Clinical pluralism
Multiple narratives arise from all clinical situations. We have the narrative of the patient or those receiving care. We may also have narratives from all those involved in the patient’s life such as partners and relatives. Then again there are the narratives of the health care professionals involved and perhaps other agencies such as social workers or the police.
The increasing negotiation of these narratives in online environments adds further complexity. The compulsive tendency to keep on ‘self view’, the ability to see yourself along with others on the screen, amplifies a performative preoccupation which may lead to overly mannered gestures from participants. This sense of there being an environment of many eyes without the intimate communication of the directly experienced gaze leads to a quality of the Panopticon, the all-seeing other whose gaze can never directly be ascertained, but which may nonetheless always feel present. This panopticonic quality undermines the fullness of communication through the filmed theatrics, and the experience is impoverished through the absence of live bodies.
Furthermore, people have a reduced capacity to engage with informal and ad hoc conversation, in, for example, corridors and carparks. This impedes the ongoing work of negotiating what can and cannot be discussed in relation to complex clinical situations, the vulnerable people at their centre and the inevitable politics of difference which emerge around their care. We generally tend to underestimate the threats to individual and group identities that are felt to be at stake in the clinical conversation and which have to be affirmed, negated, defended and negotiated.
It is important to recognise that the coherence and apparent homogeneity of the clinical narrative, for example the story of a fall and subsequent actions or treatment plans, may mask considerable underlying differences between people. Sometimes these differences may seem irreconcilable and on occasion cause serious splits within a team leading to feelings of personal enmity and the breakdown of collaborative working.
A paradox of conflict and collaboration
Therefore it is necessary to further understand the social psychology of how a multi disciplinary team comes to negotiate the many meanings inherent in the narratives which comprise the clinical situation. The process of collaboration may be seen as paradoxically conflictual since it frequently requires this negotiation of a plurality of perspectives.
Let us take, for example, a meeting of different professionals brought together for the purpose of discussing the events of a patient’s fall. Each individual present will have a unique view of the issues which led up to and constituted the event. This unique view can also be understood as a unique capacity to identify with those involved, or to find a sense of the experience of the patient within their own experience.
One’s own experience is of course formed through personal history. In the clinical setting this will include training and knowledge of other related situations. In other words, a number of individuals are present in this meeting with unique histories and identifications whose views may differ and sometimes collide.
Such a meeting is always an encounter with difference and is therefore always potentially conflictual. These differences have in some way to be negotiated more or less successfully so that help may be provided to the patient. Help in this context might mean the thought-through capacity to do nothing, as well as the capacity to do something. So the process of more fully understanding a situation may be an end in itself, may or may not lead to definitive action or may contribute to the development of cultures in which there is greater ability to act in unknown futures.
There will always be attempts made to establish facts which include a linear analysis of the events around a fall but meaning is inevitably required for learning to be engaged with. We may know that John has a tendency to throw himself out of his bed every night and end up underneath. We may however learn more about John when we make sense of his terror of living through the Blitz and a possible connection between him diving under his bed with the unexpected loud noises of a busy ward.
In other words, a hermeneutic process inevitably occurs when we seek to more fully understand and learn about the clinical situation. This team process of interpretation, which may eventually mask itself as an factual exposition, can also,in practice, be highly contested and can feel personally disturbing and anxiety provoking as well as enriching and helpful.
So why should the necessary work of a multi disciplinary team sitting down together to discuss a fall represent both opportunity and dilemma and can we have one without the other?
Sitting with the discomfort of inquiry
I suggest that we cannot have the opportunity to inquire and to develop meaning together without the possibility of disturbance and conflict. The work of the team is to develop the capacity to engage with an encounter with each others’ differences with courage and perseverance whilst maintaining the primacy of their relational interdependence. This means essentially that engaging with the politics of difference is an inevitable quality of clinical team work, not something to be got rid of or masked behind an idealised template of behaviours but something to be taken up and entered upon as part of the process of developing meaning.
So, the development of meaning takes place between people who identify with the situation in different ways. Thus a battle of sorts may ensue to establish meanings and often the dominance of a particular view. It is important to consider this struggle in the light of two characteristics, firstly the threat to identity and secondly the contextual power relationships.
The threat to identity comes about through an encounter with the differences of others who may hold different identifications and thus different narratives. To move in one’s view of a situation can subtly, and sometimes quite dramatically, change or threaten to change one’s identifications and therefore one’s sense of self. This can be disturbing and produce dilemmas about exclusion from the group. To mitigate against the fear of exclusion, identification with a team on who one depends and allegiance to an implicit view or at least the performance of allegiance, can produce a pressure to collude prematurely with a single narrative.
Power
All of the above takes place in the context of power relations which in turn are affirmed or contested in this negotiation of difference.
The emergent constraints of power relations lead to various strategies of coping and sometimes avoidance, in order to maintain team cohesiveness or a sense of personal integrity. These may include self-silencing or ‘not putting one’s head above the parapet’, a refusal to listen to the other, denigration of the other overtly or covertly through mechanisms such as gossip or collusion through fear of exclusion.
I have tried to show in the above, that the clinical conversation requires an encounter with difference which is difficult and not always recognised as part of the work. Furthermore I have tried to draw attention to how such conversations may require movements in the sense of self and therefore in how one is positioned in relation to colleagues upon whom one might be interdependent.
During the pandemic these processes have been further challenged by the constraints of online working which of course are also enabling in other ways. I am no longer, so anxious about physical safety for example, for myself or others when working with aggressive people in psychotherapy groups although the affectual resonance remains so there are words that can be said that could not be said so easily before but perhaps there are also words that cannot be found which could have emerged before in the fullness of embodied conversation.
Note: this blog post was originally published as "The potential for conflict in the clinical setting and in the time of the Covid pandemic" at complexityandmanagement.com
Comments