Received: 24 March 2016 Revised: 16 November 2016 Accepted: 30 December 2016

DOI 10.1111/jep.12713

ORIGINAL ARTICLE

A novel clinical framework: The use of dispositions in clinical

practice. A person centred approach
Matthew Low MSc, BSc, MMACP, MSCP

Lead Clinician Physiotherapist, The Royal

Bournemouth and Christchurch NHS Trust, Abstract
Bournemouth, UK This paper explores a novel clinical framework that is underpinned by a specific philosophical
Correspondence perspective of causation and its utility in clinical practice. A dispositional theory of causation
Matthew Low, Lead Clinician Physiotherapist, may overcome challenges that clinicians face in complex clinical presentations including those that
The Royal Bournemouth and Christchurch
are medically unexplained. Dispositionalism identifies causes not as regular events necessitating an
NHS Trust, Castle Lane East, Bournemouth,
BH7 7DW UK. effect but rather phenomena, which are highly complex, context‐sensitive, and which tend toward
Email: mattlow128@gmail.com an effect. Diagnostic uncertainty and causal explanation are significant challenges in terms of clinical
reasoning, communication, and the overall therapeutic outcome. This novel framework aims to
facilitate improved collaborative clinical reasoning, enhanced patient‐practitioner interaction, and
supported treatment planning. The paper uses a real case study of a patient1 with nonspecific spinal
pain to demonstrate the clinical framework as used in clinical practice.

KEY W ORDS

causation, clinical practice, clinical reasoning, dispositions, philosophy, physiotherapy

1 | B A CKG R O U N D psychological, and social profiles; however, problematically, it could

also lead to categorical thinking where complex presentations are
There has been significant progress within the field of biomedical reduced into their psychological, somatic, and environmental compo-
science, exemplified by the elimination of fatal diseases such as nent parts. Pincus et al6 found that the bio‐psychosocial model may
smallpox and reduction in the incidence of polio. Conversely, medically have been misunderstood and therefore ineffectively applied, both in
unexplained symptoms accompanied with multimorbidity continue to research and clinical practice with only 10% of classification systems
increase.1,2 In a traditional biomedical model, conditions are incorporating a bio‐psychosocial framework.7 This may be because
3
conceptualised, diagnosed, and treated as single discrete entities with the bio‐psychosocial model fails to explain the body/mind problem,
illness and suffering ascribed to a certain part of the patient’s body such with the biomedical paradigm on one side and the psychological and
as the back, liver, or the heart.4 Recent epidemiological evidence sug- social perspective on the other with no clear theoretical link between
gests that viewing people in this way is increasingly inappropriate as them.8 From a patient’s viewpoint, the distinction between body and
comorbidity and multimorbidity are normal in contemporary medicine mind may be impossible to grasp as the experience is situated within
and facilitate “silo‐based” treatment and management.2–4 Diseases the patient’s own lifeworld as an embodied person. Their body is at
may be perceived as affecting the whole person but then treated and the centre of the experience of symptoms that occurs at a
managed as parts of the whole person leaving the patient’s personal, prereflective level and may not correspond to the healthcare practi-
relational, and contextual circumstances adrift in a vacuous space. tioners’ categorical understanding of disease and to the distinction
Bridging the gap between the biomedical endeavours epitomised between mental and physical manifestation of the illness, disease, or
by scientific objectivity and evidence‐based medicine and the suffering.9
subjectivity of psychological and social factors is challenging. The The following questions arise: What do clinicians do when they
bio‐psychosocial model5 recognises the individual’s biomedical, are faced with managing conditions that are unexplained medically?
How do practitioners manage and understand the multiple and varied
For the purposes of the paper, I shall refer to the patient as a person that is
causal factors within a clinical reasoning approach and apply it in
embodied and enactive within their sociocultural environment seeking help for
their symptoms. The distinction is made purely to avoid confusion between practice? In what ways do clinicians communicate these encounters
describing the treating clinician from the person seeking help. to patients?

