By N. Tamkosch. Midwestern Baptist College.

    Understanding Michel Foucault’s concept of modern power opens up new understandings of how oppressive practices and self-subjugation operate buy keppra 250 mg with visa. Power is distributed unequally among members in the culture cheap keppra 500mg with visa, privileging the voices of some while marginalizing the voices of others (Foucault buy 500mg keppra visa, 1979, 1980). White and Epston (1990) describe how Foucault used the prison ar- chitectural structure designed by Jeremy Bentham in the eighteenth cen- tury as a metaphor to speak about the operation of modern power in our cultural and historical landscape. The Panopticon was a structure designed to house prisoners that made it possible to achieve the greatest degree of social control. A round building surrounding a courtyard housed prisoners in individual cells, isolating them from their fellow inmates. A tall tower stood in the middle of the courtyard, from which guards could see into every cell. In exploring the effects of this over time, Foucault describes how the gaze of the guards would recruit the pris- oners into modifying or policing their own behaviors, acting as if they were always being watched. In the context of social or relational isolation, part- ners practice self-surveillance and self-regulation based on socially con- structed norms. When this form of power remains invisible to couples, its effects can be insidious (Foucault, 1979; White, 1991). Narrative therapists listen for oppressive (often invisible) discourses that influence a couple’s relationship. Once identified, therapeutic inquiry de- constructs the assumptions and beliefs that support the taken-for-granted Narrative Therapy with Couples: Promoting Liberation 173 status of the discourse. When an oppressive discourse is made visible, cou- ples are invited to renegotiate their position within that discourse or to choose an alternate discourse that is less restrictive. By refusing to comply with a marginalizing discourse, couples are challenging the status quo and promoting social justice in the larger community. Anorexia had successfully recruited Suzanne into self-subjugating practices of self-starvation, excessive exercise, rigid rules regarding eating, and continual practices of measuring up. The meaning she has constructed of the events in her life is that she is a "mess," unable to handle the stres- sors in her life and "codependent. By unveiling the tricks Anorexia uses and the cultural discourses that keep it alive, Suzanne and Pete are able to join forces in reclaiming their relationship from the problem’s grip. Suzanne enlists Pete’s support in resisting Anorexia’s attempts to under- mine her efforts, and as a result, she is no longer silenced by Secrecy and Shame. In the following, Pete and Suzanne are invited to consider the socio- cultural influences that have supported Anorexia: "Suzanne, how do you think Anorexia gets women to participate in self- shrinkage and diminishment? How do we challenge practices that position us as "agents of social control" (Foucault, 1979)? Narrative thera- pists turn a critical eye on practices that might inadvertently maintain dominant ideologies by supporting certain groups over others (Freed- man & Combs, 1996; Madigan, 1993). Although it is not possible to com- pletely flatten the hierarchy inherent in the therapeutic relationship, we remain vigilant about using our power in support of client agency and empowerment. Whether we are talking about a couple, two religious groups, or two nations, narrative practice is inter- ested in how people handle the process of differing. Do conversations around difference create space for many perspectives, or do they quiet the voices that stand outside the dominant view? How do cultural discourses influence the ways in which a couple handles day-to-day dilemmas? Western society privileges productivity and gives power to individuals and groups based on binary positions; educated/uneducated, rich/poor, white/person of color, heterosexual/gay, thin/large, young/old, able- bodied/disabled (Cushman, 1995). Dominant and privileged groups de- velop exaggerated entitlements that lead to abuses of power and the ongo- ing oppression of less-dominant groups (Winslade & Monk, 2001). Narrative therapists challenge discourses related to race, class, gender, sexual orientation, age, and mental and physical ability. The following ex- amples illustrate the deconstruction of any oppressive discourse.

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    These structures enable us to associate particulars in categories without imposing a straitjacket of rigid inclusion criteria over all individual differences cheap keppra 250mg line. Fuzzy and partially portable boundaries allow variable splitting and amalgamation of continua into manageable numbers of parts for varying purposes purchase keppra 500mg. Imaginative metaphors grow organically by describing the relatively distant and strange in terms of the close up and familiar cheap 250mg keppra otc. Because such descriptions are recog- nized not to be literal, multiple metaphors depicting events, cause and effect, and various cognitive models of goals such as "health" can coexist and contribute alternate perspectives without being mutually destructive. Most important for medicine are the partially metaphorical understandings of "health" and "disease" and narratives of helping, endurance and recovery which are built using these metaphors. Since understanding the semantic architecture of disease is so important as the cognitive background within which examples of means/ends reasoning used here work, the entire second chapter is devoted to that subject. In reviewing the broad imagistic and metaphorical structure underlying informal means/ends reasoning in medical care we need to highlight its two great divergences from formal logics. First, it is neither arbitrary, in the way that the axioms of different logical systems as well as the entailment rules can be arbitrary. Nor is it any unique privileged system grounded eternally in a realm of reason and taking no measure of the human. It has grown organically out of our fundamental biological and existential embodiment. We cannot simply set up rules for understanding and reasoning by fiat, nor have we inherited them for all eternity. While cognitive structures are somewhat flexible, it is not possible to depart radically from existing ones. The basic bodily predicament into which we have been thrown is the only starting point, the only jumping off place from which the rest of experience can make any sense and to which it can be referred. We are incarnated in our ways of thinking and it is from within them, not outside of them, that our degrees of freedom will be found. Empirical thinking has slack, redundancy, room for ambiguity and even for multiple changing evaluations. There are no absolute rules forcing us to ride roughshod over variations and subtleties. Such empirical and informal reasoning does more justice to many clinical encounters than do formal rules, which try to treat medicine like chess. Categories Individual entities, as we choose to define and pick them out, are considered for different purposes as belonging in various types of groups. Classical categories of these individuals are sets defined by necessary and sufficient conditions for membership. Individuals possessing the specific required features or properties which characterize a category are conceived of as members of that category. Such categories are metaphorically conceived to be containers with rigid boundaries having inclusion or exclusion as an all or nothing matter. The essence of an individual, 14 CHAPTER 1 defined by the necessary and sufficient conditions, is all that counts in reasoning about that individual as a set member. Membership in classical sets can overlap, be mutually exclusive, or hierarchical, and such relationships determine the ways that individuals can be reasoned about as members of more than one category. Hierarchical sets are often visualized as nested containers: thus the varieties of plants are nested within a species which is nested within a genus, etc. Some other hierarchical sets are arranged metaphorically more like pyramids: Admiral, Vice Admirals, Rear Admirals, Captains, Commanders, Lieutenant Commanders.

