By Neil Maltby — author of the becomingmorehuman blog, a physiotherapist in the UK, and a CauseHealth collaborator
She seemed straight forward enough on assessment. 45yrs old. Sudden pain onset from a seemingly innocuous movement many years ago. Episodic but progressive back pain since. Almost full range of movement. No significant neurological, inflammatory, vascular or other suspicious signs. One thing did sit in my mind though. It was as I asked her to reach down to the floor. She hesitated. After a gentle re-assurance she moved tentatively towards her toes. With minimal discomfort. I start piecing her story back together. Using pillows for comfort. New mattress. New fitflop shoes. Stopped exercise. Hmmmmm.
I like the word history for the subjective beginning to a healthcare encounter. Some people like to use interview. Some subjective. But I like history best. It suggests sifting through an individual story to get some hints of causation (the why). The historian E H Carr describes “the study of history is the study of causes“. How one set of things leads to another set of things. The sum of historical parts.
You’re history! Literally. What would you be without it? A void. It is impossible to change it. Your previous choice of job, degree, partner, hobby. Your exposure to family life, upbringing, culture, sports, arts, influential others. Even your genetic make up. Our histories intertwined with previous generations (for whom I blame my hairline!). It would be hard to look at these historical events without acknowledging their causal power in who you are now. What if I had been born into a richer/poorer family, the opposite gender, part of a majority/minority group? Would these not be causally relevant in who we become?
With me so far? Here’s where it gets a bit murkier. This can be viewed as situational attribution. The situation determines the outcome. So it seems context dependent. There doesn’t seem to be a problem here. Indeed situational attribution underpins a great deal of how we do science: ceteris paribus. The thinking is if we put people through the same context or situation we will get the same output. The problem with this are that the outcome is determined by the immediate context only, detached from history. Say we randomly take 100 people off the street and show them the film Terminator. The situation is the same for each person. Same cinema, same time, same popcorn. Will they have the same reaction to the film? Of course not. Because history is more than just events. History is about people. People have dispositions. The best history for me is where people defy their circumstance. This is where we meet personal (or dispositional) attribution.
Dispositional attribution helps explain individual differences to the same stimulus or situation. This is not to say our situation has no impact on us. Clearly it does. It may help shape future dispositions. In life we lean on our internalised dispositions, feelings, previous experience. Two people (or even a single person with a time gap) may internalise the same situation in very different ways. This means we cannot rely on humans reacting robotically especially to complexity.
Is this even important?! Well I’d say so. It means as healthcare clinicians we are not striving for uniformity in treatment (situational attribution) because, as research shows, not everyone will respond to this. I think there is a lingering hope one day we will come up with perfect protocols for LBP, fibromyalgia, tendon pain, IBS, depression. This seems to be the aim in most research I read. Treatments based on pathology tend ultimately to look at situational attribution and not the dispositions of the individual.
The other benefit is hope. Very often I encounter people consumed by their situation. Their history a weight around their neck. We cannot hope to change history but we can look to write a new one. Not that this is easy or a cure. But I think this is where science and philosophy would benefit from exploring. This will likely need new methods and thinking. Do we have a Terminator mindset of attempting to change the past? Or do we accept the past has happened left its mark and use this to move forward. Can we help people defy their circumstance? Out of pre-destination to new destination. If our interventions help by scaffolding a situational benefit this will last only until that situation changes or deteriorates. Only through changing a person’s disposition can we hope they are more resilient to situational changes. Unless we want them to rely on our interventions. Hasta la vista, baby (goodbye for now).
The most pleasing part of this experience was not that clinically she improved but that her story changed. “You’ve made me feel strong again. I thought I was on a downhill slope. If I was like this at 45yrs old then what would I be like in another decade. I realise that I don’t need special footwear, or fancy beds. I just needed to have confidence in my body and to build myself back up.” This was music to my ears and I was glad I had noticed that hesitation.
Be more human. Be less Terminator.
Thanks for reading this far.
Neil
Causality, Complexity and Evidence in Health Sciences 
Lovely read – thanks
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Thank you – a lovely view of how to consider the journey through to the problem now
I like to take patients back to when there was no problem – rather than the onset
I ask for a quick synopsis of each decade – teens on – to understand the rhythm and balance of life through the decades – and then details of relevant times/ onset/ episodes – with enough detail of these “to make a film” (as I was taught in A+E about the mechanism of injury)
(It takes mere moments to run through these – if taking more time then its really important to do)
My small but significant observations often come in the history – and put into context ongoing beliefs and actions – often just a single comment – or nuance – or a tear of a difficult unresolved time
I love your observation of research trying to manage “situational attribution” – so many clinicians of all disciplines try to distill the problem to a primary cause in one aspect of our biopsychosocial models – rather than accept the complexity or subtlety that may be involved
many thanks
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