What If There are Limits to Understanding?

POTTER'S PAPER RAISES several questions of great interest to the clinician. First, to what degree is it necessary to understand the patient's experience in order to treat a patient's disease? Second, to what degree is it possible to understand a patient's experience? And third, to what degree ought understanding be the goal of psychotherapy?

Potter quotes Cassell that "the clinician cannot know the patient, the illness, or the circumstances without true awareness of the patient's experience" (Cassell 1991, 216). Although this seems intuitively correct, it may confound a number of ideas that might usefully be separated. Is Cassell talking about disease or illness? The model of disease includes pathology (even if unknown), etiology, diagnosis, epidemiology, treatment, response, and prognosis. Illness, in contrast, can be seen as the patient's experience of the disease, and may involve very different ideas about explanation and feelings about treatment. The effective clinician is perched between illness and disease. For treatment to work best, patient and doctor must find points of agreement between the model of disease and the experience of illness. If we are treating a person with pneumonia, at least initially we must be more interested in the gram stain than in the emotions the patient feels about being sick. But because we are treating a person with pneumonia, if we do not form an alliance, and establish a shared explanation of our task, we may not have a patient at all—the person may be unwilling to take medication, may refuse diagnostic tests, and reject other forms of treatment offered by the doctor. This is not an unusual stance in a young person first diagnosed with bipolar disorder, for example. It is the skill of the doctor in creating a bridge to the patient's experience that makes possible the collaborative work of treatment.

Potter offers a discussion of moral tourism and world traveling as a way to deepen and enrich the doctor's approach to the patient. Moral tourism implies that we are outsiders, tourists in foreign territory, which brings with it both advantages and disadvantages. The tourist/clinician is interested in learning and can quickly gather information and form an impression. Pattern recognition is what distinguishes experienced from inexperienced clinicians; it is an essential part of the clinical armamentarium and essential to the disease model. But evaluations based on familiar paradigms may obscure other perspectives. As outsiders we do not know, without asking, what depression or psychosis is like for a particular patient, although we may have a general idea of how those processes affect individuals in general (for example, depressed people are often hopeless, but we do not know if a particular depressed person is hopeless, or about what; psychotic people often feel anxious and vulnerable to harm by others, but we do not know how frightened a specific person may be, or where he or she looks for evidence). We do not even know whether our particular patient wishes to get rid of the symptoms we identify as markers of a disease; some people want to keep their auditory hallucinations, which provide them company in an otherwise painfully lonely world, just as the catatonic patient, Peter, wants to remain in his catatonic state. And there may be things that, as outsiders, we cannot know.

Potter worries that if we believe we cannot know, it may lead us to classify the mentally ill as alien and animal. She offers world traveling as a way of overcoming our experience of the patient as an outsider. Beyond empathy, which can help us to understand the feelings of another to some degree, world traveling includes the broader understanding of that person in a particular culture, a particular socioeconomic class, a particular gender, and the attached cultural demands that the person accepts or rejects. World traveling asks us to attempt to grasp the person and their feelings in their world. In moral tourism, we look for ourselves in others...