Thank you Roger. I think one way we are often criticized is for making up stories to explain what "is" and then making up theories to provide further explanation of our stories. Or, believing in theories that we try to bend the concrete observations to fit. If we operate with a degree of humility, and with the spirit of always looking for concrete evidence, concrete observations upon which to base our theories and stories, we will be going in the right direction. We need to be concrete and scientific in our manner of thinking.
In clinical work we have what we call the "case formulation." This is essentially a "made-up" story for how we think the patient came to have the problems he or she has. In a case write up, this is a section that tends to be problematic, in that it is derived from whatever "theory" the writer is coming from. The story that goes in the case formulation is just a story, it may or may not be true. Many clinicians follow theories that are 100+ years old and that have little or no support from empirical (concrete) evidence. Nevertheless, the formulation is derived from those theories, and clinicians try to wrap the evidence they see in the clinic, around the often erroneous formulation. Instead of building the formulation such that it is derived directly from concrete clinical evidence, they start with the theories of how they believe they should think the patient's problems developed. They have a rigid theoretical framework, and try to fit the evidence into that, often mangling the evidence in the process.
This does not serve patients well because the formulation (story told about etiology) then influences the clinician in terms of style and mode of treatment. I see this all time. Let me give an example. The clinician believes that mental disorders are derived from difficult childhood experiences, particularly with the parents. In this hypothetical case (my own made up story), one of the patient's parents (usually the mother, according to many clinicians) is exceedingly volatile, non-consistent, difficult. The clinician, based on a belief in the assumptions of a particular theory, the childhood experience theory, assumes that the patient's problems come from "childhood trauma." If the clinician were following another theory, the patient's problems were likely to be genetic in origin, with some environmental stressor, like exposure to neurotoxins, or to pathogens setting things off. In this scenario, another story emerges. The difficult parent, on close examination of the concrete symptoms reported by the patient from his or her childhood, suffered from an untreated bipolar II illness. The patient happened to have inherited the difficult parent's genetic material, and is prone to bipolar II depression (a very serious kind of depression, one that leads to suicides not infrequently), and obvious mood instability.
The clinician, following a theory and formulation that rests on the idea that childhood experience with parents, decides to treat the patient with talk therapy alone. When the patient doesn't get better, the therapist sends the patient to a psychiatrist and tells the psychiatrist (before hand) that the patient had difficult childhood experiences. The psychiatrist, going on the same assumptions and theory (formulation) as suggested by the clinician, decides to treat the patient with an SSRI type antidepressant and his/her additional talk therapy which focuses on the "bad parent" and the horrible effects of growing up with that "bad parent." The patient, following the onset of the SSRI treatment, either is struck down with their first manic psychotic episode, or becomes suicidally depressed. This is all the result of the theory and formulation being off, its a story and an erroneous story at that. To make it worse, the patient begins to obsess about the evil effects of his or her "bad parent."
The other theory leads to another formulation. The patient's "bad parent" was suffering from untreated bipolar II. The patient has inherited the parent's genes, and to top that off, has been exposed to the usual neurotoxins we all live with. The combination of some bipolar genes and environmental stressors (like neurotoxins or specific pathogens) sets off the bipolar vulnerability in the patient. The presenting symptoms of depressive mood, mood instability, difficulty in relationships, self-destructive behaviors, etc., are the product of a bipolar process. A psychiatrist with this "story" or formulation, upon hearing about the specific behaviors of the "bad parent" has a hunch that the parent was bipolar, and the patient's symptoms are indicative of a bipolar condition. The psychiatrist begins treatment with lamictal (a good medicine for bipolar II depression, if the patient doesn't respond with a potentially lethal rash that is rare, but occurs. I have seen that happen in my own practice and my patient was switched to another mood stabilizer on which she did very well). The patient gets much better and within a few months is functioning at a much higher level, and is neither depressed, nor manic, although remains more prone to high anxiety and sensitivity to criticism.
A different theory resulting in a different "story" or "formulation" about etiology, leads to a different treatment, in this case a more effective treatment. The point of all this is that in our fields of study, we have to be cautious in the stories we make up by way of explanation. Sticking to real symptoms (the parent's and the patient's), more concrete evidence of whatever, is likely to lead to more accurate diagnoses, more accurate "stories" (it is still all a story because we in fact know so little about mental disorders), and more effective treatment. Moral of the story, stick to the concrete evidence as much as possible and maintain some humility about our stories or methods of explanation.
I think that is what you are saying Roger, so thank you.
Lynn E. O'Connor, Ph.D.
Professor, The Wright Institute
Associate Clinical Professor, University of California, Berkeley
Director, Emotion, Personality & Altruism Research Group
Phone: (415) 821-4760
See what's free at http://www.aol.com.