A Basic Model of Human Functioning
By Nick Child
This paper has never been published before. It's too basic for any academic journal. I didn't try very hard either - where would I send it to?! It's mainly conceptual or philosophy, but certainly not good enough for that kind of journal. The story behind its development is in John Macmurray. Derived from his philosophy of Self as Agent and Persons in Relation which I found in the early 1970s, I was forced to shape it down in the heated forge of my excitement with the ideas (which are already in ordinary language), and the wish to convert it into even simpler language that would engage my philosophy (but not Macmurray-) interested colleagues. Then in the even hotter hothouse of the Edinburgh Young People's Unit Senior Registrar training, I wanted to use it to make more sense of what I was learning there.
I presented this argument in a series of developing forms in various papers presented in Edinburgh and after starting in Lanarkshire in 1981. In Glasgow, the following 1984 version - starting from the sentence "I start by leaving aside all ..." - was one of the papers that I had junior psychiatrists read (and a few actually did!) as part of my twice annual 'Thursday Morning' teaching on Conduct Disorders. That teaching, in turn, after 17 years of further development, became the paper "The Limits of the Medical Model in Child Psychiatry" (CCPP 2000).
Because it was for psychiatrists, it is framed in those terms. But really it is valid for all helping professions and lay people to read and use. I have not updated the argument or references. It is a fairly cybernetic family-systems model. The accent is more on people's problems and proposed actions than the solutions and reflective views (that inform those actions) that some more recent post-modern approaches in Family Therapy would focus on. This paper began long before Solution-Focused Therapy showed up! It links problem solving to a solution focus, but I have to admit I was more problem- than solution-focused then.
Possibly the most important derived concept I took to Lanarkshire as a blueprint was the notion of teams being primarily personal- (not professional discipline-) based egalitarian groups who collaborated in serving the collective task - providing a child and family mental health service in our case - only secondarily bringing in one member's specialist solutions to serve this overall purpose.
This paper has never been published before. It's too basic for any academic journal. I didn't try very hard either - where would I send it to?! It's mainly conceptual or philosophy, but certainly not good enough for that kind of journal. The story behind its development is in John Macmurray. Derived from his philosophy of Self as Agent and Persons in Relation which I found in the early 1970s, I was forced to shape it down in the heated forge of my excitement with the ideas (which are already in ordinary language), and the wish to convert it into even simpler language that would engage my philosophy (but not Macmurray-) interested colleagues. Then in the even hotter hothouse of the Edinburgh Young People's Unit Senior Registrar training, I wanted to use it to make more sense of what I was learning there.
I presented this argument in a series of developing forms in various papers presented in Edinburgh and after starting in Lanarkshire in 1981. In Glasgow, the following 1984 version - starting from the sentence "I start by leaving aside all ..." - was one of the papers that I had junior psychiatrists read (and a few actually did!) as part of my twice annual 'Thursday Morning' teaching on Conduct Disorders. That teaching, in turn, after 17 years of further development, became the paper "The Limits of the Medical Model in Child Psychiatry" (CCPP 2000).
Because it was for psychiatrists, it is framed in those terms. But really it is valid for all helping professions and lay people to read and use. I have not updated the argument or references. It is a fairly cybernetic family-systems model. The accent is more on people's problems and proposed actions than the solutions and reflective views (that inform those actions) that some more recent post-modern approaches in Family Therapy would focus on. This paper began long before Solution-Focused Therapy showed up! It links problem solving to a solution focus, but I have to admit I was more problem- than solution-focused then.
Possibly the most important derived concept I took to Lanarkshire as a blueprint was the notion of teams being primarily personal- (not professional discipline-) based egalitarian groups who collaborated in serving the collective task - providing a child and family mental health service in our case - only secondarily bringing in one member's specialist solutions to serve this overall purpose.
ABSTRACT
The need for an integrating, basic model for psychiatry is described in relation to the medical and psychosocial models already in use. The model presented is that of persons engaged in tasks and problems, solutions often requiring the help of others; inter-personal and intra-personal conflict may need to be resolved before problems can be solved by an enabling or by a detaching process. Some of the applications of this model are outlined.
INTRODUCTION
Psychiatry today remains mysterious enough to be simultaneously supported and attacked by its public. Within psychiatry we use various approaches. Some psychiatrists strongly support one approach and attack others. Some profess eclecticism in their understanding of multi-factorial aetiology and in their therapeutic management. The wide variety of patients and conditions we meet in a National Health Service such as ours requires some measure of eclecticism. But I believe the clinical task requires us to be quite clear - at least to ourselves - at any one time with any one patient what is implied by our advice and treatment; that is, what model we are using and how to follow it through. To start our patients on a little bit of everything, however benevolently, is to promote further mystification for them and us. For many patients who cannot confidently turn away from us, the result may be a life of chronic institutionalised attendance for prescriptions or other forms of interminable therapy (Balint et al, 1970). We know that a ridiculous proportion of the western world belong to this group, if only from the sales of benzodiazepines. It is this sort of evidence which is used to attack psychiatry (New Internationalist, 1984), yet also shows how well the public (aided by drug companies and general practitioners) supports some forms of psychiatric approach.
I wish to outline a basic model to help us underpin our clinical work, to give logic to the various models and so co-ordinate our eclecticism. A good basic model (I suggest), like a good map, should help us understand each other's terrain within psychiatry, and help patients, public and other professionals to find their way around us. A good basic model of human functioning should be a description which does not need a special investigation or vocabulary in the first instance since we are humans ourselves. It should appear so obvious as to not need stating and so simplistic as to call for immediate development to account for any specific aspect or situation. If we believe that we live in a broadly unitary world, the model should provide some integration between the different models that are genuinely developed by sane enough people. At the same time, we can allow different frameworks of description and explanation to co-operate for different areas of knowledge. Thus, the cellular biologist conceives of membranes and nuclei and is not put out by the molecular biologist who can explain these away as molecular structures 'really', and so on. A good basic model of human functioning should also be capable of being explained away in other terms.
In psychiatry, two approaches may be distinguished - the medical model and the psychological models. The medical model is easily the most established, well defined, widely understood and accepted. The psychosocial models are no match for it, yet the fledgling psychiatrist may be urged to set it aside in their favour.
THE MEDICAL MODEL
The medical model entails the scientific and objective, biological and pathological study and investigation of an individual's body, with the clinical aim of identifying a diagnosis for the patient's condition and the lesion or aetiology determining the symptoms and signs (Balint, 1957). The diagnosis usually determines the treatment to be recommended. Medical training is primarily an academic, scientific one in the teaching centres and hospitals, and only secondarily a practical one arising from a knowledge of people's everyday life, their problems and the various kinds of help they might need. This emphasis has been supported throughout history by individual patients and by society in general.