J Eval Clin Pract 2017; 1–9 wileyonlinelibrary.com/journal/jep © 2017 John Wiley & Sons, Ltd. 1
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Dispositionalism, a philosophical theory of causation, may help 3 | CAU SAL COMP LEXI TY —N O N ‐ L I N E A R
with such difficulties. INTERACTION AND MUTUAL
The dispositional theory of causation proposed by Mumford and MANIFESTATIONS
Anjum10 interprets the concept of cause as a cluster of powers, or
dispositions, orientated toward an effect. Powers can be thought of Many causal factors have been cited in respect to low back pain onset
as the causal component of the properties of things. For example, a and maintenance. Examples include cognitive factors (negative beliefs,
wine glass has a disposition of fragility. The glass has certain properties fear avoidance behaviours, catastrophising, hypervigilance, and poor
that could causally explain why it may break if it were to fall to the pacing),22 psychological and emotional factors (anxiety, depression,
ground because of the material from which it is made. However, the stress, and maladaptive coping strategies),23 physical factors (pain
fact that the glass has fallen onto the floor does not necessarily mean provocative postures and movement behaviours and muscle guarding
that it will break. Other causal powers may interrupt, counteract, or and deconditioning),17 lifestyle factors (inactivity, social withdrawal,
intervene. The effect is reached when a single or combination of sedentary behaviours, and sleep deficits),24–26 and environmental
dispositions exceed a threshold. This can be graphically represented factors that include socioeconomic factors,2 negative childhood experi-
as a vector model. ences, and allostatic load.6 All of these factors may coexist, are context
The purpose of this paper is not to compare or contrast dependent, and interact in a nonlinear fashion. In contrast, a traditional
philosophical accounts of causation or to offer robust accounts of Humean view of causation favours empirical‐based observations that
11
causal explanation beyond those in the current literature. However, are seen with regularity, temporal asymmetry and occur together with
this paper does attempt to describe how a dispositional theory of respect to time and space. This Humean view is one that sees the same
causation has been beneficial for the author in its utility in clinical cause producing the same effect and therefore, in a healthcare context,
practice and that it may benefit from further research and the same treatment would provide the same effect in each clinical
development in the future. encounter. The complex interactions of causal relationships are not
accounted for and can only be seen as correlations. Causation in clinical
practice simply cannot be reduced this way into regular and linear
2 | DIAGNOSIS AND CAUSAL CLAIMS observable events. Such complexity in clinical practice requires a differ-
ent ontological view of causation.25 Mumford and Anjum10 describe
Diagnosing conditions is regarded as an essential element of medical that dispositions, or powers, can exist unmanifested but through inter-
practice,12 and correspondingly acquiring an acceptable diagnosis is a action with other dispositions can facilitate causal processes to be initi-
significant feature within the patient’s illness experience that offers ated. Therefore, no causal factor or mutual manifestations necessitate
practicality, provides psychological reassurance, and provides social an effect. A disposition can lead to a number of different effects, depend-
acceptance.13 Diagnosis effectively ascribes a causal claim, which sug- ing on their causal context. This theory and model favours uniqueness,
gests a biomedical explanation of illness, whereby the illness can be context sensitivity, and holism, in contrast with the traditional reduction-
controlled and treated14 with the potential for subsequent optimism ist medical approach. A model that successfully conveys this is the vector
and hope about the future. Additionally, diagnosis has legal and political model (Figure 1).
implications giving individuals the opportunity to access welfare bene- The vector model provides an overview of the causal powers that
fits. It also plays a significant social function by validating illness.15 act in a specific situation. They convey the relative strengths of power
Diagnosis is therefore of exceptional importance in the management indicated by a vector’s length in relation to each other and direction
of medical conditions. Non‐specific low back pain is defined as low back towards or away from the manifestation of an effect or not. The overall
pain not attributable to a recognisable, known specific pathology (eg, tendency is a composition of all the powers that mutually manifest in a
infection, tumour, osteoporosis, fracture, structural deformity, inflam- given context.
matory disorder, radicular syndrome, or cauda equina syndrome). By
its very definition, a biomedical causal claim is contested.16 However,
commonly in clinical practice, back pain is considered from a purely bio-
medical perspective17 despite poor associations between radiological
imaging and symptoms.18,19 On the one hand, having a diagnosis of
exclusion (eg, cancer) is reassuring,20 but, on the other, diagnostic
uncertainty remains where the cause of the pain is unknown, which
appears to lead to pain‐related guilt, disability, and depression.21 Jarvik
et al17 completed a 3‐year prospective study to determine predictors of
new onset of low back pain by reimaging 148 subjects via magnetic res-
onance imaging (MRI). They did not find a relationship between MRI
scan structural changes and first onset of low back pain but did find that
FIGURE 1 Example of the vector model.10 The solid vertical line
depression was an independent predictor of first onset of low back
indicates the starting situation, F and G represent 2 qualitative
pain, rather than effect. This study is an example of the difficulty in outcomes, and T is a certain threshold effect. The arrows show causal
establishing perceived causal relationships and the nature of their factors that dispose towards or away from the threshold effect. The
interactions. thick arrow R represents the overall tendency of the situation
LOW 3

