It starts from day one, actually. I recall those early years of medical school, when in a discussion with a family member, someone would inevitably ask, “I have this nagging pain in my right hip, what do you think it could be?” There were always dozens of possibilities, but I always felt obligated to give an answer. “Sounds like IT band syndrome. Try resting it for a while, maybe some ice; you can also try some NSAIDs for a few days.”
It sure beat “I don’t know.”
We do this in psychiatry all the time. We listen to patients’ complaints and problems. We probe their histories; we evaluate their predisposing factors and environmental triggers. Sometimes we administer a questionnaire to quantify their symptoms. And we end by giving a diagnosis: an explanation.
These explanations are rooted in our understanding of psychopathology and neuroscience, society and culture. But our understanding is less than perfect. In the absence of sophisticated molecular or biochemical tests to prove the presence of a particular gene mutation or chemical deficiency, our biological explanations cannot be proven unequivocally. And our psychological interpretations can take even more forms—depending on our theoretical orientation—many of which can be contradictory.
That doesn’t mean treatment can’t commence, or that it won’t work. Treatment does work, surprisingly often.
Sometimes, however, patients describe experiences that violate our expectations: perhaps a unique side effect of a drug, or a failure to make the anticipated gains in therapy, or a subjective phenomenon that the patient attributes to medication withdrawal, but which isn’t described in the literature. In cases like these, what do we do? As with anything else, we like to give some sort of explanation. It’s hard to say, “I don’t know.”
I recently met with a patient (not my own) who had, in her words, a prolonged withdrawal reaction after stopping a low dose of an SSRI antidepressant; she later experienced emotional and physical problems for months after discontinuing an SNRI, and is currently being maintained successfully on a microscopic (some might say “homeopathic”) dose of an anticonvulsant.
As I listened to her story, I was struck by how her experiences would have been entirely unexpected. Unexpected, that is, according to the conventional knowledge presented in our texts. As her doctor, it would have been easy to say, “Hmm, that’s interesting, but withdrawal symptoms are usually more limited than what you describe. Perhaps you were experiencing a recurrence of your depression. And your current dose of medication is extremely low; the benefit you experience is probably a placebo effect.”
Would that have been incorrect? Not according to conventional psychiatry. But with a response like that, I would have completely invalidated her own subjective interpretation—her own reality.
Much of what we see in practice is similar. When a patient experiences recurrent psychosis after discontinuing an antipsychotic, is this a withdrawal phenomenon? Or a relapse? When an antidepressant is tapered off and the patient reports fatigue, malaise, and anhedonia a month later, is this recurrent depression, or a delayed withdrawal effect? The answers we give reflect our biases, and not necessarily the patient’s own interpretation (or reality).
A 2001 paper by Williams and Healy1 introduced the concept of an “exploratory map” to understand the subjective experiences of mental health patients. After interviewing 34 subjects presenting to a community clinic, the researchers found that individuals often entertained numerous causes for their psychological problems. Most of these diverged from the more absolute “explanatory models” offered by modern medical science. The idea of the “exploratory map” has recently re-emerged in the literature on the recovery model in mental illness,2 as it preserves—and prioritizes—the patient’s subjective experience, rather than offering an explanatory (often biological) rationale which may mean very little to the patient.
When we work with patients whose experiences don’t align with our expectations, we must be careful not to dismiss those experiences simply because they clash with the overriding psychiatric paradigm. The patient’s exploration of his or her symptoms, as well as the causes and the meaning of those symptoms, are what truly matters. To preserve the therapeutic relationship—not to mention the patient’s hope and power—we should honor those interpretations, and engage in further exploration with the patient, instead of offering an answer that our experience says is “right” but which the patient may perceive as utterly wrong.
References
1. Williams B, Healy D. Perceptions of illness causation among new referrals to a community mental health team: "explanatory model" or "exploratory map"? Soc Sci Med. 2001;53:465-476.
2. Amering M, Schmolke M. Recovery in Mental Health: Reshaping Clinical and Scientific Responsibilities. West Sussex, UK: John Wiley & Sons, Ltd.;2009.
