Do Psychiatrists Hear Their Patients' Voices? The Importance of Qualitative Research on Brain-Related Technologies

During the past few decades there has been an upsurge in neuroscience research. Unprecedented intellectual efforts and financial resources have been invested in order to unravel the conundrums of the brain and the mind. Some of these prestigious neuroscience projects have been motivated, at least in part, by the ambition to translate and harness the fruits of their studies for the benefit of patients who suffer from brain-related disorders.

In comparison to the plethora of neuroscience research, qualitative research on psychiatric patients’ views pertaining to the clinical use of brain-related technologies is scarce. It is suggested that current predominant trends in psychiatry may explain the relative neglect of qualitative research pertaining to patients’ perspectives. Following the path of Karl Jaspers, who emphasized the central role of patients’ subjective experience in the understanding of psychopathology, it is argued that awareness of psychiatric patients' subjective perspective is crucial for the appropriate clinical and ethical use of brain-related technologies.

Lawrence and colleagues’ study (Lawrence et al. 2019) regarding patients’ beliefs about deep brain stimulation for treatment-resistant depression seems to be motivated by vulnerability-related ethical concerns. Nevertheless, Lawrence and colleagues’ qualitative approach expanded the ethical discussion beyond the conventional decision-making capacity considerations. Indeed, patients’ subjective experiences, including their “hopes and fears,” should play a greater role in clinical and ethical decision making.

THE BIOLOGICAL–PHENOMENOLOGICAL GAP

Neuroscience is a heterogeneous and multidisciplinary field. In spite of the impressive progress that has been achieved during the last few decades in our understanding of basic neuronal structures and processes, the complex neuronal basis underlying high-order mental functions is yet to be even remotely understood. Given the fact that the biological basis of neuroscience is mostly based on animals that lack the rich and complex consciousness-oriented capacities of humans, it is questionable whether neuroscience will be able to overcome this methodological barrier and provide practical solutions to mental disorders in the foreseeable future (Gold and Dudai 2016). Contrary to various neurological disorders that are not consciousness related (e.g., movement disorders, sensory deficits), almost all psychiatric disorders are consciousness-oriented; that is, they are directly related to higher order reflective and interpretative thinking. In other words, there is a wide gap between neuroscience and psychiatric disorders. Thus, unless one ideologically presupposes that all mental disorders are reducible to basic biological, chemical, or physical pathologies, neuroscience has to overcome major methodological barriers before it will be able to effectively address the heart of psychiatric disorders.

With this in mind, deep brain stimulation (DBS) is a good example for a potential effective intervention that may lead to clinical benefits in spite of the fact that the etiology and pathophysiology of the disorders it claims to treat are poorly understood. Given the foregoing, it is not surprising that this intervention was initially tested on neurological conditions, and only later was its use expanded to psychiatric disorders. The clinically positive outcomes of DBS in the treatment of several psychiatric disorders (Graat et al. 2017) may erroneously be interpreted as a proof for the biological reductionist approach to psychiatric disorders, including the argument that minimal attention should be paid to the subjective conscious experience of patients. According to this view, the fact that patients who suffer from obsessive-compulsive disorder (OCD) may be helped by a “brain pacemaker,” regardless of the specific content of their symptoms (e.g., obsessions about contamination or symmetry-oriented compulsions), illustrates that the phenomenology of mental disorders—that is, patients' specific conscious content—is quite peripheral in the clinical arena. Put differently, overenthusiasm about the biological dimensions of psychiatric disorders may compromise attention to and awareness of the phenomenological dimensions of mental illness.

The tension between the biological and the phenomenological approaches to mental disorders is hardly new. Karl Jaspers, more than a century ago, criticized the “cerebral mythologies” approach, “which … sought to interpret phenomenology and replace it by theoretical constructions of physiological and pathological cerebral processes” (Jaspers 1968, 1322). In the same vein, in his book General Psychopathology (Jaspers 1963) he intended “to present a psychopathology which … is not enslaved to neurology and medicine on the dogmatic grounds that ‘psychic disorder is cerebral disorder’” (4). He emphasized that "we must … as scientists, keep an open mind for all the empirical possibilities and guard against the temptation to reduce human experience to one common denominator" (6).

The phenomenological method Jaspers proposed is based on the capacity to “describe patients’ subjective experiences and everything else that exists or comes to be within the field of their awareness” (53). He called for an empathic “inward” understanding of patients’ subjectivity in parallel to the search of objective “outward” explanations that characterize the natural sciences. According to Jaspers, awareness of patients’ conscious experience is crucial: “We must begin with a clear representation of what is actually going on in the patient, what he is really experiencing, how things arise in his consciousness, what are his feelings, and so forth” (Jaspers 1968, 1316). Following his humanistic approach, Jaspers also recommended that psychiatrists “should acquire some of the viewpoints and methods that belong to the world of the Humanities and Social Studies” (Jaspers 1963, 36).

