On thoughts and thinking

Dr Claire Norman wrote an article about how she asks whether her patients think of self-harm or suicide. It is very welcome when clinicians engage with scholars studying clinical communication and I applaud the article. However, I think the article could go further and here is my reflection on it.

Dr Norman quotes a question she is likely to ask. It goes something like this:

I’m really sorry, it’s just something we have to ask everyone, but you’ve not had any thoughts of hurting yourself or anything like that have you?

and adds that the question in the negative is likely to prime the patient to respond in the negative (she quotes a great paper by Joe Ford and others).

She then says that when she changed the question to:

Sometimes when people are feeling low and down like this, they have thoughts of hurting themselves or ending their life. Is that something that you’ve experienced?

She received responses in the affirmative.

But then comes the fragment in the article that I want to comment on. Dr Norman says

A clinician asking about it sensitively is unlikely to make them think ‘you know what? I hadn’t thought about hurting myself but now that you’ve mentioned it, I think I will!’.

Let me explain. When the GP asks formal, diagnostic questions, she enquires about thoughts; when she offers a hypothetical response and suggests what her patient might say, she actually doesn’t use the word ‘thoughts’. She imagines the person to use the verb ‘think’. The change is significant, as it reflects the shift from the doctors talk to how patients are likely to talk. We are unlikely to talk about our thoughts, we are likely to tell people what we think (about). And when Dr Norman takes off her diagnostic hat, the thought-units disappear and thinking, a continuity appears. Like in real life.

Let me go further. I don’t do ‘thoughts’. You know, whatever happens in my head cannot be explained by one thought starting, then ending, then another one, and another. All beautifully formed, ready to be harvested by a clinician. In contrast, I do thinking. It’s continuous, sometimes conflicted, often about a zillion things at the same time. Yet, both in English and in my native Polish, medics keep asking people about their thoughts. And, I think, it’s just about the only context when we are likely to hear such questions. In the ‘real world’, we tend to ask people about what they think (about), but never what thoughts they have (unless, in English, by ‘thoughts’ you mean opinions, but that’s different).

Why do medics ask such questions? There are at least two (related) sources of such questions. First, it’s medicine’s insistence on dealing with clear objects. They offer semblance of objectivity and through this an opportunity for inspection. What I say, my story, told in Mishler’s ‘language of the lifeworld’, is translated into the ‘language of medicine’ and the fuzziness of my experience is turned into the clarity of an object medicine can deal with.

It’s also worth stressing that no matter how great a medic you are, you actually have no access to my ‘thoughts’. All you have is access to what I tell you about my thoughts. And as clinicians have access only to stories of ‘suicidal thoughts’, it makes sense to open space for them. Yet, Dr Norman’s article shows interest only in existence of ‘thoughts’, it also shows that the space for the story is explicitly closed. Dr Norman’s hypothetical consultation redirects the story it to the Crisis team.  Note, incidentally, that I have no idea what happens in the surgery, what I have is also only Claire Norman’s story.

Furthermore, accounts of suicidal ideation have a linguistic form. Justyna Ziółkowska and I wrote a paper on stories of suicidal thoughts. We found that stories of ‘suicidal thoughts’ created a much more heterogeneous group than is currently assumed by medicine/psychiatry. By focusing only on their existence, clinicians are likely to lose clinically significant information, let alone miss the opportunity to engage with patients’ experience.

The second source of talking about thoughts, rather than about what people think, are texts of diagnostic criteria which reduce human experience to observable objects that are subject to medical examination and classification and whose existence is only to be confirmed. There is evidence that the way medics talk can be traced back to the diagnostic manuals. But while you can just about understand why diagnostic manuals engage in such discursive reduction, their texts are not meant to be used in clinical practice. Indeed, authors of clinical guides in mental healthcare are adamant that it is expression of patients’ experience that should be encouraged and engaged with by the clinician. Putting it differently, people don’t do diagnostic criteria, people have a host of experiences they should be able to talk about during a medical encounter.

If there is a term that keeps popping up in today’s medicine, it’s the focus on the patient (patient-centred medicine), in all their contexts. As you do not have access to what I think, how I live, to my relationships, worries and joys, the only way to gain insight into me as a social human being is through my stories. And you can start by letting me tell you my story by asking what I think about, and not what my thought-units are.


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