Psychiatrists have appropriated the medical model into psychiatry and child psychiatry, undeterred by the proliferation of axes and categories of conditions and factors, and by the absence of proven explanations of psychiatric conditions and their treatments, or of explanatory 'mechanisms' for the multi-factorial 'associations' statistically shown to correlate with psychiatric disorders (Rutter 1977; WHO 1978). Virtually anything presented to us can be and is labelled wih a diagnosis and may be treated with what then have to be called 'therapies' such as behaviour, psycho and family therapies. This is presumably so that they stand comparison with those treatments employed in medicine and surgery proper. The test of (any) therapy's efficacy is held on empirically objective grounds with controlled trials to isolate the effects of the drug (or whatever) from those of suggestion (for example). Yet those who acknowledge the existence of 'suggestion' in every properly controlled drug trial they conduct, often scorn those who wish to study such subjective inter-personal processes in their own right, problematic as this might be for objective science. Unfortunately, by calling psychosocial management 'therapy' we can be hoist by our own petard into emulating trials of treatment in which we may be required to control out the very factors that the therapies may be constituted by. There is relatively little comparable work on the efficacy of suggestion etc. except in it's negative form, failure to comply with prescribed drug treatment. There are, of course, understandable reasons why research on physical treatments is massively supported - material objects are easier to think about, pay money for, investigate, obtain research funds for and so to further medical and academic careers. In short, the physical world suits the medical model. It is not possible here to explore the features of the medical model and the merits and demerits of their transfer to the psychosocial world.
THE PSYCHOSOCIAL MODELS
Within psychiatry there is no unifying model for all the many psychosocial approaches. Their proponents themselves remain in serious conflict because their approaches use various combinations of : determinism, self-determinism or indeterminism; biology, psychology or sociology; empiricism or humanism; and they focus variably on the individual relationships. It follows that the kinds of help offered are equally varied. However they have basic features in common. All entail at least two people meeting to talk about the problems and how to proceed with them (as does the medical model); and the models imply that the individuals exist in relationship to others. For example, behaviourist programmes require someone else to institute or control the rewards; psychoanalytical interest is (increasingly) in relationships, as in transference, identification etc.
Apart from this variety and indefinability, psychosocial models can be further cricticised in stronger terms than the medical model - the following can be applied to some or all :-
The terminology can only be vaguely defined (e.g psyche, social, personality, individual, self, psychosomatic, relationship, love etc.) although it is interesting to trace changes in the meaning of the words through the centuries, often reversing their sense (Williams, 1976)
Many of the concepts are not specific and can be applied to material or biological matters as well as to psychosocial (e.g behaviour, system, gestalt, interaction, development, maturation etc). The models may not be reflective. That is, although they belong to the same class - human beings - clinicians and scientists may not be considered subject to the same rules that they apply to their subjects (e.g a patient's behaviour may be seen as determined by nervous or other impulses or by learning maladjusted patterns, but clinicians declare that they have responsibilities and rights to determine their own practice). Popper writes separately about the rules for judging scientific work and about the less orderly creative processes of the scientist as he does it (Magee 1973). Kelly tackled this point directly by proposing a model for ordinary human beings as 'scientists' of their own lives (Bannister and Fransella, 1971). Rutter (1977) at least urges us to distinguish between behaviour that is the person's solution, from behaviour that is a symptom; but he does not consider how this is to be done.
High level academic theory seems to be the main consideration, operating perhaps on the assumption that, as human beings, we all share a natural and unanimous 'low level' description of what human beings are and how we all operate in ordinary settings (such as our interview rooms). The presumption during training is generally that expert skills and conscious knowledge must first be acquired and then that somehow this will turn into the correct professional action towards the client or patient, rather than that this expertise is a resource available to the people involved (professional and client - with the client as final judge of the quality of service). In an increasingly technical field such as modern medicine, there is some excuse for the emphasis on highly specialised knowledge. There is less excuse in psychosocial fields where competence and efficacy are not necessarily the product of high level training or awareness of high level theory. Outside psychiatry there is a model of human beings that is a systematic and comprehensive psychosocial account in terms of 'self as agent' and 'persons in relation'. Macmurray, the philosopher who developed this account (1957 and 1961) has stimulated many writers but has been otherwise neglected (Conford 1977). The basic model presented below is based on Macmurray but employs even more ordinary language and far less sophistication.
It can take some time to develop a full sense of what a person's 'agency' can mean and there is no readily available vocabulary to translate the pro-active or doing quality of that concept. The best words I could find - task, problem etc - unfortunately emphasise far too much a conscious, cognitive and compulsory aspect of human activity. These terms are intended to be broad enough to refer to all that would be described by the potential answers to the questions 'What am I doing' and 'What am I going to do' (e.g 'I'm reading, or 'I'm relaxing and keeping my mind blank', or 'I'm going to the doctor's'). The question 'How am I (doing)?' might produce answers that would not be specific enough (e.g 'Fine!') or only express the passive part of the predicament a person faces (e.g 'I'm bored') when it is the active sense that completes it ('I'm feeling bored'). 'Feeling bored' or even 'feeling sleepy' describe (for present purposes) a person engaged in a task, though usually a further task or problem is implied ('What shall I do about feeling sleepy? - perhaps 'Allow myself to go to sleep'), and this may also imply a reflective task ('I wonder why I'm feeling sleepy?' - perhaps 'It's this boring article'). Given this interpretation it will be apparent that the basic model can be translated back into a sophisticated version. It helps to remember that, just as riding a bicycle requires that momentum is continuous, the person as an active agent is always in a dynamic state, even when s/he is physically static, and what s/he is doing is 'nothing'.
PERSONS, TASKS, PROBLEMS AND SOLUTIONS
I start by leaving aside all considerations of what cause or aetiology a problem has. Instead I propose that all human beings are characterised by their constant engagement in tasks and problems. Anything can be formatted in this way - how to get to some address, what diagnosis to make or treatment to institute with a patient, what to say to your spouse when you are late home, how to understand what you are reading, how to deal with your unhappiness or your illness, how to get your parents to give you more sweets or to get that rattle to make that noise again, and so on.
We solve these tasks by various methods, including ignoring or avoiding them. A person then is always tackling tasks, (even some s/he does not know about) and tasks and their solutions are always attached to a person.
The need for an integrating, basic model for psychiatry is described in relation to the medical and psychosocial models already in use. The model presented is that of persons engaged in tasks and problems, solutions often requiring the help of others; inter-personal and intra-personal conflict may need to be resolved before problems can be solved by an enabling or by a detaching process. Some of the applications of this model are outlined.
INTRODUCTION
Psychiatry today remains mysterious enough to be simultaneously supported and attacked by its public. Within psychiatry we use various approaches. Some psychiatrists strongly support one approach and attack others. Some profess eclecticism in their understanding of multi-factorial aetiology and in their therapeutic management. The wide variety of patients and conditions we meet in a National Health Service such as ours requires some measure of eclecticism. But I believe the clinical task requires us to be quite clear - at least to ourselves - at any one time with any one patient what is implied by our advice and treatment; that is, what model we are using and how to follow it through. To start our patients on a little bit of everything, however benevolently, is to promote further mystification for them and us. For many patients who cannot confidently turn away from us, the result may be a life of chronic institutionalised attendance for prescriptions or other forms of interminable therapy (Balint et al, 1970). We know that a ridiculous proportion of the western world belong to this group, if only from the sales of benzodiazepines. It is this sort of evidence which is used to attack psychiatry (New Internationalist, 1984), yet also shows how well the public (aided by drug companies and general practitioners) supports some forms of psychiatric approach.
