect on the particular medico-scientific explanatory model they are using to conceptualise a patient’s illness. For this process, we propose questions for psychiatrists to consider, complementary to those of Kleinman et al.
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: 1. What is the main medico-scientific model you are applying to conceptualise the patient’s illness and treatment? For example, biomedical, psychodynamic psychotherapy, social psychiatry. 2. Are there other relevant medico-scientific explanatory models that can provide additional understanding? For example, a patient with Parkinson’s disease related anxiety during off-periods of dopaminergic treatment may repeatedly call their son or daughter due to attachment-related dynamic issues. 3. How does your explanatory model both align with, and differ from, the patient’s explanatory model of illness, treatment and recovery? For example, a patient suffering from schizophrenia-related hallucinations from a particular cultural background may have traditional folk medicine or spiritual explanations for their experiences. 4. How can psychiatric aetiology, pathophysiology, diagnosis, prognosis and treatment complement patient and carer explanatory models of illness, treatment and recovery? For example, the process of psychiatric formulation of a patient’s illness requires iterative evaluation in constructive work with the patient and carers, and may involve the adaptation of a number of patient and doctor explanatory models.
5. How can subspecialist expertise and/or the involvement of a multidisciplinary health professional team help achieve the goals of collaborative care with patients and carers?
Medico-scientific explanatory models and related therapeutic interventions are therefore perspectives and tools that can be employed to provide care for patients, rather than technical solutions seeking a problem. 8 The most essential consideration for psychiatrists is the first question posed above, as the predominant medico-scientific explanatory model conditions framing of patient care.
Frame reflection, developed for complex urban policy decision-making, is an approach that involves re-considering the different perspectives for the conceptualisation of a problem or dilemma. 9 In psychiatry, such frames include idioms of distress, illness explanatory models and socio-cultural contexts. Co-design of effective care with patients and carers is essential, given the potential for competition between various explanatory models. 8 To better align the means and goals of treatment, consideration of the predominant medico-scientific model includes exploring ways to bridge to patient explanatory models. Psychiatrists lead multidisciplinary teams (MDTs) providing care to patients. MDT members also provide important complementary perspectives on patient, carer and other medico-scientific explanatory models, as well as advice on framing collaborative interventions.
Conclusion
The key epistemology of mental illness comprises understanding the narrative idioms of distress and the patient’s experience through socio-cultural explanatory models. A parallel medico-scientific epistemology underpins psychiatrists’ understanding of mental illness, and can also encompass socio-cultural science. Facilitated by the above proposed questions, alignment of patient narrative and medico-scientific explanatory models can assist in more effective care planning.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