4 | T H E UT I L I T Y O F D I S P O S I T I O N S I N emphasised that a clinical framework based on this model would be

CLINICAL PRACTICE purely qualitative. The vector model is intended to give both the clini-
cian and the patient an idea of the causal powers at a specific moment
People who suffer with painful conditions wish to know and under- in time; the powers included may change over time because of the
stand the cause of their symptoms. Linear models are insufficient to changes in the patient’s presentation and circumstances. The aim is
provide an adequate explanation as conditions and contextual factors to facilitate the analysis of the patient’s unique situation and identify
vary with time. A traditional, biomedical model can be seen as linear the relative intensity of the causal powers involved. Assigning numeric
with respect to assessment, investigation, establish a diagnosis value to the causal powers to try to make this qualitative model seem-
followed by treatment using traditional positivist ontology. This ontol- ingly more quantitative is superfluous and possibly counterproductive
ogy favours monocausality reductionism (single cause and single to the patient’s treatment and outcome. The strength and direction of
effect) and dualism (mind/body dichotomy). Sufficient evidence has the relative causal power can be used to provide a reflection of the
been gathered that suggests that this approach has been unsuccessful coconstructed perspectives of both the therapist and the patient. In
to manage patients with low back pain in terms of prevalence,27 addition, the context and intensity of the causal power may be a way
28
cost, and in particular, when using singular therapeutic in which treatment(s) can be discussed and prioritised. This approach
approaches.29–32 avoids references to probability studies and seeks to reduce unneces-
Despite the development of the bio‐psychosocial model that sary labelling and negative judgements of patient behaviours and cir-
emerged in response to the challenges of the traditional biomedical cumstances whilst increasing patient confidence and optimism by
approach,5 the bio‐pyschosocial model has been criticised for ignoring substituting the concept of tendency for the concept of necessity or
the patient’s experience in distinguishing illness from disease and inevitability. The concept of necessity or inevitability implies that
neglecting the distinction between pain and suffering as an irreducible causal outcomes are absolute and final. In complex, adaptive biological
experience.33 Rather, it compartmentalises the condition into biologi- systems, it would be bold to suggest that this can be the case; in fact,
cal, psychological, and social phenomena.33 The importance of the outcome could be deleterious. For example, in language, using the
interpreting the experience in such ways that both patient and thera- term “wear and tear” to describe age‐related changes in the spine is
pist make sense of it lies comfortably within a dispositional ontology. commonly used as causal reason for low back pain.38 However, the
The utility of dispositions in clinical practice may avoid the tension that term wear and tear meant to patients that they were “rotting away”
classification systems create by being noncategorical in so much that and that there was no treatment available to them resulting in having
multidimensional causal mechanisms replace simplistic linear ones. An to live with the symptoms (inevitability).38 Patients defined “degenera-
example of a simplistic linear explanation for a patient with low back tive change” as a condition that would (necessity) progressively worse
pain may be that they have had investigations that exclude a serious and that nothing could be done (inevitability).38 The terms’ meaning in
cause, but their MRI shows degenerative disc disease at a level that their view was that degenerative change and wear and tear would
is sensitive to palpation. The symptoms may also correlate to move- necessitate and inevitably lead to future on‐going back pain and dis-
ment thought to induce load and anterior shear forces through the ability, which is not entirely supported by the clinical research.18 The
disc34 such as repeated or sustained flexion; and therefore, the symp- term “tendency” acknowledges the complexity and relative uncertainty
toms are attributed to this in light of normal neurology and lack of involved in the clinical encounter, but it is less likely to be met with the
other findings. The presence of symptoms (C) could have been seen negative associations of absolute certainty and provide a realistic and
to arisen because of a history of repeated flexion or sustained loading balanced view alongside other causal factors that recognise the whole
(A) and the presence of degenerative changes on MRI (B) (A + B = C). picture. A dispositional view of causation can convey and account for
However, imaging findings such as disc degeneration, disc bulges, the interference of powers that may manifest toward symptom gener-
annular tears, and prolapses are highly prevalent in pain‐free popula- ation. An example of this is how restorative sleep can counteract
tions and are not strongly predictive of future low back pain and corre- symptoms of irritability, fatigue, and mood, all of which, including sleep
late poorly with pain and disability.19,27 A dispositional view recognises disturbance itself, may contribute or cause increases in low back
singular and multiple causal factors that tend towards an effect rather pain.39,40 There may be situations where causal powers oppose each
than necessitate them. The strength and direction of the causal powers other resulting in equilibria states whereby a number of causal powers
recognise a holistic view that recognises uniqueness rather than of various strengths oppose in an equal manner, which creates no
assuming that individuals are examples of a statistical averages. Clini- change to a resultant vector. This would be advantageous in circum-
35,36
cians recognise the multifactorial nature of conditions, but reason- stances where rehabilitation programmes and medical interventions
ing and communication may be adversely affected by the difficulty in were aiming to stabilise (eg, maintain vital signs of a critically unwell
establishing causal relationships. The vector model could help over- patient) or prevent (eg, injury prevention) a health condition.
come such difficulties. Within a clinical framework, the vector model A causal dispositional account of fitness has been described in the
provides a visualisation of the set of causal powers that dispose literature and demonstrates nicely the emergence of fitness within the
towards or away from the manifestation of the symptom. These causal context of time and the relationships between fitness and the func-
powers are offered through the patient’s narrative and interpreted tional dispositions that compose it.41 It exemplifies how causation
collaboratively with the therapist to make sense of the condition,33 can take time in an unfolding process that is sensitive to context rather
to provide empathetic rapport, and to address the patient’s issue to than a Humean view of relating causation to static events bereft of
bring greater benefit to the therapeutic encounter.37 It should be context.
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FIGURE 2 A graphical representation of