I wish to outline a basic model to help us underpin our clinical work, to give logic to the various models and so co-ordinate our eclecticism. A good basic model (I suggest), like a good map, should help us understand each other's terrain within psychiatry, and help patients, public and other professionals to find their way around us. A good basic model of human functioning should be a description which does not need a special investigation or vocabulary in the first instance since we are humans ourselves. It should appear so obvious as to not need stating and so simplistic as to call for immediate development to account for any specific aspect or situation. If we believe that we live in a broadly unitary world, the model should provide some integration between the different models that are genuinely developed by sane enough people. At the same time, we can allow different frameworks of description and explanation to co-operate for different areas of knowledge. Thus, the cellular biologist conceives of membranes and nuclei and is not put out by the molecular biologist who can explain these away as molecular structures 'really', and so on. A good basic model of human functioning should also be capable of being explained away in other terms.
In psychiatry, two approaches may be distinguished - the medical model and the psychological models. The medical model is easily the most established, well defined, widely understood and accepted. The psychosocial models are no match for it, yet the fledgling psychiatrist may be urged to set it aside in their favour.
THE MEDICAL MODEL
The medical model entails the scientific and objective, biological and pathological study and investigation of an individual's body, with the clinical aim of identifying a diagnosis for the patient's condition and the lesion or aetiology determining the symptoms and signs (Balint, 1957). The diagnosis usually determines the treatment to be recommended. Medical training is primarily an academic, scientific one in the teaching centres and hospitals, and only secondarily a practical one arising from a knowledge of people's everyday life, their problems and the various kinds of help they might need. This emphasis has been supported throughout history by individual patients and by society in general.
Psychiatrists have appropriated the medical model into psychiatry and child psychiatry, undeterred by the proliferation of axes and categories of conditions and factors, and by the absence of proven explanations of psychiatric conditions and their treatments, or of explanatory 'mechanisms' for the multi-factorial 'associations' statistically shown to correlate with psychiatric disorders (Rutter 1977; WHO 1978). Virtually anything presented to us can be and is labelled wih a diagnosis and may be treated with what then have to be called 'therapies' such as behaviour, psycho and family therapies. This is presumably so that they stand comparison with those treatments employed in medicine and surgery proper. The test of (any) therapy's efficacy is held on empirically objective grounds with controlled trials to isolate the effects of the drug (or whatever) from those of suggestion (for example). Yet those who acknowledge the existence of 'suggestion' in every properly controlled drug trial they conduct, often scorn those who wish to study such subjective inter-personal processes in their own right, problematic as this might be for objective science. Unfortunately, by calling psychosocial management 'therapy' we can be hoist by our own petard into emulating trials of treatment in which we may be required to control out the very factors that the therapies may be constituted by. There is relatively little comparable work on the efficacy of suggestion etc. except in it's negative form, failure to comply with prescribed drug treatment. There are, of course, understandable reasons why research on physical treatments is massively supported - material objects are easier to think about, pay money for, investigate, obtain research funds for and so to further medical and academic careers. In short, the physical world suits the medical model. It is not possible here to explore the features of the medical model and the merits and demerits of their transfer to the psychosocial world.
THE PSYCHOSOCIAL MODELS
Within psychiatry there is no unifying model for all the many psychosocial approaches. Their proponents themselves remain in serious conflict because their approaches use various combinations of : determinism, self-determinism or indeterminism; biology, psychology or sociology; empiricism or humanism; and they focus variably on the individual relationships. It follows that the kinds of help offered are equally varied. However they have basic features in common. All entail at least two people meeting to talk about the problems and how to proceed with them (as does the medical model); and the models imply that the individuals exist in relationship to others. For example, behaviourist programmes require someone else to institute or control the rewards; psychoanalytical interest is (increasingly) in relationships, as in transference, identification etc.
Apart from this variety and indefinability, psychosocial models can be further cricticised in stronger terms than the medical model - the following can be applied to some or all :-
The terminology can only be vaguely defined (e.g psyche, social, personality, individual, self, psychosomatic, relationship, love etc.) although it is interesting to trace changes in the meaning of the words through the centuries, often reversing their sense (Williams, 1976)
Many of the concepts are not specific and can be applied to material or biological matters as well as to psychosocial (e.g behaviour, system, gestalt, interaction, development, maturation etc). The models may not be reflective. That is, although they belong to the same class - human beings - clinicians and scientists may not be considered subject to the same rules that they apply to their subjects (e.g a patient's behaviour may be seen as determined by nervous or other impulses or by learning maladjusted patterns, but clinicians declare that they have responsibilities and rights to determine their own practice). Popper writes separately about the rules for judging scientific work and about the less orderly creative processes of the scientist as he does it (Magee 1973). Kelly tackled this point directly by proposing a model for ordinary human beings as 'scientists' of their own lives (Bannister and Fransella, 1971). Rutter (1977) at least urges us to distinguish between behaviour that is the person's solution, from behaviour that is a symptom; but he does not consider how this is to be done.
High level academic theory seems to be the main consideration, operating perhaps on the assumption that, as human beings, we all share a natural and unanimous 'low level' description of what human beings are and how we all operate in ordinary settings (such as our interview rooms). The presumption during training is generally that expert skills and conscious knowledge must first be acquired and then that somehow this will turn into the correct professional action towards the client or patient, rather than that this expertise is a resource available to the people involved (professional and client - with the client as final judge of the quality of service). In an increasingly technical field such as modern medicine, there is some excuse for the emphasis on highly specialised knowledge. There is less excuse in psychosocial fields where competence and efficacy are not necessarily the product of high level training or awareness of high level theory. Outside psychiatry there is a model of human beings that is a systematic and comprehensive psychosocial account in terms of 'self as agent' and 'persons in relation'. Macmurray, the philosopher who developed this account (1957 and 1961) has stimulated many writers but has been otherwise neglected (Conford 1977). The basic model presented below is based on Macmurray but employs even more ordinary language and far less sophistication.
