This series of blog posts first appeared a few years ago on a now defunct blog called ‘Care Training’. It was inspired by the training maxim of ‘making the unconscious conscious’. It is intended to take what really ought to be the most basic principles of health and social care and put them down on paper. The series isn’t only an exercise in stating the obvious though whatever the title might suggest. It’s actually intended as a philosophical foundation manual for workers and informal carers to help them get their care ‘on track’ and then to keep it that way.
The clinician’s illusion sounds as though it would only apply to clinical, therapeutic situations but that’s not the case at all. This is one of the most widespread examples of faulty thinking and we are all susceptible to it. Essentially it’s one of several logical errors that are based upon the false idea that ‘my experience is all there is’.
There are very good reasons why human beings are so vulnerable to the clinician’s illusion. Many would argue that it’s inevitable because we base our judgements upon our experience of the world. In evolutionary terms that’s one of the main reasons why our species has survived at all. This is probably as ‘hard-wired’ into consciousness as any human trait could ever be. We all learn from experience.
Unfortunately that experience can be misleading as we shall see.
To make sense of the clinician’s illusion I want to tell you a little about my own experience as a mental health nurse on acute psychiatric wards. Then, having made the point we’ll widen the scope a little to show how the clinician’s illusion is both applicable to all of us. We’ll also show how our vulnerability to it is used by cynical persuaders from private citizens to politicians who manipulate our understanding to gain agreement or endorsement of their views.
When I worked on the wards my colleagues and used a familiar expression – a cliche if you will. It went like this:
“We don’t have much money but we do see life.”
It was, as much as anything a relatively light-hearted way to acknowledge amongst ourselves that sometimes we witnessed and were involved in situations that were distressing, unpleasant and occasionally harmful. What we saw on a fairly routine basis had the potential to cause very real psychological trauma in its own right and I have known many mental health nurses who have been unable to bear its weight. The use of clichés such as this is more than just a way to acknowledge that ‘shit happens’ – it’s also a way to demonstrate mutual awareness and support. Like the ‘gallows humour’ so often heard on ward nights out (and so often criticised by the uninitiated) it’s part of an arsenal of psychological defence mechanisms that nurses at the front line employ to keep themselves sane.
But there’s a major problem with this. It’s not true. Well – the not having much money part might be but not the rest. Acute nurses do not see life – at least they don’t see very much of life. They see the worst of life but not the best.
By definition patients in acute psychiatric wards are distressed and they are not coping well. If they were then they’d be somewhere else getting on with their lives. Acute nurses meet people at their most unwell – and only at their most unwell. And many of them return repeatedly to the wards as their mental health breaks down.
Our experience then, as ward based nurses was that everyone with a diagnosis of serious and enduring mental disorder comes back to us sooner or later. We see them come back every working day and that experience of working with relapsing patients is what we used to form our opinions. That’s why, when I was an acute nurse I didn’t believe in recovery from mental disorders such as schizophrenia. I had no experience of it. Everybody I met at work had relapsed (or I expected that they would one day based upon my past experience of other people).
But not everyone comes back.
According to the Royal College of Psychiatrists own figures only about a third of people diagnosed with schizophrenia experience lifelong deterioration and another third (give or take) get beyond their problems altogether. We didn’t see those people on the wards because they never needed us again. We only saw the people who did relapse.
Not everybody relapses
The clinician’s illusion is the illusion that comes from limited experience. Clinicians see ill people and so they come to believe that everybody is ill – or at least likely to become so.
The clinician’s illusion is what happens when we place too much weight upon our own limited experience and ignore the wider experience of others. It’s the fatal flaw that underlies the statement so beloved of many that..
“I speak as I find”
It’s laudable, of course to learn from our own experience but not to the exclusion of everything else. If we really want to make sense of the world we need to be prepared to look beyond our own experience and take account of the experiences of others.
Oscar Wilde once remarked that only a fool learns from his experience. The wise man learns from the experience of other people. Perhaps Wilde would have called the Clinician’s illusion the ‘fool’s illusion’ for precisely that reason.
But it’s not enough just to say ‘learn from everyone’. It’s necessary to have some means of judging the reported experiences of others too – otherwise we’re open to all sorts of abuses and misrepresentations. My own view is that ‘evidence is the thing’.
Don’t worry too much about anecdote – that can be misleading. Follow the evidence. Otherwise we end up making just as many mistakes.
For example there is a narrative in UK about people with disabilities and those who need to rely upon state benefits to survive. The narrative is that disabled people are workshy scroungers and that honest hard-working people should not be asked to support them. This narrative has proven to be very persuasive and many people (largely those who do not work with disabled people) believe it. Let’s look at why..
Ever since the ConDem government came into power back in 2010 UK citizens have repeatedly been told that benefits claimants are predominantly abusing the system. Government ministers have repeatedly made that claim and the real evidence about claimants and their circumstances has repeatedly been suppressed.
Right wing media articles repeatedly publish stories about people ‘swinging the lead’ and even ‘fly on the wall’ television shows present benefits cheats to the nation on a very regular basis. For the majority of people (who don’t regularly come into contact with severely disabled citizens) this constant procession of fraudsters becomes the only experience they have of disabled benefits claimants. And cynical politicians know this all too well.
So the clinician’s illusion (my experience is all there is) means that the population is easily swayed by arguments about benefits fraudsters because they believe that it’s a real problem when in fact official figures (the evidence from a range of experiences) show that only a tiny proportion of claimants are ‘swinging the lead’. But that’s not what our political leaders want us to believe. So that’s not what we are shown.
Unless we become alert to the notion of the clinician’s illusion in our own lives we will remain susceptible to persuasion by any Tom, Dick or Harry who wants to manipulate our opinions for their own cynical ends.
For example, if your only experience of someone you meet is what they tell you about themselves it pays to look a little deeper before you jump in and support their endeavours. You might just be being played.
I’ll end with another cliche.
“Self praise is no recommendation”