Awakening the sense of the possible: the Symptoms Clinic as liminal affective technology 2025 Greco et al

Andy

Andy

Senior Member (Voting rights)

Highlights​

  • Causal complexity characterises persistent physical symptoms (PPS) disproportionate to disease.
  • The Symptoms Clinic Intervention recognises the reality of PPS and co-constructs explanations.
  • Causal dispositionalism offers a second order explanatory vocabulary for complex singular cases.
  • Liminal affective technologies catalyse change by shifting dispositions.
  • The Symptom Clinic operates by crafting experiences of liminality in a structured medical setting.

Abstract​

Persistent (‘medically unexplained’) physical symptoms (PPS) that are disproportionate to detectable disease are common in all clinical settings, with significant impacts in terms of quality of life and cost to health services and society. In the absence of an orthodox biomedical explanation, PPS are often attributed to psychological causes and associated with significant stigma. Emerging neuroscientific approaches to symptom explanation imply causal complexity – involving factors across biological, psychological, and social systems – which exceeds what a conventional diagnostic consultation is designed to address. A successful clinical model needs to be able to open, but also contain, a discursive space for the type of complexity that is relevant to PPS.

In this paper we present the Symptoms Clinic Intervention (SCI) as a new model of consultation for patients with PPS. While the SCI was developed in the context of a system broadly organised by the norms of biomedicine we argue that, in its operation, it deviates from such norms in significant and instructive ways. Drawing on causal dispositionalism and on liminality theory, we offer an account of the efficacy of the SCI focused on its ability to shift problematic dispositions. We propose that a carefully crafted experience of liminality can catalyse change by shifting hardened dispositions even in the context of a relatively brief and time-limited intervention such as the SCI. Importantly, this shift refers not only to dispositions in and of the patient, but also to the dispositions of the medical system and of the clinician as its operator and representative.

Open access
 
I first came across the word liminal when doing a poetry writing course. I think it should have no place in medical articles, it's too vague and confusing, intended to sound like they have important understanding of the problem when they are talking bullshit.

This is another output of social scientist Monica Greco (who has written garbage with Michael Sharpe) and GP Christopher Burton, long known as a proponent of BPS rubbish and carrying out a failed project that trained GP's to persuade people with undiagnosed physical symptoms to make up unevidenced BPS models to explain their symptoms. The clear target being to get these pesky patients to believe it was all their fault and to stop bothering their GP.
 
This is essentially an argument to address the biomedical dualistic strawman they’ve created themselves.
While there are valid grounds to reject ‘MUS’ as scientifically inaccurate and clinically unhelpful (Creed et al., 2010), the expression is sociologically interesting in that it points to an enduring difficulty in acknowledging symptoms as a medically relevant reality in their own right.
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As far as I know, MUS was created by the BPS crowd in an effort to force a psychosocial explanation to all «unexplained» phenomena.
This difficulty stems from the epistemic structure of modern biomedicine (Fabrega, 1990; Deary, 2005), also referred to as the ‘disease model’ (e.g. Van den Bergh et al., 2017). In the biomedical or disease model, the (subjective, unobservable) experience of symptoms is considered secondary or epiphenomenal with respect to the (objective, observable) reality of underlying pathology, such that the reality of illnesses that are not supported by evidence of disease cannot be veri-fied, or ‘made true’. By epistemic default, such illnesses therefore appear ‘imaginary’ (or ‘in the mind’).
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This is another problem with the BPS model. Because in contrast to the biomedical (physicalist) model, the BPS model allows for symptoms without a physical cause. In the biomedical model, the symptoms have to have a physical cause, so all symptoms are valid (we just don’t know what causes them). There is no «in the mind» in the biomedical model.
Despite multiple proposals and developments – from the ‘biopsychosocial model’ to patient-centred medicine – that have sought to address the limitations of biomedicine, these ontological assumptions continue to underpin mainstream (Western) medical practice at a fundamental level. The consequences of this epistemic structure have been intensified by the emergence of evidence-based medicine, and the formalisation of hierarchies of evidence informing the development of clinical guidelines (Dumes, 2020).
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There’s plenty of things that are wrong with the evidence based model (as discussed here), but «all in the mind» isn’t a consequence if EBM, but rather of the dualism (which BPS still is even though they say that it isn’t).
 