It can take some time to develop a full sense of what a person's 'agency' can mean and there is no readily available vocabulary to translate the pro-active or doing quality of that concept. The best words I could find - task, problem etc - unfortunately emphasise far too much a conscious, cognitive and compulsory aspect of human activity. These terms are intended to be broad enough to refer to all that would be described by the potential answers to the questions 'What am I doing' and 'What am I going to do' (e.g 'I'm reading, or 'I'm relaxing and keeping my mind blank', or 'I'm going to the doctor's'). The question 'How am I (doing)?' might produce answers that would not be specific enough (e.g 'Fine!') or only express the passive part of the predicament a person faces (e.g 'I'm bored') when it is the active sense that completes it ('I'm feeling bored'). 'Feeling bored' or even 'feeling sleepy' describe (for present purposes) a person engaged in a task, though usually a further task or problem is implied ('What shall I do about feeling sleepy? - perhaps 'Allow myself to go to sleep'), and this may also imply a reflective task ('I wonder why I'm feeling sleepy?' - perhaps 'It's this boring article'). Given this interpretation it will be apparent that the basic model can be translated back into a sophisticated version. It helps to remember that, just as riding a bicycle requires that momentum is continuous, the person as an active agent is always in a dynamic state, even when s/he is physically static, and what s/he is doing is 'nothing'.
PERSONS, TASKS, PROBLEMS AND SOLUTIONS
I start by leaving aside all considerations of what cause or aetiology a problem has. Instead I propose that all human beings are characterised by their constant engagement in tasks and problems. Anything can be formatted in this way - how to get to some address, what diagnosis to make or treatment to institute with a patient, what to say to your spouse when you are late home, how to understand what you are reading, how to deal with your unhappiness or your illness, how to get your parents to give you more sweets or to get that rattle to make that noise again, and so on.
We solve these tasks by various methods, including ignoring or avoiding them. A person then is always tackling tasks, (even some s/he does not know about) and tasks and their solutions are always attached to a person.
This common sense model is also found
in the maturational task model of adolescence and in psychodynamic
models (Evans, 1982) and in many other psychologies as well as
in the legal and social work assumption that people have responsibility
for their actions. I repeat, tackling tasks and finding solutions
may require reflective action, including all varieties of asessment
and research, thought and imagination.
The tools for our tasks include our body and its abilities, which both support and limit our actions and without which we could do, and therefore would be, nothing. We disrupt ourselves if we turn our attention from what we are using the tools for and focus on the tools themselves (Polanyi, 1961) . This should happen, however, if the tools are faulty, for example when our body is diseased. It is then that the expert knowledge of such diseases and their repair is called for. Here is a clear place for the study of the body's healthy functioning, pathology, and treatment. Since almost anything can go wrong with the body, and in any organ or system of it, it would be surprising if the brain was the only organ exempt from physical pathology. Unfortunately, the close relationship the brain has to the operations of the person it belongs to, makes it notoriously difficult to establish in theory and in practice how that person and his or her brain mesh, especially when it does go wrong (Foulds and Bedford, 1975). Nevertheless, this logic gives the medical model its validity - in psychiatry as well. The logic emphasises that the importance of any disease (and death) is that it disrupts people in tackling their personal life tasks, however much this personal life may also be congruent with an underlying biological survival instinct which disease also threatens. That personal and biological life should be distinguished needs only one illustration, that central concern in psychiatry, suicide. Similarly, that some of us are established as a profession to care for the diseased would be seen as arising out of a personal or social concern for others; that is, the arrangement is only partly congruent with biological requirements such as the survival of our genes, the race and/or the fittest.
Now, if an individual person cannot work out what to do about this task, then we could term it a problem. The solution is characteristically to seek advice or help from another person, or one might just like working with other people. So a group of two forms to share the problem-solving process
The tools for our tasks include our body and its abilities, which both support and limit our actions and without which we could do, and therefore would be, nothing. We disrupt ourselves if we turn our attention from what we are using the tools for and focus on the tools themselves (Polanyi, 1961) . This should happen, however, if the tools are faulty, for example when our body is diseased. It is then that the expert knowledge of such diseases and their repair is called for. Here is a clear place for the study of the body's healthy functioning, pathology, and treatment. Since almost anything can go wrong with the body, and in any organ or system of it, it would be surprising if the brain was the only organ exempt from physical pathology. Unfortunately, the close relationship the brain has to the operations of the person it belongs to, makes it notoriously difficult to establish in theory and in practice how that person and his or her brain mesh, especially when it does go wrong (Foulds and Bedford, 1975). Nevertheless, this logic gives the medical model its validity - in psychiatry as well. The logic emphasises that the importance of any disease (and death) is that it disrupts people in tackling their personal life tasks, however much this personal life may also be congruent with an underlying biological survival instinct which disease also threatens. That personal and biological life should be distinguished needs only one illustration, that central concern in psychiatry, suicide. Similarly, that some of us are established as a profession to care for the diseased would be seen as arising out of a personal or social concern for others; that is, the arrangement is only partly congruent with biological requirements such as the survival of our genes, the race and/or the fittest.
Now, if an individual person cannot work out what to do about this task, then we could term it a problem. The solution is characteristically to seek advice or help from another person, or one might just like working with other people. So a group of two forms to share the problem-solving process
This second person may be a friend,
a relative, a colleague (or a book they have written); or it may
be a helping agent like the general practitioner, a teacher or
a lawyer. Some people do not seek help - they behave in such a
way that other people believe they need to be helped. For example,
delinquent children and families draw in the legal and social
services; babies draw in their parents. Developmentally this group
of two is the first stage - the baby and the mothering person
- since for a baby even the most simple task is a problem which
requires the help of others. Although the traditional psychiatric
interview mirrors this twosome, the group is usually more than
two.
Especially in child and family psychiatry we discover that 'other persons' may include: one or two parents, step-parents, siblings, extended family, friends and neighbours, and sometimes as many other helping agents. Even dead people's ideas may be kept alive by a family (e.g. 'your grandfather would have wanted it this way').
Especially in child and family psychiatry we discover that 'other persons' may include: one or two parents, step-parents, siblings, extended family, friends and neighbours, and sometimes as many other helping agents. Even dead people's ideas may be kept alive by a family (e.g. 'your grandfather would have wanted it this way').
The concept of groups or systems
of people united by a common task or problem occurs in social
and clinical psychology, group psychotherapy, family systems theory
and in the study of all kinds of other work-groups, committees
and organisations.
Influenced by the external group of persons, particularly one's family of origin, another group of persons develops, the inner persons or selves.
Influenced by the external group of persons, particularly one's family of origin, another group of persons develops, the inner persons or selves.
The concept of the mind or psyche
being a more or less integrated collection of intra-personal selves
is found in all forms of psychodynamic theory.
