The detective , the psychiatrist and post-modernism

The similarity between the work of the fictional detective and that of the psychiatrist has often been remarked. Both Marcus (1984) and Shep herd (1985) have compared the technique of the archetypal sleuth, Sherlock Holmes, with that of Sigmund Freud. The sage of Baker Street attempted to solve criminal cases by finding links between items in the external world, such as footprints, bloodstains or broken locks, while Freud tried to make sense of the mysteries of the mind by making connections between events in the inner world, such as dreams, thoughts and desires. Both attempted to provide an all-encom passing explanation of seemingly disparate phe nomena. Over the years, the literary descendants of Holmes have become increasingly similar to psychiatrists, because, as well as attending to the external events, they also take account of the individual psychology of the criminal and the social context of the crime. Agatha Christie's Miss Marple created a 'char acter' typology, which she based on the residents

The detective, the psychiatrist and post-modernism

Allan Beveridge
The similarity between the work of the fictional detective and that of the psychiatrist has often been remarked.Both Marcus (1984) and Shep herd (1985) have compared the technique of the archetypal sleuth, Sherlock Holmes, with that of Sigmund Freud.The sage of Baker Street attempted to solve criminal cases by finding links between items in the external world, such as footprints, bloodstains or broken locks, while Freud tried to make sense of the mysteries of the mind by making connections between events in the inner world, such as dreams, thoughts and desires.Both attempted to provide an all-encom passing explanation of seemingly disparate phe nomena.Over the years, the literary descendants of Holmes have become increasingly similar to psychiatrists, because, as well as attending to the external events, they also take account of the individual psychology of the criminal and the social context of the crime.Agatha Christie's Miss Marple created a 'char acter' typology, which she based on the residents in her village.Equipped with this encyclopedia of personality traits, she was able to identify the villains of the piece by their resemblance to the prototype villagers.Hercule Poirot did not even have to leave his room to solve a mystery.By studying the individual psychology of the sus pects, he maintained that he could arrive at the solution.More recently.Ruth Rendell's novels have concentrated on the psychopathology of the criminal, while in the stories of Faye and Jonathan Kellerman, the detective is actually a psychologist.The role of social factors in the perpetration of crime has been examined in Raymond Chandler's novels, where society itself is portrayed as sick.In similar vein, William Mcllvanney's Laidlaw and Ian Rankin's Rebus have continued the genre's enquiry into the sick society.
Like the literary detective, the modern-day psychiatrist has to process a wide range of data, relating to mental symptomatology, personal biography, social factors and the results of physical investigations.Like the detective who interviews witnesses, the psychiatrist speaks to the patient's family and friends, and has to decide on the accuracy of their testimony.Is there a hidden agenda?What is the nature of their relationship with the patient?Are they trying to hide anything, for example sexual or physical abuse?Like the detective, the clinician studies documents, such as previous medical notes, letters by the patient or textbooks.From this diverse array of facts, observations and intuitions, the psychiatrist has to come to some kind of clinical conclusion, or more specifically, a diagnostic formulation.He has to construct a plausible explanatory theory as to what is wrong with the patient; why he is ill now; and the factors, physical and psychological, which have led the patient to his present predicament.Like the detective, he seeks to bring order to chaos.
In the light of post-modernist theory, however, the question arises: are both the fictional detective and the psychiatrist misguided?Is their attempt to find an over-arching explanation a doomed venture?A Quixotic quest with little hope of success?Post-modernism holds that the earlier modernist view that rational enquiry would ultimately lead to the uncovering of the objective truth, is now untenable.Where mod ernism held that truth was fixed, permanent and universally agreed, post-modernist theory con tends that truth is provisional and fleeting.There is no single 'truth'; rather there are multiple 'truths' -competing versions of reality, which are constructed by people and which are contingent on context and power (Fernandez-Armesto, 1997).Hodgkin (1996) has applied post-modernist theory to contemporary clinical practice and argued that medicine can no longer assume that there is a single truth 'out there', which can be discovered by rational investigation.Instead, there are conflicting claims, and no amount of evidence-based analysis, founded on the belief that there is a single, objective, verifiable reality, can resolve this.If post-modernism undermines the tenets of medicine in general, how much more vulnerable is the project of psychiatry in particular, based, as it is, on the comparatively 'softer' data of human behaviour, emotion and thought.Further, within psychiatric discourse, as Fulford (1996) has pointed out, there are competing theories of mental illness, such as the biological, the social and the cognitive, and no single one can lay claim to being the last word on the subject.Surely, then, as post-modernism implies, the creation of a diagnostic formulation is an arrogant enterprise, a self-deluding activity which convinces the psychiatrist that he has arrived at the truth about a particular patient.
Indeed, Thomas (1997) has suggested that psychiatrists and patients speak different lan guages: while psychiatrists talk about symptoms and signs, neurotransmitters and neuroleptics: patients speak of loneliness, poor housing and lack of money.As a result there is a fundamental failure of communication.From a post-modern ist perspective, psychiatrist and patient are offering different versions of reality, neither of which is any more valid than the other.The psychiatrist who assumes that his version is more privileged than that of his patient is not only making a post-modernist error, but he may also fail to establish a therapeutic relationship with his patient.
Is the situation hopeless?Is all relative?A Babel of conflicting tongues?One response may be to take Charlton's (1993) line that post modernism is a pretentious fad, which is inapplicable to medical science.Instead, he contends, medicine should hold to the modern ist notions of certainty and rational enquiry.In the case of psychiatry, such a dismissal of post modernism seems rather unadventurous.There are real limitations with the positivist tenor of modernist psychiatric medicine, which treats patients as faulty mental machines, whereas there are potential advantages in a theory which gives equal weight to the testimony of the patient.
Perhaps a more fruitful response to the dilemmas thrown up by the post-modernist theory of relativity is that suggested by Brody (1987), who maintains that when a doctor takes a history from a patient, they are both involved in constructing a "story of sickness".They are creating a narrative of the patient's illness, seen in the context of the sufferer's biography and experience.The narrative gives meaning to the patient's predicament, and thereby goes some way to lessen his or her suffering.The doctor and patient negotiate the plot of the story, and they may or may not reach an agreement as to the final version.If agreement is reached, it is more likely that a therapeutic relationship can be forged.Here it is important to realise that the mutually agreed 'story' is not necessarily considered by the participants as representing an ultimate truth.The version of the story may be re-negotiated at a later stage in response to changes in the patient's symptomatology or situation.What is crucial is that doctor and patient agree on the plot.Marcus (1984) has suggested that individuals find the contemporary world extraordinarily difficult to comprehend: there is nothing settled about the social or psychological order, and people need help to understand what is happen ing.In fact, he says, "... we all need a detective.Whether he is a private eye or a third ear, we need him to help us to get our lives and their stories straight".Sherlock Holmes attributed his success to his ability to pay his undivided attention to what his clients were saying to him.By closely listening to their stories, he found clues, which helped solve the case.Lown (1997) has recently contended that doctors have lost the ability to listen to their patients.With the rise of high technology diagnostic machinery and the need for haste, doctors now place less value on the taking of a clinical history, and consequently, they spend less time actually talking to their patients.As a result, they have lost the art of healing.If psychiatrists are to avoid this fate, they could do worse than emulate the listening skills of the great fictional detectives.