intersubjective communication in clinical
practice and the intersubjective space.
Modified from Øberg et al43

5 | T HE I M P O R TA N C E OF A P E R S O N’ S perspectives of the clinician and the patient but is initiated from the cli-
NARRATIVE: A COLLABORATIVE APPROACH nician’s perspective initially. However, it is important to discuss the
content of the mind map in an open way with permission given to
The person’s narrative generates the context for the causal powers. the patient to change any element, as they feel appropriate in an
Careful history taking in the spirit of motivational interviewing can attempt to bridge the intersubjective space. This process encourages
elicit a rich story through the use of open questions, affirmations, active listening, empathy, and openness, qualities that have been
reflective questions, and summaries.42 recognised as important in practitioner/patient interaction.42 Opportu-
A systematic and appropriate physical examination evaluates the nities to discuss the complex interaction of causal factors can be initi-
supporting and negating information regarding hypotheses related to ated particularly in relation to tendencies rather than necessities. This
the condition. Attention is paid in particular to red flags and features approach also reduces the risk of the patient feeling judged, which
of sinister pathology. Completion of the physical examination provides may inhibit the therapeutic relationship and cause barriers to facilitat-
further evidence that needs to be carefully evaluated and openly ing change.42 Establishing empathetic rapport and addressing the
discussed with the patient. patient’s issue has been associated as significant factors for facilitating
All patients, particularly those whose symptoms are medically behaviour change for a positive therapeutic outcome.37 Causal expla-
unexplained, require their experiences to be heard, understood, and nation is complex, and a number of explanatory models exist in the lit-
related to. Kirkengen and Thornquist eloquently call for medicine to erature ranging from amplification and sensitivity theories to illness
embrace the lived body that is free from objectification in favour of behaviour and autonomic nervous system dysfunction theories.46
an approach that appraises the values and meanings of an ethically However, without the context of the narrative to frame such explana-
informed epistemology.43 The lived body acknowledges that human tions, they can become misunderstood, potentially threatening and
experience is embodied in the world and embraces a phenomenologi- facilitate a negative therapeutic outcome.47 It is therefore imperative
cal view beyond subjectivity and values embodied intersubjective that if causal powers are provided in a vector model and are to be used
communication. The bringing together of the patient’s narrative, collaboratively with the patient as part of a reasoning process, that it is
thoughts, feelings, beliefs, and previous experiences combine with that based upon the patient’s narrative and carefully gathered from a phys-
of the therapist. The combining and sharing of these two worlds come ical examination. Using this method of collaborative and coconstructed
together into an intersubjective space where careful respect and approach may support a positive patient‐therapist interaction that is
understanding are required to convey a useful, purposeful, and shared associated with improved rehabilitation outcomes.48
clinically reasoned impression that informs further decision making
(Figure 2). Both primary and secondary intersubjective methods are
simultaneously used to engage with the patient and are explained in 6 | T H E V E C T O R M O D E L— A V A L U A B L E
detail by Øberg et al.44 and by Edwards et al.45 A mind map can help C L I N I C A L R E A S O N I N G TO O L
communication and bridge the “intersubjective space” through the
inclusion of key aspects of the history and the dialectical reasoning The causal factors are added to a vector model with the relative and
processes to provide a collaborative tool for both clinician and patient. resultant tendencies towards or against the manifestation of the
The mind map acts as a bridge between the intersubjective current complaint. The vector model represents the current contextual
LOW 5