So far then, the model presents a picture of all these persons getting on with the job, which is to identify (or simply do) their tasks and problems, including the tackling of individual and family maturational tasks, communicating and integrating their abilities and ideas to result in affectionate, respectful and supportive co-operation. Because they are functioning so positively, or at least well enough, such groups and individuals do not present themselves for further investigation or help. If it exists, many of us may not have experienced such functioning, and this may limit how far we can take our patients back towards such a healthy state - even though we may be employed by a 'health' service (Davidson, 1984). What is missing in the description so far comes under one heading, conflict:
CONFLICT, CONSENSUS, ENABLING, ABLING AND DISABLING
Conflict can be inter-personal and/or intra-personal. Like the original task, problem and solution, inter (and intra -) personal conflict and its resolution can be seen to be a universal and perpetual process varying only in degree and enjoyment (Galtung, 1967). Some conflicts are cultivated for fun as in the fields of sport, love, academics and politics. Inter-personal conflict comes to psychiatrists and other helping agents when it gets unpleasantly disagreeable - a patient is behaving disturbingly, a child does not do what his parents would like and vice versa, the parents do not really pull together anyway, or the whole family may be unable to keep its members from breaking the law of the land; one helping professional may disagree with another about what should be done, and the patient may not put their doctor's prescriptions and advice into practice anyway, and so on. A person may come to fear the consequences of inter-personal life and keep involvement with other people and helpers to a superficial minimum. Their need for attention (and so the potential for inter-personal conflict) may then be expressed indirectly using more impersonal symptoms of need carried on complaints of real or imaginary illness, or of self-imposed fate such as parasuicide or anorexia nervosa.
So far then, the model presents a picture of all these persons getting on with the job, which is to identify (or simply do) their tasks and problems, including the tackling of individual and family maturational tasks, communicating and integrating their abilities and ideas to result in affectionate, respectful and supportive co-operation. Because they are functioning so positively, or at least well enough, such groups and individuals do not present themselves for further investigation or help. If it exists, many of us may not have experienced such functioning, and this may limit how far we can take our patients back towards such a healthy state - even though we may be employed by a 'health' service (Davidson, 1984). What is missing in the description so far comes under one heading, conflict:
CONFLICT, CONSENSUS, ENABLING, ABLING AND DISABLING
Conflict can be inter-personal and/or intra-personal. Like the original task, problem and solution, inter (and intra -) personal conflict and its resolution can be seen to be a universal and perpetual process varying only in degree and enjoyment (Galtung, 1967). Some conflicts are cultivated for fun as in the fields of sport, love, academics and politics. Inter-personal conflict comes to psychiatrists and other helping agents when it gets unpleasantly disagreeable - a patient is behaving disturbingly, a child does not do what his parents would like and vice versa, the parents do not really pull together anyway, or the whole family may be unable to keep its members from breaking the law of the land; one helping professional may disagree with another about what should be done, and the patient may not put their doctor's prescriptions and advice into practice anyway, and so on. A person may come to fear the consequences of inter-personal life and keep involvement with other people and helpers to a superficial minimum. Their need for attention (and so the potential for inter-personal conflict) may then be expressed indirectly using more impersonal symptoms of need carried on complaints of real or imaginary illness, or of self-imposed fate such as parasuicide or anorexia nervosa.
The solution to inter-personal conflict
is inter-personal conflict resolution. The techniques (at least
in child and family psychiatry) are designed for this purpose
- family and team meetings, case conferences etc. Less mature
methods of conflict resolution are avoidance, force, submission
and compromise. Healthy methods entail a positive and open exploration
of the conflict, especially the basic assumptions that hold it
together, until some new understanding, resolution or way of perceiving
things arise. The result of conflict resolution should be inter-personal
consensus and cooperation, the degree required being itself a
matter for debate. For example, some have the skill, authority
or charisma to engage families or individuals directly in therapy
where others have to liaise with other agencies in order to channel
a patient back to continue the work. This model emphasises that
the purpose of any work is ultimately set in the dimension of
the future; and that attention to boundaries is always required,
that is, to do with which personnel are to make what commitment,
in deeds more importantly than words; of time and energy to the
task; and that, where boundaries are themselves problematic, limit-setting
becomes the basic element of any effective work.
The detailed study of how groups do or do not organise themselves to carry out their tasks and solve their problems, and how they may be helped, is the province of those who study and work with families and other groups systems and organisations. An appropriate framework here would the the McMaster Model of family functioning (Epstein and Bishop, 1978). Unfortunately, in itself this approach is too skeletal for clinical work and training. The guts and the muscle have to be supplied by the practitioners themselves with help from other approaches.
The more intimate varieties of inter-personal conflict in family life are the most complex kind, so especially sophisticated methods of family therapy have been developed. The complications are largely to do with the second category of conflict - intra-personal conflict. Intra-personal conflict can be said to be when one individual feels, thinks, talks or behaves, simultaneously or over a period of time, as if s/he were two or more people differing, disagreeing or conflicting with each other over what should be done. The person is said to have mixed feelings, ambivalence or to be in two minds about something.
The detailed study of how groups do or do not organise themselves to carry out their tasks and solve their problems, and how they may be helped, is the province of those who study and work with families and other groups systems and organisations. An appropriate framework here would the the McMaster Model of family functioning (Epstein and Bishop, 1978). Unfortunately, in itself this approach is too skeletal for clinical work and training. The guts and the muscle have to be supplied by the practitioners themselves with help from other approaches.
The more intimate varieties of inter-personal conflict in family life are the most complex kind, so especially sophisticated methods of family therapy have been developed. The complications are largely to do with the second category of conflict - intra-personal conflict. Intra-personal conflict can be said to be when one individual feels, thinks, talks or behaves, simultaneously or over a period of time, as if s/he were two or more people differing, disagreeing or conflicting with each other over what should be done. The person is said to have mixed feelings, ambivalence or to be in two minds about something.
The solution is again conflict resolution.
The methods used are individual (or sometimes group) psychotherapies
or case work, which are inter-personal situations, however. The
result of such work should be greater intra-personal consensus
with its associated personal integration and greater capacity
and freedom for dealing with internal and external reality (including
other people).
The detailed study of how individuals do or do not organise themselves (that is, their internal group) to carry out tasks and solve problems, and how they may be helped, is the province of those who study individual psychology and work with individuals in psychotherapy, psychoanalysis and case work. An appropriate framework here might be the 'action language' developed by Schafer (1976). Unfortunately in itself this approach is too skeletal for clinical work and training. The guts and muscle have to be supplied by the practitioners themselves with help from other approaches. It is a pity that outsiders find that many of these other approaches in psychodynamic theory use the word 'object' without reservation to mean 'person' when a person is usually defined by contrast with an object. There are also much broader problems over the nature of the language used (Schafer, 1976; Brandt, 1961; Bettleheim, 1983)
Once conflict is resolved in any particular instance so that sufficient consensus and integrity exist, two forms of co-operation can be described that lead to the solution of the original problem. First, enabling, which corresponds to Fairbairn's 'mature dependence' (1941) and is the basic form of all psychotherapy.
The detailed study of how individuals do or do not organise themselves (that is, their internal group) to carry out tasks and solve problems, and how they may be helped, is the province of those who study individual psychology and work with individuals in psychotherapy, psychoanalysis and case work. An appropriate framework here might be the 'action language' developed by Schafer (1976). Unfortunately in itself this approach is too skeletal for clinical work and training. The guts and muscle have to be supplied by the practitioners themselves with help from other approaches. It is a pity that outsiders find that many of these other approaches in psychodynamic theory use the word 'object' without reservation to mean 'person' when a person is usually defined by contrast with an object. There are also much broader problems over the nature of the language used (Schafer, 1976; Brandt, 1961; Bettleheim, 1983)
Once conflict is resolved in any particular instance so that sufficient consensus and integrity exist, two forms of co-operation can be described that lead to the solution of the original problem. First, enabling, which corresponds to Fairbairn's 'mature dependence' (1941) and is the basic form of all psychotherapy.
