Context

A social constructionist view of knowledge

Knowledge in the Dark Ages

In the Dark Ages knowledge was established by royal or religious decree. Knowledge was valued according to the power and position of the person who espoused it. The revolutionary change in this view which is referred to as the Copernican revolution was the idea that knowledge can be gained by the individual knower, initially with astronomy, by careful observation of the heavens. In a modern context it is hard to conceive that this was revolutionary, but it was experienced as that at the time and gave rise to Modernism and the scientific method.

Modernist epistemology

Modernism was the foundation of modern science, technology and medicine. On this view knowledge is understood as building sequentially towards absolute truth. Scientific method maximises objectivity. Language is understood as a mirror of reality, to use words to describe reality was seen as in the nature of holding up a mirror, so the audience might perceive what was described objectively, as the speaker did. A primary activity is to seek causal explanations in terms of underlying structures. It has been very successful. It works. It underpins almost every aspect of our modern lives, including evidence-based practice.

Evidence-based practice

Evidence-based practice is grounded in the modernist study of natural phenomena. Deducing and testing hypotheses are valued activities, with the randomized, controlled trial being prioritized. It has yielded helpful treatment interventions which can be lifesaving and have the potential to improve people’s quality of life. It is strongly institutionally supported. However, no intervention works for everybody and implementing them is dependent on labeling and categorizing and is explicitly prioritized over personal knowledge.

Social constructionism

Social constructionism is a post-modern view of knowledge. Rather than being understood as a progression to an absolute truth, knowledge is understood to be represented in meaning which is constructed in social interaction through generations and day to day. While starting off with innate reflexes and behaviour patterns a new baby learns to attend preferentially to what is important to its parents. This is in contrast to the idea of knowledge being 'found' by objective study and looking underneath (an approach found unrewarding in subatomic physics). Meaning is embedded in language. To describe oneself as a clinician, or this document as an academic paper, subsumes a range of cultural understandings and is unlikely to be conveyed by holding up a mirror. In a simplistic way we can describe language and shared constructions as lenses through which we perceive the world. Our sense of ourselves and reality is socially constructed.

Constructions are value laden and can serve power groups. For example, feminists describe the qualities identified as feminine, nurturing, non-confrontative, in need of protection, as supporting male power. Karl Marx, in describing religion as the opium of the masses was identifying how religious ideas prioritise the morality of one’s actions and hopes for the afterlife over attaining an equitable share of resources in this life, as serving the interests of the capitalists. Diagnostic systems such as DSM IV and ICD 10 can be seen as serving the interests of mental health professionals by increasing the number and availability of diagnostic labels, thus increasing the perceived credibility and sphere of influence of psychiatry.

Constructions can be evaluated by usefulness and effect but do they work? Evidence- based practice has considerable claim to be valued on this basis. Resonance with people’s understandings and values supports the Recovery Approach.

The value of social constructionist epistemology for collaborative practice

A social constructionist epistemology frees us from a modernist epistemology where there is a truth so some people will be more right than others. It opens us up to the possibility of multiple viewpoints, each with validity. It gives us a way of understanding people’s knowledge as sitting beside ours, rather than having to let go of one to take up the other. Knowledge constructions can be evaluated according to their usefulness in the value system of the people using them.

It allows us to let go of the idea of the 'underneath' explanation which leads us to pathologising formulations in terms of individual and family pathology. It opens us to the possibility of a range of systemic explanations which can be taken up as they are found useful, empowering and supporting movement. For example with adolescent disorders such as Anorexia and Deliberate Self Harm one might support the person and family to identify self reinforcing cycles precipitated by the worry and distress for the family members in response to the illness behaviours and look at how they can be instrumental in changing these patterns and supporting the young person. Such formulations are more likely to be empowering and support movement than explanations based on individual and family pathology.

It gives form to the understanding of diagnoses as ideas, rather than real entities. DSM IV and ICD10 are explicitly developed constructions designed to be useful within the context of evidence-based practice. The process of developing diagnostic labels is not understood as a process of discovery of disease entities in the world and connecting them to the correct label. It is understood as developing constructions which are helpful, in communicating, focusing research effort, etc.

The term 'Schizophrenia' is an interesting example. While effective among professions in communicating, focusing research, etc, it has considerable stigma attached to it which means that workers and researchers working in the area of early intervention of psychotic illness tend to use the generic term 'psychosis', rather than 'Schizophreniform Disorder' or 'Schizophrenia'. A social constructionist view of knowledge makes sense of offering a diagnostic label as a potential way of understanding an issue, rather than as a statement of fact.

Profound respectfulness

Profound respectfulness involves:

In asking a question the focus is:

“what can I learn here about the knowledge, values, resources this person has which will enable movement?”

rather than:

“what are the vulnerabilities and pathologies which have led to this dysfunction?”

One way of illustrating this is the difference in attitude when inquiring of a colleague whose competence we respect, or a colleague whose competence we doubt, as to how they made an unexpected clinical decision. Where competence is respected the inquiry is made in the hope of learning something, the implication being that if this competent person made a decision we would not have made, that this is likely to be because they have some knowledge or understanding we could learn from. In the latter case the inquiry is made with vigilance for deficits in competence. In collaborative clinical work, inquiry is based on the attitude of profound respectfulness for the person’s resourcefulness and personal knowledge. We are making the inquiry in the hope of bringing forward knowledge which we can learn from and which is likely to be an important component of enabling forward movement. This goes a lot further than the non-specific stance of 'unconditional positive regard' advocated by Carl Rogers. It implies commitment to positive action towards discovery, discovery of what might not be evident to us or the person themselves, without our endeavours.