FIGURE 3 A mindmap representing Jack’s narrative and potential relationships between them

elements at the present time through coconstruction with the patient. was particularly difficult. In addition, his long‐term relationship with
It provides a snapshot of all known causal powers that have been his girlfriend was ending and had become increasingly socially isolated.
elucidated through the narrative and examination, gathered from the Jack felt that his symptoms needed to be explained through a struc-
patient’s perspective, the clinician’s clinical experience, and current tural mechanism and focused on how his muscles around his scapula
research literature. From here, strategies can be made to facilitate must be the cause his symptoms as a previous practitioner described
changes to affect the identified causal factors. The vector model may him as having scapula dyskinesia. Jack had completed exercises on a
also shed light on factors that may not be amenable to physiotherapy daily basis to correct this but they did not change his symptoms. He
and that may benefit from treatment from other healthcare profes- had become frustrated and was anxious because each day appeared
sionals or agencies. In causal factors that are seen as modifiable, plans to be the same with no end to his pain in sight. He suffered with poor
can be put into place with joint goal setting; for example, movement‐ sleep patterns and felt low in mood. This culminated in negative feel-
related fear may be counteracted through education, graded exposure ings regarding the future. Jack’s movements appeared guarded with a
activities, and movement modifications. The vector model may bring tendency to maintain upright and rigid postures, believing them to be
awareness to causal powers to both the clinician and therapist such helpful in keeping the pain he had at current levels. To add to this,
as specific lifestyle and environmental factors, sometimes overlooked he tended to hold his breath during low load tasks, which may increase
by alterative clinical frameworks. It is important to note that the vector spinal loading.49 Despite this, he had maintained a good level of
model is a representation of complexity, context, tendencies, thresh- physical activity and, although he was fearful of lifting activities, was
olds, linear/nonlinear composition, interference, strength, and direc- keeping fit.
tion. It is not a model that merely describes causal factors, which Initially, an exploration of Jack’s narrative of the events and
may determine causal claims. circumstances that led up to the manifestation of his symptoms was
documented as a mind map (Figure 3). Physical examination findings
found no loss of range or function of the cervical, thoracic, or shoulder
7 | C A S E EX A M P L E —J A C K regions; however, a tendency to increase muscle activity prior to
movement appeared to occur. Widespread allodynia and hyperalgesia
A 25‐year‐old apprentice lift engineer presents with a two‐year history were found on sensory testing across the upper aspect of the thoracic
of neck, scapula, and thoracic back pain with no history of injury or spine and shoulder girdles. Neurological integrity examination was
trauma. Following investigations that included normal MRI scan imag- normal as was upper limb power. Pain was reported as increased on
ing of the cervical, thoracic and scapulae regions, and normal blood all movements and steady at rest.
tests, he was referred to physiotherapy. Previous physiotherapy and A theoretical relationship between the narrative, the context, and
chiropractic intervention had not been successful. His work was very the subsequent behaviour was explained through the mind map and
stressful due to the nature of his apprenticeship and difficulty with then the relative powers represented on a vector model (Figure 4).
relationships with his coworkers. Just prior to the onset of symptoms, The intensity of the powers drawn on the vector model were
his parents were undergoing a breakdown in their relationship, which coconstructed by the therapist and the patient to bring personal and
6 LOW