The second person advises, interprets,
educates or whatever, so that the first person is enabled to sort
out his or her problem, thus converting it (according to my definition)
back into the first person's task. The problem is not detached
from the first person. The aim of the exercise is increasing the
first person's abilities - enabling. Examples of problems appropriately
handled this way are: learning anything from 'do it yourself'
skills to professional expertise; coping with chronic or recurrent
illness (e.g. diabetes, epilepsy, most mental illness) where the
sufferer characteristically has to play a large part in the management
because such conditions cannot be detached from them; all kinds
of life problems (e.g about one's education, employment, leaving
home, getting married and so on) as well as the emotions that
naturally arise in tackling such life tasks, problems and conflicts.
Emotions arising in this way are not detachable despite widespread
attempts to detach them, for example, with volumes of pills or
alcohol.
The second type of problem-solving interaction is detaching or abling, which corresponds to Fairbairn's 'infantile dependence' (1941) and is also the basic form of the medical relationship. The second person can detach some kinds of problem from the person they are attached to. For example, a toddler's shoe lace is done up for him, a broken down car is taken off by the garage mechanic, or a broken body is taken to the doctor for an operation etc. Each instance still has to be negotiated with the first person (where possible), even if this is just the routine signing of permission to repair the car or operate on the body. The exercise of detaching problems is not complete unless the mended car or body is handed back to the owner or some explanation made otherwise.
The second type of problem-solving interaction is detaching or abling, which corresponds to Fairbairn's 'infantile dependence' (1941) and is also the basic form of the medical relationship. The second person can detach some kinds of problem from the person they are attached to. For example, a toddler's shoe lace is done up for him, a broken down car is taken off by the garage mechanic, or a broken body is taken to the doctor for an operation etc. Each instance still has to be negotiated with the first person (where possible), even if this is just the routine signing of permission to repair the car or operate on the body. The exercise of detaching problems is not complete unless the mended car or body is handed back to the owner or some explanation made otherwise.
The first person who hires the expert's
services does not gain any knowledge or ability as a result of
this - s/he is returned only to her or his previous able bodied
state, which is the only way the non-expert can judge that the
expert has done their job properly. Successful detaching is therefore
an 'abling' exercise. We all may experience how this delicate
process of detaching problems can go wrong and lead to various
forms of distress or lessened ability ('disabling') - even if
the original problem is solved in the process. For example, there
may be side effects of the treatment or the frustration of the
doctor-patient relationship that is so like the parent-infant
one. This view emphasises that, before treatment is started or
patients admitted to hospital, due consideration be given to what
a patient will face at the end of the exercise when the treatment
is stopped and the patient discharged.
DISCUSSION
This basic model fits most of the criteria suggested in the introduction. If it is accepted, many implications arise out of it. It is not possible to deal with them here, but I think it would be useful to clarify some of the confusions (also described in the introduction) of the various models used in medicine and psychiatry at present - and especially in child and family psychiatry (which I know best).
According to this model, psychiatrists must be able to operate the medical model in order to deal with the psychiatric and biological order of problems presented. But we must also be proficient in handling the rather different personal order of life's tasks, problems and conflicts. Although the biological and the personal are to be distinguished, it is often not a clear cut decision in psychiatry as to which of them a particular problem belongs, or should be first treated as belonging (since there may be uncertainty in this matter). The decision is therefore a matter for general and particular debate and discussion.
Such debate in academic and in clinical arenas (journals, case conferences etc) is itself an example of conflict and its several forms of attempted resolution (avoidance, force, compromise etc). The argument over which theory or diagnosis is the right one can resemble the argument between the blind holy men in the Sufi tale where each one held a partial but correct idea of the nature of the elephant they examined in the dark according to which part of the elephant they handled. Long debate is possible when the conflict is one of relatively abstract theories, ideas or labels.
The more usual conflict in the reality of our lives, families, clinical work and committees, is the less abstract conflict over what solution or action to take. Often the conflicting parties have the same aim otherwise they would not be in conflict over how to achieve it. Watzlawick et al (1974) provide a good illustration or conflict of action - two sailors desperately leaning backwards over opposite sides of their yacht trying to steady an already steady boat. Apart from their intended illustration of the perpetuation of a problem by 'more of the same' solution, the metaphor of boats and sailors can help to put our medical and psychosocial models in their place.
In much of medicine proper there is effectively only one sailor - the doctor. The doctor is acknowledged to be the expert who is allowed to sail the boat of illness steadily through the relatively straightforward waters of diagnosis and treatment while the patient sits quietly and hopefully in the bottom of the boat. The boat is steady because everyone already agrees without discussion that 'illness should be diagnosed and treated and that this is the doctor's job'. In other words, the medical model is based on ready-made inter-personal consensus.
At the other end of the spectrum (with adult psychiatry somewhere in the middle), in the boat of child care (which is what child and family psychiatry is largely about) everyone is an expert. Everyone may roughly agree that we all want what is best for the child or the patient. However, everyone also feels it is they who know what the best is - or a last they know when others have got it wrong. If the child in the middle is the boat they are trying to sail, even the boat shows a mind of its own. In child care, at least, we find that there may be up to two dozen sailors, many with pretensions to being captain, trying to guide the situation. It is unlikely that asserting that you should be captain because you are a doctor is going to help in the long run. Nowadays, what is often needed is fewer people, not more, in the boat. That is, child and family psychiatry if not general psychiatry as well, is largely dealing with interpersonal and intrapersonal conflict and their resolution, in a field where consensus is not ready made.
In child and family psychiatry, two characteristic pictures appear corresponding to the problem solving style adopted by those involved. A steady and impossibly strained state may have been reached with tense over-organised concern and efforts (as in Watzlawick et al's illustration); or all the crew may be rushing around with under-organised concern and efforts (Jenkins 1983). In both instances, the key sign that distinguishes them from healthily organised crews is their lack of having flexible options available. In short, there is no room for productive discussion, argument, play or humour. In both over-organised and under-organised situations, more effective discussion and co-operation are required, but this is difficult because of loyalty to well-tried if repeatedly unsuccessful methods. The reason a medically trained person may validly be asked to join the crew is because someone believes that they have an ill or mad crew member on board.
This metaphor emphasises several assumptions. For example, psychosocial disorders may be more validly classified as 'styles of problem solving' than as symptom complexes or diseases. Neurotic families and children would be those whose problem solving style is an over-organised one; the under-organised styles are those employed by 'problem families' with delinquent or conduct disordered children. This categorisation does generate the forms of help we put into practice. The over-organised need disorganising a little, psychotherapy being a gentle way to loosen defences and speak about the unspeakable; but instead they may receive a tense over-organised response from a single agency (usually medical) which does not help. The under-organised need organising, psychiatrists and social workers often requiring auxiliary authority from legal agencies, but instead the agencies are often collectively rather unorganised themselves, which therefore does not help much.
