Antaeus and androgogy: Negotiating paradigm exhaustion and pursuing professional growth in clinical practice

American Journal of Clinical Hypnosis,  Apr 2003  by Kluft, Richard P

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Keywords: Antaeus, androgogy, hypnosis, Dissociative Fugue, Dissociative Identity Disorder (DID), Dissociative Disorder not Otherwise Specified (DDNOS), paradigm exhaustion, professional growth.

Introduction

As a medical student I was amazed and awed by the academic conferences and grand rounds at the various Harvard teaching hospitals. Preeminent among them were the Clinical-Pathological Conferences at Massachusetts General Hospital, which were often then printed in the prestigious New England Journal of Medicine. A case of amazing complexity, usually replete with unusual and confusing findings and involving a patient who had been autopsied, would be presented to a respected physician, serving as an expert discussant. From the history, laboratory studies, imaging procedures, and clinical course, the expert discussant would ask a series of questions to further clarify matters, and then, in a stupendously learned set of observations, which included numerous citations from the literature, reason things out to a final diagnosis and a definitive pathophysiology. Thereafter the pathologists, who had studied the entire case and also examined the deceased, would reveal what the autopsy, microscopic sections and other final evaluations had shown. Invariably, it seemed, the deductive reasoning and clinical wisdom of the expert discussant would be confirmed.

This was the ideal held out to us-the physician scholar could, should, and would find his or her way to the bottom of any clinical mystery in a manner so precise that the autopsy would simply confirm what he had figured out. This is how we could, would, and should practice medicine.

In my subsequent training in psychiatry, other erudite discussants would also appear to see more deeply than others, and discern the mysterious processes that underlay the difficulties of the challenging patient. It seemed to me that while some clinical situations involved matters that our science did not yet understand, in general difficult problems in medicine, and psychiatry, however complex and challenging, could, should, and would yield to the doctor who possessed the prerequisite learning and skills. That I did not yet possess them did not trouble me, because I was sure that at some point my learning and skills would reach "critical mass," and what currently confused and boggled my mind would be made clear in the foreseeable future.

Then I entered the world of practice. There I discovered that many patients, even those under treatment with the most accomplished and admired of my colleagues, simply did not act like the "material" presented in grand rounds and conferences. Patients in my own practice, and patients of colleagues, often failed to respond to the very interventions that, at a conference or consultation, appeared to be exactly the right course of action. They were much more complex than the neat summaries presented in case presentations would have suggested; they might very well decline to go along with what the experts in my training and my books had proposed; they had difficult lives that made abstract models of the treatment process impossible to apply; and, unlike patient "material," these real patients had minds and ideas of their own, and were involved with third parties to the treatment capable of exerting profound and problematic influences. Furthermore, from time to time the consultants I called upon for help offered advice that initially sounded fantastic, but proved to reflect the superimposition of their own favored paradigms of understanding and intervention, and had little to do with the patients with whom I needed help. In the real world, not even the super-experts predictably knew absolutely everything. Nor, I began to appreciate, could they.

Overview Dr. Jasper has written a paper that illustrates the world of practice, with all of its complexity, inconclusiveness, loose ends, frustrations, and uncertainty. He generously provides us with a surprisingly candid account of his efforts to assist "Joe," a middle-aged engineer who suffered a Dissociative Fugue. He also depicts the vicissitudes of the clinician's lifelong quest to better his or her understanding and skills.

Antaeus, son of Terra, was a legendary wrestler. He was impossible to defeat because every time he was thrown to the "mother earth" (Terra), he arose all the stronger. However, Hercules was able to destroy Antaeus because he held Antaeus above the earth as he attacked him. Unable to reconnect with the source of his strength, he perished.

Androgogy is the education of adults. While pedagogy, the teaching of children, of the young, involves conveying information and skills and concepts selected by some authority to students who are expected to accept it rather passively, the education of the adult learner is a different matter. The adult learner generally exercises choice over what he or she wants to learn, and makes that choice in connection with wanting to master some situation or problem with which he or she is confronted. The adult learner is self-motivated, and comes with an agenda. He or she takes a more active role in determining the direction and course of the educational process. I have reviewed these concepts elsewhere (Kluft, 1990).