Zen and the art of clinical discourse

Abstract

The question ‘Where does my fist go when I open my hand?’ may initially seem trivial but was posed by Alan Watts¹ to highlight how we often consider actions or processes as things. Is this relevant to clinical practice?

A discourse can be considered as an underlying shared framework within which a particular statement or concept has meaning and is considered acceptable. The French philosopher Michel Foucault distinguished between practical knowledge in a discourse (which he termed ‘savoir’) and theoretical knowledge (or ‘connaissance’). He argued for a close relationship between what we are able to do within a discourse, which he termed power (‘pouvoir’), and what we actually do. In the words of Gayatri Chakravorty Spivak, ‘if the lines of making sense of something are laid down in a certain way, then you are able to do only those things with that something which are possible within and by the arrangement of those lines. Pouvoir-savoir – being able to do something only as you are able to make sense of it.’² Foucault viewed discourse as a way of interpreting and managing reality, as ‘a violence which we do to things … a practice which we impose upon them’³ but accepted the need to practise within a discourse as we cannot communicate effectively without one.

Our clinical discourse includes concepts such as cerebral palsy, participation, lived experience, function, impairment, deformity, tone and spasticity. These terms have a generally accepted meaning within the discourse and are often considered as independent entities rather than as interrelated outcomes of underlying shared biological, psychological, and social processes. If we were to look for a correlation between deformity and participation, for example, we would be likely to find one as these are not independent variables but are outcomes of shared underlying processes. Alternatively, if we were to consider muscle tone or spasticity as independent entities and as targets for intervention, we would miss the opportunity to consider and understand the underlying processes of which they are outcomes.

Gilles Deleuze, another French philosopher, saw reality as consisting of a problematic field within which solutions emerge as outcomes.⁴ From this perspective, participation could be considered as an outcome or solution emerging from the problem posed by factors including a person's cognitive and physical development, the social environment in which they are located, and their own interests. Similarly, activities such as walking would not be seen in a normative manner as independent entities needing intervention and improvement, but instead would be viewed as a child or adult's individual strategy or solution to a problem posed by their particular neurological and musculoskeletal development and by their physical and social environment.

It can be argued that although such an approach may have theoretical value it would be difficult to implement on a practical basis and would involve a change in our discourse. The question is whether our clinical discourse exists primarily for the benefit of the users of the discourse or the people who become its subjects. Jacques Derrida, our final French philosopher, argued that although defining people within a discourse involved a certain metaphysical violence, some violence or limitation was necessary as ‘a speech produced without the least violence would determine nothing, would say nothing.’ He argued that ‘the best liberation from violence is a certain putting into question’⁵ and perhaps this is the most pragmatic approach: accepting the need for a clinical discourse while appreciating that any discourse is contingent and is open to question, balancing the practical utility of such a discourse against the acceptance that it cannot capture the totality and individuality of the persons to whom it refers.