Jaspers was aware of the challenge his methodology confronted pertaining to the appropriate categorization of subjective experiences, given the fact that “phenomena can be arranged in quite different ways according to the purpose one has in view” (Jaspers 1968, 1320). He differentiated between the form and the content of subjective experiences. For example, a hallucination (form) is distinct from its specific content (a man, a tree, a threatening figure). Jaspers held that “phenomenology finds its major interest in form.” However, he acknowledged that “for patients, content is usually the one important thing.” As a result, “the psychologist who looks for meaning will find content essential and the form at times unimportant” (Jaspers 1963, 58–59).

It seems that the later editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) have followed the descriptive phenomenology approach that had been proposed and developed by Jaspers (Jablensky 2013), including the focus on the form and the relative neglect of the content. For example, the diagnosis of schizophrenia according to DSM V is built upon the existence of hallucinations and delusions, regardless of their specific content. Nevertheless, the humanistic spirit that characterized Jaspers’s approach can hardly be found in the DSM. According to Andreasen (2006, 111), “DSM has had a dehumanizing impact on the practice of psychiatry … DSM discourages clinicians from getting to know the patient as an individual person because of its dryly empirical approach."

In sum, current trends in neuroscience and psychiatry tend to minimize the role of patients’ subjective experience. In this setting, in addition to other factors that are beyond the scope of this discussion, it is not surprising that there is a relative neglect in qualitative research that focuses on psychiatric patients’ perspective. It is not an intentional neglect, but rather it is a by-product of a cultural trend that rests upon the predominance of the biological reductionist approach to mental illness.

HEARING VOICES

Arguably, the most iconic question that characterizes the psychiatric examination is the question “Do you hear voices?” When psychiatrists ask their patients this question at almost every intake, they intend to ensure that their patients are not suffering from auditory hallucinations. Psychiatrists understand that missing this symptom—hearing unreal voices—may lead to inaccurate diagnosis and treatment. However, it is equally crucial that psychiatrists should consider that not fully hearing the real voices of their patients may also lead to inaccurate diagnosis, treatment, and management.

The lack of attentiveness to patients’ subjective experience, in the context of the clinical use of brain-related technologies, may be problematic from clinical and ethical perspectives. For example, researchers assume that electroencephalogram (EEG) studies have no potential of causing any physical harm. However, this perception, which is probably correct from an “outward” objective biological perspective with regard to normal subjects, may be mistaken for some psychiatric patients, due to “inward” subjective reasons. The data pertaining to electroconvulsive therapy (ECT)-related anxiety (Obbels et al. 2017) may suggest that undergoing a procedure that includes a direct attachment to a patient's head may provoke realistic and unrealistic fears. This may be especially disturbing with regard to subjects who suffer from psychotic disorders. It is not unrealistic to assume that for some of these patients, the utilization of an unfamiliar (especially in the case of an invasive) brain-related technology may give rise to a paranoid attitude toward the medical staff conducting the study. Theoretically, this concern is more disturbing with regard to patients with delusional content relating to thought insertion or thought broadcasting. In turn, one can expect that the patient's adherence to therapy will be reduced. In this scenario, the brain-related intervention will indirectly result in a negative effect on the patient's well-being. Indeed, subjective experiences have been found to be a contributing factor to nonadherence to antipsychotics (Moritz et al. 2014; Taira et al. 2006).

It seems impossible to detect and effectively address this form of potential negative side effects of brain-related technologies unless researchers and clinicians are attuned to the subjective experience of their subjects, including the specific content of their symptoms. The investigation of the short- and long-term consequences of brain-related interventions should be focused on both the phenomenological and the biological levels. Informed consent protocols and institutional review board (IRB) policies may be adjusted based on the findings of these studies.

Given the unique characteristics of psychiatric disorders, the translation process of neuroscience from the laboratory to the patient should include a meticulous consideration with regard to potential effects of these interventions. An integral part of such consideration should be hearing the patients, in their own voice, thus reflecting their conscious subjective experience.

The future of psychiatry is at stake. The temptation to overlook patients’ subjective perspective may seem irresistible. Powerful sociological and economical forces push psychiatrists to ignore the “subjective” and focus their clinical attention on the “objective.” Neuroscience-oriented psychiatry sounds fancier, more prestigious, and more attractive in terms of fundraising. Unfortunately, it seems that neuroscience-oriented psychiatry comes with a price. The art of listening and appropriately responding to the countless shades of human experience gradually becomes extinct. One can only hope that qualitative research, such as Lawrence and colleagues’ study, will promote the attentiveness to patients’ subjective perspectives and will serve a vehicle to amplify their voice in the clinical arena. ▪