David Corfield Hugh

Eleanor Alexandra Byrne https://pubmed.ncbi.nlm.nih.gov/32170570/

Charge: If the patient declares themselves to be (self-identifies as) someone with a biologically-caused illness, then what right do you have to go against them? You claim to have transcended the BMM with your BPS, but all it is is an instrument for greater oppression in an imbalanced situation where you have all the authority. Now not only are you allowed to decide on a biological story, you can also impose your psychosocial views against those of the patient.

You, Svanaeus, a supposed ally of the patient, the phenomenologist who took seriously the lived experience of the patient after years of biomedical bullying, are advocating a new form of BPS bullying.

Response: If all we are to do is go along with the patient, believe not only that they experience what they do, but that their interpretations of the situation are correct, then we do damage to the patient. I expect in my interactions with friends and family at times to question their interpretation of the world. This doesn’t make me a bad person for undermining them. Indeed, I take it as my duty to do so. Similarly, as a doctor, such as Nick Read, I find that some patients will come to realise the role that their lives are having in their illness experience, and that the best route to improvement comes from changing those lives. If I merely go along with their biological understanding, this won’t happen. Of course, I don’t force my views on them, but I look to see whether such issues can be explored. There is a gap between their interpretation and how things are, and this isn’t merely a gap between their and my interpretation. Consultation isn’t just about a battle of interpretations, but about what is in fact the best course back to health

Perhaps there’s an objective story to be told about how ill health arises, is resolved, etc. and this is fuller when understood through the BPS model than through the BMM model. Expanding the BPS in the dynamic manner of the attached document leads to a very rich account.

But even accepting some or other model, then there’s also the question of how to intervene. One could buy into the BMM and still think it worthwhile to get to understand the patient on their own terms, if only to help with compliance with treatment. This might include sympathetic listening to their ideas about illness.

The BPS presents a problem, however, in that, arising from its psychotherapeutic beginnings, it’s likely that aspects of psychological causes of illness are opaque to the patient. So while it’s a shock for the patient to hear of underlying biological dysfunction, this is something they expect. On the other hand, to raise the issue of psycho-social dysfunction threatens the patient’s own self-understanding. We expect to be surprised biologically, but not psychologically. So where the BPS appears to go in the direction of the phenomenologist’s demand to listen to patient experience, the BPS may also be deployed to challenge the patient on their own ground.

Now, I could understand this issue but still think that it might be possible to deploy a BPS account of an illness. Then instead of dictating this account directly to the patient, I could look to begin very sensitively an exploration of their lives, understanding the need for the patient to participate in the process of proper self-understanding.

But I think some of these hermeneuts would have trouble even with this. They seem to be objecting to it being beneficial to provide a patient with an account which departs from their own. Taken to its extreme, it seems absurd. Imagine the patient takes their diabetes symptoms to be the result of a viral infection. Of course, the doctor should challenge this interpretation, and let the person know there’s an issue with their insulin levels. Or if they’re sure the lethargy they’re feeling is due to stresses at work, and you find there’s a tumour causing it, of course, this version prevails.

It seems OK to most, I imagine, to allow a true biological cause to trump a false biological cause or a false psychological cause. But there seems to be a difficulty in proposing a psychological cause over a false biological one.

I think in a way this reflects the radical and conservative wings of the phenomenologists, and what each lacks.

Conservative wing: BMM is fine, but do take into account how the patient lives through the illness via phenomenology. This will help them to cope with the illness.

Radical wing: the illness episode just is the patients’ experience.

In some ways a detailed BPS approach is braver as it allows for an objective account of the causes of the illness, and these may involve problematic self-understandings of the patient. But then issues of ‘epistemic injustice’ arise. If the doctor’s enters the consulting room in a semi-psychotherapeutic capacity and the patient has made the appointment as a person undergoing a biological problem, there’s an issue of the terms of engagement. Normally someone seeing a psychotherapist goes fully aware that that is what they’re doing.

I think that’s right that the hermeneutical worry about BPS is that it’s quite possible to take the P and S ‘objectively’ as involving factors beyond the conception of the patient. It might be that the best access to P is to be had by speaking to the patient, but equally one might take the patient to fail to have the right psychological insight into their situation. By medicalising the P, one might be said to fail to do justice to the patient’s point of view. But then why sanctify the latter as though it’s inviolate? As you point out, it would be odd to this in the case of an evident B condition.

The undiscovered aetiology of CFS/ME appears to leave us in such binds, but is it so clear that providing a medical explanation (perhaps a BPS one) untangles things? Say we agree on an account of shingles as an immunological response to a circulation of a pre-existing viral infection, that is often brought about when its immunological suppression is disturbed by life events, but maybe also through aging. Does this change Blease’s insistence that we follow the patient’s conviction that we attribute symptoms to the virus? Would they object to the doctor pressing the patient to see if, say, an unresolved bereavement or impending financial insolvency is a factor? What to do if you think it highly likely that bereavement counselling would improve the symptoms better than any biomedicine?

The P seems to have at least 2 roles. There’s (P1) the psychological factors in a condition, which may be beyond a patient’s awareness or avoided by them. Then (P2) there’s the P of their sense of themselves and the way they interact with the doctor. Blease seems to be very concerned with doctors thinking they know best about (P1). Admittedly in practical terms one would have to manage (P2) carefully - too blunt an assertion of (P1) and the patient may run. A gentler probing of (P1) might overcome resistance. But then Blease seems enormously protective of their sense of self, and would no doubt dislike such a formulation.

Some of the difficulties in pinning down dualism charges maybe concerns such P1/P2 issues. I’m sure Blease would accuse a BPS-er who takes P = P1 of dualism. While, as you write, Blease seems guilt of a P2-reductionism.