There is an Arabian proverb which is helpful here:

A friend is one to whom one may pour out all the contents of one’s heart, chaff and grain together, knowing that the gentlest of hands will take and sift it, keep what is worth keeping and with a breath of kindness blow the rest away

To practice collaboratively we need to believe in the existence of the grains, regardless of how obscured they are by chaff, value the grains, exercise tenacious commitment to, and develop skills in, clearing the chaff and bringing them forward. This is a particularly challenging task in the context of severe mental illness, part of the chaff can be cognitive disorganization, delusions, hallucinations, etc.

The context we work in

The context we work in sets us up to be experienced as disempowering

The expectation of being pathologised (i.e: understood in terms of deficit and dysfunction) held by many people can function as a barrier to accessing care and frame perceptions of our interventions. At the time of seeking help from mental health services they often feel disempowered, experiencing their own knowledge and resources as overwhelmed and there is often a sense of relief if we take control in a paternalistic manner. There is a prominent role for judgment and pathologising even in general discourse. This can be seen in newspaper accounts blaming parents, condemning modern youth, politicians, administrators, etc. A group of people will commonly be more easily able to list ten of their faults than ten good points. Some families specifically seek pathologising of an identified patient.

Part of the set up which leads people who come to see us to expect to be told, not expecting their views to be respected lies in the predominance of 'telling' over 'listening' in common conversation. Much conversation consists of people putting forward their views and waiting for a gap to do more of this, rather than listening. Those with more power talk more, have their jokes laughed at more, are paid more attention, challenged less. Because of the risk that a conversation where people holding different ideas can deteriorate into battle for dominance people commonly will not express contrary ideas, particularly if experiencing themselves as holding a lesser share of the power. Thus a person seeking psychiatric help is more likely to expect to be told and hesitate to put their views forwards.

There are also popular beliefs that psychiatrists have special powers and will find madness/pathology lurking within people which they might otherwise be able to keep hidden. There are some roles which feed into these concerns. Mental health services have responsibility to identify and address risk, to self, others and care and protection issues for children. This means we cannot afford to confine ourselves to areas people discuss comfortably, to focus only on strengths and achievements. To fulfill the expectations placed on us we need to access people’s darkest thoughts and moments. In order for us to make the effective treatments we have available it is important to identify illness syndromes despite the stigma involved in attaching a label of mental illness, the sense of spoiled identity.

Particular roles which focus negative perceptions include instituting the Mental Health Act, prescribing and administering medication and compulsory care. Maintaining optimism is challenging in mental health service work. We usually see the least resourced people, and as they engage with their resource they will often move out of our services. Thus, the people we have the most contact with are those who do not manage to move out of our services.

Thus, mental health clinicians do not need to do any active pathologising, undermining or spirit breaking for the person to feel it. If we go with the flow it is likely some pathologising and undermining of personal agency will happen. Add strengths and stir is not enough (Rapp 1998). If we are to avoid being experienced as pathologising and spirit breaking we need constant attention to and skills for, interrupting the flow.

Fragility of holding of personal knowledge from a patient role

Emanuel and Emanuel (Emanuel and Emanuel 1992) in their classic paper on models of physician-patient relationship, identified the option of working 'with the patient to reconstruct the patient’s goals and aspirations, commitments and character' (p. 2222) the patient themselves may not be consciously aware of. However they described physicians as unlikely to have the skills or time to do this, thus physicians may unwittingly impose their own values and the patients, 'overwhelmed by their medical condition and uncertain of their own views, may too easily accept this imposition.' (p. 2224). This same issue contributes to the experience some people describe, of mental health services as disempowering, deficit-based and spirit-breaking. Much of mental health practice, such as diagnosis, use of biological treatments and the medical model, is experienced as inherently disempowering (Rose and Black 1985) (Townsend, 1998). Patricia Deegan (1990), coming from a consumer perspective, describes mental health services as dehumanising and depersonalizing. From the recovery perspective our work is described as 'spirit-breaking'. Charles Rapp (1998), in advocating the Strengths Model, decries our dominance of deficit model, blaming the victim, etc, and described our work as 'oppression dressed up in the clothes of compassion'.

The British Journal of Psychiatry published an editorial by William Faulkner (Faulkner and Thomas 2002) stating:

“the dominant paradigm in psychiatry renders the views of people with mental illness invalid and negates the person as an individual.”

This focuses on the effect of being subject to psychiatric forms of description. A doctor visiting a psychiatrist in the role of a patient described this experience.

“I went because I thought I was having a few problems. And he told me I was depressed and that I needed antidepressants and I was devastated and I remember coming out of that thinking ‘God I didn’t realise it was this serious’ … it felt like I had my feet taken out from underneath me and it kind of felt a bit like I’d had my power taken away … I guess the thing I didn’t do… I didn’t argue against it. I didn’t argue with him because he knew.”

In order for people to experience contact with mental health services as empowering and collaborative rather than disempowering and colonizing we need skills in bringing forward people’s knowledge and resources.