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    For example discount keppra 500 mg on-line, if an ations trusted keppra 500mg, using multiple stimulation methods that differ investigator wishes to examine alterations in pain along important dimensions will be most informative discount 250 mg keppra fast delivery. A common measure used in QST 100 is the pain threshold, defined as the minimum amount 80 of stimulation required to produce a pain. Another measure is pain tolerance, which refers to the maxi- 60 Clinical pain rating (55) mum amount of stimulation an individual is willing to experience. These measures have the advantages of 40 being intuitively appealing and quantitative. However, 20 Actual pain Predicted pain they are also one dimensional and likely represent match (49. The self-report methods described Temperature (ºC) above can also be used to assess perceptual responses to supra-threshold painful stimuli. Behavioural and physi- is predicted that the patient will match his/her clinical pain ological measures can also be obtained. The actual temperature (49°C) to which the patient matched his/her clinical pain is quite close to the predicted temperature, suggesting that this Behavioural measures patient used the VAS scale consistently to rate both clinical and thermal pain. Triangulation provides a measure of clini- Research in non-human animals has long relied on cal pain anchored to an experimental pain stimulus as well behavioural responses to noxious stimuli as indices as an index of how consistently the patient is rating pain of nociceptive processing. PAIN MEASUREMENT IN HUMANS 75 Technically, self-reports of pain, such as those reliably elicit changes in measures including blood described above, can be construed as verbal pain pressure, heart rate, electro-dermal responses and behaviours; however, pain behaviour typically refers pupil dilatation. Other emotional and physical and quantifying overt pain behaviours exhibited by stressors are able to evoke similar patterns of auto- patients with clinical pain have been described and nomic activation. Commonly observed pain behaviours can be accompanied by increased responses on some include guarding (e. These behavioural measures Indeed, substantial individual differences are present have been correlated to patients’ self-reported pain in physiological responses to painful stimulation. Pain behaviours increase in the pres- A variety of muscle reflexes that appear to be related ence of a solicitous spouse and are reduced by multi- to nociceptive processing (e. A specific aspect of pain reflex, exteroceptive suppression of the temporalis behaviour that has received considerable attention is muscle) have been described. Methods for classi- correlated with pain reports and are sensitive to anal- fying facial expressions have been well validated in gesic treatments. For example, the facial action cod- ise and resources for measuring these responses, they ing system provides specific criteria for judging facial are primarily relegated to laboratory research. While this system ition, they actually represent neuromuscular nocicep- was originally developed for the study of emotion, it tive responses and as such should be considered has been successfully applied to experimental and supplementary measures, rather than a substitute for clinical pain. Heretofore, these behavioural and facial observation In recent years, functional imaging has garnered methods have primarily been employed in research tremendous attention in pain research. In humans, settings, due to the time and expertise required for techniques such as single photon emission computed implementation. However, less complex systems for tomography (SPECT), positron emission tomog- behavioural observation in the clinical setting have raphy (PET) and functional magnetic resonance been developed, which greatly increase the practical imaging (fMRI) have been applied to quantifying utility of behavioural pain assessment. The major cerebral activity associated with clinical and/or advantage of behavioural measures is their accessibil- experimentally induced pain. These imaging methods ity to investigators; that is, they can be directly actually detect changes in regional cerebral blood flow observed and quantified. This can be particularly use- (rCBF), which is closely related to synaptic activity. Moreover, both in scientific this chapter and readers are referred to Casey and and clinical arenas, concerns are frequently expressed Bushnell’s (2000) book Pain Imaging for more detailed over the complete reliance on patients’ self-reports information. Behavioural measures provide an additional able, though not always consistent, information source of data on which to base treatment decisions. For exam- Interestingly, pain behaviours and self-reported pain ple, some (but not all) clinical chronic pain conditions can provide conflicting information, presenting a have been associated with decreased resting thalamic dilemma for the clinician or scientist. It is important activation and many clinical pain states are character- to remember that pain behaviour, while more directly ized by increased activity in the anterior cingulate observable than self-report, is not necessarily a more cortex. These findings in clinical populations appear to valid or accurate measure of patients’ pain.

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