Whether or not diagnostic classification is altered, this model implies that the psychiatrist's clinical task may be to use medical authority to diagnose psychological health as far as possible (or at least to know the limits of treatment available for any medical conditions present) and then know how to help the person, their family and any other helpers involved to discover how to get on with life without the aid of a real or imaginary illness (if that is what they were doing). For clinical purposes, letters to general practitioners etc, there are more ordinary (and so, more comprehensible) ways to express the nature of the problem and problem-solving methods of our patients and their families than to employ the recommended diagnostic codes (at least for non-psychotic disorders - 300-313 in the I.C.D. (W.H.O. 1978) and also to describe our proposed interventions with less mystification.
Consultants, I understand, used to consult more literally to the nursing sisters of hospitals and to general practitioners. Nowadays, patients are generally taken into the hands of hospital doctors as out-patients - a detaching process. It seems that, despite the ready availability of the telephone, the 'enabling' consultation process is not now approved of or considered to be as worthwhile a use of time as the more direct technical forms of investigation and help. Even so, whatever form the specialist service takes (including admission to hospital, or any other residential setting for that matter), the aim of the exercise is generally to discharge patients having returned their normal functioning by detaching their problems (abling them), or (if that is not possible) to enable them, their families and primary carers in the community (if they are to return to the community) to cope with the undetachable problems. Thus, all specialists and professionals have an influence on individual, family and community functioning. Therefore, the question is not whether to do anything about this aspect or not, but whether what we are doing, be it a large scale intervention or a minor comment, is positive (abling or enabling) or negative (disabling) on the functioning of those served. Since our answer must be that we wish to have positive effects, the question essentially becomes one of how to achieve them.
REFERENCES
BALINT, M (1957) The Doctor, His Patient and the Illness. London:Pitman.
BALINT, M. , HUNT. J., JOYCE, R., MARINER, M.M. & WOODCOCK, J. (1970) Treatment or Diagnosis: A Study of Repeat Prescriptions in General Practice. London : Tavistock.
BANNISTER, D & FRANSELLA, F. (1971) Enquiring Man: The Theory of Personal Constructs. Pelican.
BETTLEHEIM, B. (1983) Freud and Man's Soul. London. Chatto & Windus
BRANDT, L.W. (1961) Some notes on English Freudian terminology. Journal of the American Psychoanalytic Association, 9, 331-33
CONFORD, P. (1977) John Macmurray: a neglected philosopher. Radical Philosophy, 16, 16-20.
DAVIDSON, L. (1984) The acquisition and development of technical resources: a personal view. Health Bulletin (S.H.H.D), 42/1, 5-13.
EVANS, J. (1982) Adolescent and Pre-adolescent Psychiatry. London: Academic Press
EPSTEIN, N.B, 7 BISHOP.D. (1978) The McMaster model of family functioning. Journal of Marriage & Family Counselling, 3, 19-31
FAIRBAIRN, W.R.D. (1941) A revised psychopathology of the psychoses and psychoneuroses. In Psychoanalytic Studies of the Personality. London: Tavistock
FOULDS, G.A., & BEDFORD, A. (1975) The hierarchy of classes of personal illness. Psychological Medicine, 5, 181-192
GALTUNG, J. (1967) Theories of Conflict. Basic Social Science Monographs No1. Oslo : International Peace Research Institute
JENKINS, H. (1983) A life-cycle framework in the treatment of under organised families. Journal of Family Therapy, 5: 359-377
MACMURRAY, J. (1957) The Self as Agent. Faber.
MACMURRAY, J. (1961). Persons in Relation. Faber.
MAGEE, B. (1973) Popper. Fontana Modern Masters. Glasgow: Fontana/Collins.
NEW INTERNATIONALIST (1984) The Treatment of Mental Illness. No.132, London: New Internationalist Publications.
POLANYI, M. (1961) Faith and reason. Journal of Religion, 41, 237-247
RUTTER, M. (1977) Individual differences. In Child Psychiatry: Modern Approaches. (Eds. Rutter,M & Hersov, L.A.) London : Blackwell.
SCHAFER, R.(1976) A New Language for Psychoanalysis. New Haven & London
Yale University Press.
WATZLAWICK, P., WEAKLAND, J. & FISCH, R. (1974) Change: Principles of Problem Formation & Problem
Resolution. New York : Norton
WILLIAMS, R. (1976) Keywords : A Vocabulary of Culture & Society. Fontana Communications Series. Glasgow : Fontana/Croom Helm
WORLD HEALTH ORGANISATIONS (1978) Mental Disorders: Glossary and Guide to Their Classification in
Accordance with the Ninth Revision of the International Classification of Diseases. Geneva. World Health Organisation.
DISCUSSION
This basic model fits most of the criteria suggested in the introduction. If it is accepted, many implications arise out of it. It is not possible to deal with them here, but I think it would be useful to clarify some of the confusions (also described in the introduction) of the various models used in medicine and psychiatry at present - and especially in child and family psychiatry (which I know best).
According to this model, psychiatrists must be able to operate the medical model in order to deal with the psychiatric and biological order of problems presented. But we must also be proficient in handling the rather different personal order of life's tasks, problems and conflicts. Although the biological and the personal are to be distinguished, it is often not a clear cut decision in psychiatry as to which of them a particular problem belongs, or should be first treated as belonging (since there may be uncertainty in this matter). The decision is therefore a matter for general and particular debate and discussion.
Such debate in academic and in clinical arenas (journals, case conferences etc) is itself an example of conflict and its several forms of attempted resolution (avoidance, force, compromise etc). The argument over which theory or diagnosis is the right one can resemble the argument between the blind holy men in the Sufi tale where each one held a partial but correct idea of the nature of the elephant they examined in the dark according to which part of the elephant they handled. Long debate is possible when the conflict is one of relatively abstract theories, ideas or labels.
The more usual conflict in the reality of our lives, families, clinical work and committees, is the less abstract conflict over what solution or action to take. Often the conflicting parties have the same aim otherwise they would not be in conflict over how to achieve it. Watzlawick et al (1974) provide a good illustration or conflict of action - two sailors desperately leaning backwards over opposite sides of their yacht trying to steady an already steady boat. Apart from their intended illustration of the perpetuation of a problem by 'more of the same' solution, the metaphor of boats and sailors can help to put our medical and psychosocial models in their place.
In much of medicine proper there is effectively only one sailor - the doctor. The doctor is acknowledged to be the expert who is allowed to sail the boat of illness steadily through the relatively straightforward waters of diagnosis and treatment while the patient sits quietly and hopefully in the bottom of the boat. The boat is steady because everyone already agrees without discussion that 'illness should be diagnosed and treated and that this is the doctor's job'. In other words, the medical model is based on ready-made inter-personal consensus.