The paper said:
persistent physical symptoms (PPS) disproportionate to disease
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There is no basis to the idea that they are disproportionate, it's an entirely arbitrary attribution that explicitly assumes that symptoms have to directly relate to tissue damage that can be objectively observed with current widely-deployed technology, which they don't. Medicine is very far from being mature enough to make such claims.
The paper said:
The Symptoms Clinic Intervention recognises the reality of PPS and co-constructs explanations
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Writing this right after showing otherwise is... something. No, it doesn't. In fact, it's not even close. And nothing is co-constructed, plus what the hell are you even doing "constructing explanations" (i.e. making shit up) about things you know nothing about, no less?
RedFox said:
The abstract sounds like absolute gibberish.
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It absolute is. Pure word salad. Aside from being bad medicine, this is terrible philosophy. I don't know why those physicians think they can do philosophy, but they absolutely can't. And they can't do medicine either.
In the biomedical or disease model, the (subjective, unobservable) experience of symptoms is considered secondary or epiphenomenal with respect to the (objective, observable) reality of underlying pathology, such that the reality of illnesses that are not supported by evidence of disease cannot be veri-fied, or ‘made true’.
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That's not a limitation of the biomedical model, it's entirely a choice, a bad choice at that. In fact the best medical models will have a place for both, as they relate to one another, in fact symptoms are major clues in narrowing down pathology. The biopsychosocial model is the complete abandonment of reason and science, it is not only not a best of both worlds, it is literally the worst of neither, a nihilistic perspective where they have stopped trying with the intention of eliminated all traces of our existence, something that cannot possibly have good outcomes.

Quit your day job, you are very bad at it. And don't take up pop philosophy either. Some people actually should have imposter syndrome, and good grief they keep writing papers making it, should I say, superliminal.
 
In this paper we present a novel theoretical framework that addresses the problem of causality in PPS in a non-reductive way. This approach to causality helps to make sense of how and why the Symptoms Clinic may be efficacious (on the premise that its efficacy has already been empirically demonstrated by the trial results – see Burton et al., 2024).
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The trial was not clinically significant.
 
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Again, they just keep babbling nonsensically. I can't even make sense of what it is they're trying to argue other than arguing about the eternal potential of the biopsychosocial model to be effective.
While the adoption of symptom management strategies by patients in the intervention arm of the trial is observable and documentable, the suggestion that the intervention may be effective at the level of neural processes in modifying symptom-relevant ‘priors’ remains speculative. However, the positive results of the intervention (Burton et al., 2024) suggest that this is a concrete possibility, and in what follows we present an analysis of how the structure of the intervention may facilitate and support such a change.
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It is a concrete possibility that this could be effective, as in it's not entirely impossible. And to support this they rely on their own large multicenter trial which was excessively biased and did not have any clinically significant results.

Maybe if they perform a dozen very large multicenter trials they could yet again conclude that hundreds of extremely large multicenter trials may yet provide evidence of this mythical efficacy. It won't. It has exactly zero chance of doing this, because this entire methodological framework is scientifically degenerate, but it would certainly perpetuate the extremely odd myth of the magical psychobehavioral approach having its eternal potential to, one day, be effective, while at the same time it must be since it's been a standard, failing, approach for decades.

I would honestly take weird mystical gurus over this. At least those can be ignored while they babble incoherently. I would also gladly take the chicken paper over it. At least it's a good fun read.
 
Causal complexity characterises persistent physical symptoms (PPS) disproportionate to disease.

According to what criteria?

I stopped there. Don't need to eat the whole egg to know it is rotten.
 
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