Quality & Science

Editorial Comment 9/15/2020: Subjective Experience

by Editor-in-Chief: Dr. William Haning, MD, DFAPA, DFASAM | September 14, 2020

The Psychiatry Online piece below speaks to the relatedness of the experiences of mental health care workers, inclusive of those working with substance use disorders, to those of their patients.  It served as a reminder to me, further stimulated by an ongoing discussion with the Senior Editor, about the importance of subjective experience in defining an illness state.  In philosophy, phenomenology is the effort to describe and characterize internal experiences, as distinct from those that can be measured with, say, a thermometer, or even an MMPI.  In psychiatry, we document as many observable findings as we can, not least to assure the physical safety of the patient when administering the many medications that we deploy.  Sometimes it seems to be a matter of just satisfying the 3rd-part payer, but it does confer a better sense of being a scientist and a doctor when we can actually measure things. I believe that we transgress the boundary between the experience and the observation when we write statements such as, “responding to internal stimuli,” or even, “craving alcohol.” 

The only language for such experiences is metaphor: trying to convey a difficult concept by comparing it to something mundane and readily understandable. There are limits to this, of course. There are good metaphors but there is no perfect metaphor; these things are approximations.  So even when I say, “a table is like a cow,” you may immediately see the similarity resulting from both items having four legs, but choose to disagree strenuously that there are too many ways in which a table is unlike a cow. We can see pretty quickly where an even more difficult and obscure item, such as a sensory experience, does not submit readily to description.  Doctors who become very good at eliciting descriptions of these experiences, whose empathy allows them to register the patient’s effort at characterization, deserve our admiration. Most of us have been lucky enough to encounter such doctors, perhaps rarely, almost always enviably; it has been suggested that Dr. Harry Stack Sullivan could speak the language of the patient with psychosis, and there have certainly been examples among the guild of addiction specialists of those who can converse fluently in the language of addiction (who can speak “drunk”).  More than just recognition of slang – surely also important - our training expectations of Addiction Medicine fellows include a sufficient immersion in addiction culture that they will elicit the subjective experiences.

ADDENDA:  In the previous week’s edition, in the inclusion “Narcan Must Become as Commonplace as CPR,” the trade name “Narcan” stood alone and was repeatedly used throughout the article. We wish to encourage the addition or substitution of generic medication names in medical literature, in this case, naloxoneASAM Weekly and ASAM have no commercial relationship with Amphastars Pharmaceuticals, the manufacturer of the nasal spray formulation, and have no interest in supporting its use or purchase above other formulations.

Secondly, while we respect Dr. Calarco’s advocacy of the availability of naloxone for opioid poisoning and acknowledge naloxone’s safety profile, to say that its use must be as commonplace as CPR (BLS) risks being hyperbole.  As the concern in opioid poisoning is apnea, with consequent cardiac arrest, the initial treatment for cardiac arrest remains high-performance chest compressions (“HP-CPR”) regardless of the availability of naloxone or electrical cardioversion.  No amount of naloxone will prove useful if it is administered but not circulated.     [The Hill >>> ]

 Editor-in-Chief: Dr. William Haning, MD, DFAPA, DFASAM