Explanatory models in psychiatry

Dein (2002) comments on our editorial on explanatory models (Bhui & Bhugra, 2002), but fails to apprehend the conceptual flaws in his assertions, promotes a complacent attitude to the challenges of cultural psychiatry, and is threatened by a patient’s explanatory model that differs from his own. Dein agrees with us that explanatory models are not stable, and are dynamic, complex, shifting entities, making more research necessary for any consistent theory about their role in routine clinical practice. None the less, their role in improving understanding of patients’ cultural world views has not previously been in dispute (American Psychiatric Association, 2002). Although Dein gives greater weight to behavioural expressions of explanatory models, he does not question whether explanatory models can or should be considered as a psychological construct of the individual, or as a group or social– behavioural phenomenon, or both. Each of these conceptualisations is certainly distorted by theorising more concrete, but more easily understood, expressions of explanatory models. Contrary to the historical anthropological paradigm, it is not useful to psychiatric practice if valuable anthropological critiques simply ignore psychological and non-behavioural data. More worryingly, Dein assigns a patriarchal role to the psychiatrist, a role that cannot lead to a collaborative therapeutic relationship. It seems Dr Dein is not prepared to accept that a patient may pursue his or her own explanatory model and associated interventions, alongside those recommended by the psychiatrist. A fuller discussion of these alongside the psychiatrist’s own models allows for a shared vision of treatment and recovery. Why is an exorcism problematic for the psychiatrist? It is not in the realms of psychiatric knowledge or skills, and if helpful for recovery from illness, rather than disease, it should not be hindered. Dein appears to show contempt for a territory in which psychiatrists are not expert (possession and exorcisms: see Pereira et al, 1995), and certainly does not show the respect for cultural beliefs that is part and parcel of a scientific or anthropological study of healing, let alone clinical practice. His approach smacks of a patriarchal conviction that the diagnosis is more than a theory, and that psychiatric interventions are not to be questioned. To diagnose is to classify and to predict a course and treatment based on the vagaries of statistics and experience: it is to take what can be a serious risk (Romanucci-Ross et al, 1991). Although he cites a single example, it is not the case that the evidence base of traditional healing approaches are researched to the levels of esoteric knowledge found in biomedicine, except for, perhaps, acupuncture and Ayurveda where there is a growing literature. People will always be keen to try anything that helps them, biomedicine or culturally sanctioned traditional therapies. Surely he does not mean that we as psychiatrists have nothing to learn about treating illness from the traditional and complementary sector. Our view is we have plenty to learn and research. Eliciting explanatory models is a beginning of the process in consultations and offers an easily understandable method of learning about a patient’s culture. However, Dein’s view appears to be that we know enough, and need not discover more. We are surprised at this view and cannot agree.