At the other end of the spectrum (with adult psychiatry somewhere in the middle), in the boat of child care (which is what child and family psychiatry is largely about) everyone is an expert. Everyone may roughly agree that we all want what is best for the child or the patient. However, everyone also feels it is they who know what the best is - or a last they know when others have got it wrong. If the child in the middle is the boat they are trying to sail, even the boat shows a mind of its own. In child care, at least, we find that there may be up to two dozen sailors, many with pretensions to being captain, trying to guide the situation. It is unlikely that asserting that you should be captain because you are a doctor is going to help in the long run. Nowadays, what is often needed is fewer people, not more, in the boat. That is, child and family psychiatry if not general psychiatry as well, is largely dealing with interpersonal and intrapersonal conflict and their resolution, in a field where consensus is not ready made.
In child and family psychiatry, two characteristic pictures appear corresponding to the problem solving style adopted by those involved. A steady and impossibly strained state may have been reached with tense over-organised concern and efforts (as in Watzlawick et al's illustration); or all the crew may be rushing around with under-organised concern and efforts (Jenkins 1983). In both instances, the key sign that distinguishes them from healthily organised crews is their lack of having flexible options available. In short, there is no room for productive discussion, argument, play or humour. In both over-organised and under-organised situations, more effective discussion and co-operation are required, but this is difficult because of loyalty to well-tried if repeatedly unsuccessful methods. The reason a medically trained person may validly be asked to join the crew is because someone believes that they have an ill or mad crew member on board.
This metaphor emphasises several assumptions. For example, psychosocial disorders may be more validly classified as 'styles of problem solving' than as symptom complexes or diseases. Neurotic families and children would be those whose problem solving style is an over-organised one; the under-organised styles are those employed by 'problem families' with delinquent or conduct disordered children. This categorisation does generate the forms of help we put into practice. The over-organised need disorganising a little, psychotherapy being a gentle way to loosen defences and speak about the unspeakable; but instead they may receive a tense over-organised response from a single agency (usually medical) which does not help. The under-organised need organising, psychiatrists and social workers often requiring auxiliary authority from legal agencies, but instead the agencies are often collectively rather unorganised themselves, which therefore does not help much.
Whether or not diagnostic classification is altered, this model implies that the psychiatrist's clinical task may be to use medical authority to diagnose psychological health as far as possible (or at least to know the limits of treatment available for any medical conditions present) and then know how to help the person, their family and any other helpers involved to discover how to get on with life without the aid of a real or imaginary illness (if that is what they were doing). For clinical purposes, letters to general practitioners etc, there are more ordinary (and so, more comprehensible) ways to express the nature of the problem and problem-solving methods of our patients and their families than to employ the recommended diagnostic codes (at least for non-psychotic disorders - 300-313 in the I.C.D. (W.H.O. 1978) and also to describe our proposed interventions with less mystification.
Consultants, I understand, used to consult more literally to the nursing sisters of hospitals and to general practitioners. Nowadays, patients are generally taken into the hands of hospital doctors as out-patients - a detaching process. It seems that, despite the ready availability of the telephone, the 'enabling' consultation process is not now approved of or considered to be as worthwhile a use of time as the more direct technical forms of investigation and help. Even so, whatever form the specialist service takes (including admission to hospital, or any other residential setting for that matter), the aim of the exercise is generally to discharge patients having returned their normal functioning by detaching their problems (abling them), or (if that is not possible) to enable them, their families and primary carers in the community (if they are to return to the community) to cope with the undetachable problems. Thus, all specialists and professionals have an influence on individual, family and community functioning. Therefore, the question is not whether to do anything about this aspect or not, but whether what we are doing, be it a large scale intervention or a minor comment, is positive (abling or enabling) or negative (disabling) on the functioning of those served. Since our answer must be that we wish to have positive effects, the question essentially becomes one of how to achieve them.
REFERENCES
BALINT, M (1957) The Doctor, His Patient and the Illness. London:Pitman.
BALINT, M. , HUNT. J., JOYCE, R., MARINER, M.M. & WOODCOCK, J. (1970) Treatment or Diagnosis: A Study of Repeat Prescriptions in General Practice. London : Tavistock.
BANNISTER, D & FRANSELLA, F. (1971) Enquiring Man: The Theory of Personal Constructs. Pelican.
BETTLEHEIM, B. (1983) Freud and Man's Soul. London. Chatto & Windus
BRANDT, L.W. (1961) Some notes on English Freudian terminology. Journal of the American Psychoanalytic Association, 9, 331-33
CONFORD, P. (1977) John Macmurray: a neglected philosopher. Radical Philosophy, 16, 16-20.
DAVIDSON, L. (1984) The acquisition and development of technical resources: a personal view. Health Bulletin (S.H.H.D), 42/1, 5-13.
EVANS, J. (1982) Adolescent and Pre-adolescent Psychiatry. London: Academic Press
EPSTEIN, N.B, 7 BISHOP.D. (1978) The McMaster model of family functioning. Journal of Marriage & Family Counselling, 3, 19-31
FAIRBAIRN, W.R.D. (1941) A revised psychopathology of the psychoses and psychoneuroses. In Psychoanalytic Studies of the Personality. London: Tavistock
FOULDS, G.A., & BEDFORD, A. (1975) The hierarchy of classes of personal illness. Psychological Medicine, 5, 181-192
GALTUNG, J. (1967) Theories of Conflict. Basic Social Science Monographs No1. Oslo : International Peace Research Institute
JENKINS, H. (1983) A life-cycle framework in the treatment of under organised families. Journal of Family Therapy, 5: 359-377
MACMURRAY, J. (1957) The Self as Agent. Faber.
MACMURRAY, J. (1961). Persons in Relation. Faber.
MAGEE, B. (1973) Popper. Fontana Modern Masters. Glasgow: Fontana/Collins.
NEW INTERNATIONALIST (1984) The Treatment of Mental Illness. No.132, London: New Internationalist Publications.
POLANYI, M. (1961) Faith and reason. Journal of Religion, 41, 237-247
RUTTER, M. (1977) Individual differences. In Child Psychiatry: Modern Approaches. (Eds. Rutter,M & Hersov, L.A.) London : Blackwell.
SCHAFER, R.(1976) A New Language for Psychoanalysis. New Haven & London
Yale University Press.
WATZLAWICK, P., WEAKLAND, J. & FISCH, R. (1974) Change: Principles of Problem Formation & Problem
Resolution. New York : Norton
WILLIAMS, R. (1976) Keywords : A Vocabulary of Culture & Society. Fontana Communications Series. Glasgow : Fontana/Croom Helm
WORLD HEALTH ORGANISATIONS (1978) Mental Disorders: Glossary and Guide to Their Classification in
Accordance with the Ninth Revision of the International Classification of Diseases. Geneva. World Health Organisation.
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