Paris/Beaune (France) : 8-12 juin 1998
Paris/Beaune (France) : June 8-12, 1998
John Strauss, New-Haven, Etats-Unis
My concerns regarding the need for such a combined orientation began with an experience in a research interview I was conducting several years ago. " Why don't you ever ask me what I do to help myself ? " the patient had asked. It was our fourth research interview over a two year period. She had, or did have, schizophrenia, and was one of 110 subjects in our follow-up study in which we were attempting to understand processes of improvement. In this particular research we had decided to see patients every several months over two or more years so we could learn not only about the outcome of disorder but also about its course and evolution. Because our studies took what we considered at the time to be a broad approach to these processes, we asked not only about symptoms, medication, and hospitalization but also about social relationships and work. However, in repeating research interview with the same person, subjects get to know you, just as you get to know them. And here she was now, with the nerve to ask me this upstart question, " Why don't you ever ask me what I do to help myself ? "
My first response, one I kept to myself, was, " You think I'm narrow ! You should see many of my colleagues in the field ". My response out loud was, " Well, because I never thought of it ". Since that interview, over 12 years ago now, I am still trying to answer her question. I believe that I have advanced in my understanding of it, but I also believe that her question suggests that major revisions are needed regarding how most of our theories, research, and practice deal with mental illness, improvement, and rehabilitation.
The narrow positivist approaches to science and to mental illness currently dominant especially in Anglo-Saxon cultures have little room for helping oneself, for wanting to help oneself, for intentionality generally, or even for that matter, for subjectivity, outside of interest in the presence or absence of a narrow range of subjective symptoms. Although the positivist approach to measurement, sampling, operational definitions, and statistical analysis has contributed much to the progress of the field, important concepts and phenomena have come to be all but ignored.
In contrast, by focusing on concepts of French phenomenology it is possible to consider higher levels of human psychological function than are often dealt with in Anglo-Saxon approaches, notions such as intentionality, will, and sense of self and of the world.
Somehow, it is essential to combine these two orientations. Like the two sides of the human brain, both are important, but without some major connection between them, each by itself is seriously incomplete. The nature of the connection is far from simple and may actually require some revisions of the orientations preferred by each approach. The issue is certainly not, as some have suggested, that there are two worlds in medicine, the art of medicine and the science of medicine. It seems to me that the two worlds are rather, one utilizing a more atomistic kind of reasoning focusing on elements and their unstructured agglomerations, an approach amenable to the more traditional research techniques, and the other a more global constructivist approach in which the ensemble, the structure, narrative, and stories, are central. It is these two orientations, somehow linked, that I believe are crucial to an adequate human science and, as part of that, to developing adequate theory, research, and practice in rehabilitation for people with severe mental illness. Our problem, as so often occurs, in the return in adult thinking of one of the basic conceptual issues Piaget studied in children, the difficulty considering two dimensions, two approaches, at the same time.
Certainly, many of the stories that research participants in our study have told us, involve their efforts, their successes and their failures in finding themselves, pulling themselves together, during and after one or more psychotic episodes. The efforts, the struggles of these people involve in a central way finding themselves in the world, a world which, during and following their psychotic experiences, has given them labels, assistance, and stigma, a world that provides a combination of help and barriers which, along with the person's own symptoms and coping mechanisms make finding one's self especially complex.
In their efforts at finding themselves, the research participants frequently describe, at a level of higher psychic functioning the same kind of construction processes that are noted at even the most basic levels of all human mental functioning as seen for example in the Müller-Lyre illusion in which the two lines of equal length appear to be different because our perceptual mechanisms subjectively " construct " them differently because of the oppositely directed arrow heads at their ends.
If one sees these processes of constructing oneself and one's place in the world as central to improvement as patients so often describe, then rehabilitation is a central part of that process not just an ancillary approach to adjustment. For example, patients often report experiences such as, " When I work I don't hear voices ". This experience fits with Kraepelin's observation that people with schizophrenia who work often don't have the down hill course that he believed to be the hallmark of what he called " dementia praecox ".
Do such views of psychologically and socially constructing oneself as central to recovery from disorder reflect an anti-biology or anti-positivist bias ? Not at all. In the reconstruction process, biological, psychological and social factors all seem to be important. Medication, work, finding friends, " someone who cares ", and sources of assistance in these components, all appear to have roles to play, roles that sometimes are complementary, sometimes antagonistic. In the biological realm, research on neural networks appears to be particularly relevant since it provides a way for considering complex mental processes and the two way interaction between brain and experience. In assisting our understanding and treatment, positivist approaches to hypothesis development and testing have a crucial role.
And of course, perhaps at the center, there is always the role of the person, the person's efforts to help him or herself to overcome symptoms and recover a sense of self and a role in the world. And there is the role of those around that person, those of us who can develop helpful programs, can collaborate, care, assist, involve the person's participation in research, or who may tend to stigmatize, not listen, try to take over. As part of the presentation the way these concepts translate to the common everyday problems, strengths, and approaches of rehabilitation and rehabilitation programs will be described.