The mind map and vector model can be used to recognise and make
sense of the number of causal factors that are interrelated and could
tend towards the effect of widespread pain.
Other treatment strategies included focusing on Jack’s social
interaction with friends and incorporating physical activity in these
environments. Jack started boxing training and spent time outside of
home and college. These addressed many of the modifiable causal
factors in a way to counteract them (reduce stress, fear and anxiety,
and reframe beliefs), subtract (pain provocative movement), and
interrupt through an improved understanding of pain relieving use of
pharmacology such as analgesics, nonsteroidal anti‐inflammatories
and neuropathic medications.
The outcomes resulted in self‐reported improvements in pain
scores and sleep quality, stress, fear of movement, improved social
interaction, and physical activity as well as self‐reported improved
confidence and self efficacy. The vector model now shows how the
resultant vector (R) is reduced and lies under the threshold (T)
(Figure 5).
Jack’s symptoms are improved, in so much as he no longer has
FIGURE 4 A vector model used for Jack in clinical practice and is
relevant at the initial assessment. Causal vectors (a) chronic stress; (b) constant pain; however, his symptoms can and do return through a
fear of movement; (c) sleep; (d) anxiety; (e) negative beliefs; (f) mood/ potential number of causal ways. One can see that a small change in
depression; (g) social support; (h) negative previous experiences a single or a number of causal factors (vectors a‐h) can make the resul-
(questionably modifiable) (i) physical activity. Resultant vector (R); tant vector (R) surpass the threshold (T) and Jack’s constant pain
threshold (T)
returns. The variation of his symptoms could be explained though by
the complex interrelationships of causal factors. Such variation is
shared meaning. Long term stress, fear of movement, poor sleep, anx- understandably concerning, when one feels changes in pain through
iety and fear of the future, negative beliefs, lowness in mood, challeng- no discernable mechanism, but the vector model can convey this mes-
ing social circumstances, poor self efficacy, and negative experiences sage, and it can be very reassuring.
were plotted a causal relationships that tended towards the manifesta-
tion of Jack’s symptoms as all made his symptoms worse. These causal
powers have been identified in patients with persistent pain.17,22,23,35
Jack’s levels of physical activity were felt to tend away from his symp-
toms. Jack felt better for exercising, even if, as he thought, it was
because he was distracted. Figure 4 shows the resultant vector (R)
has passed the threshold (T) and is beyond the threshold. In this case,
improving just one causal relationship, or indeed, a number may not
be sufficient to reduce Jack’s symptoms. This may indicate a poorer
prognosis of recovery and/or a longer rehabilitation period or repre-
sent a more complex clinical presentation.
The treatment was initiated by using educational methods and re‐
assurance with regards to the state of the tissues through describing
and detailing the results of the investigations. Pain neuroscience
education was provided within the context of Jack’s narrative paying
particular attention to central sensitisation theory.50 Factors such as
perceived threat,51 predictive, and associative learning52 were normal
responses that could be changed and eventually improve his
symptoms. Altering movement behaviours that were provocative and
modifying them to reduce the pain supported this. The addition of
using breathing control, relaxation techniques, and cognitive reframing
provided moderate pain relief, which was rewarding and motivated
Jack to continue with the treatment plan.53 FIGURE 5 A vector model used for Jack after 4 months of treatment.
Note the resultant vector (R) lies below the threshold (T). (a) chronic
It is important to note that caution was made to ensure that Jack’s
stress; (b) fear of movement; (c) sleep; (d) anxiety; (e) negative beliefs;
experiences were not ascribed to being purely psychological in nature. (f) mood/depression; (g) social support; (h) negative previous
This is a common feeling felt by patients with medically unexplained experiences (questionably modifiable) (i) physical activity. A number of
symptoms where investigations have not yielded a causal explanation. the causal vectors have changed with the exception of d and h
LOW 7

Jack reported feeling more in control of his symptoms and related later, Jack is now exercising in the gym three times a week, achieving
the vector model to a balance scale. If circumstances “tipped the bal- success in further education, with considerably less pain and feels
ance,” he felt confident that he could counteract (relaxation techniques positive about the future.
and focus on breathing control), interrupt (use medication in the short
term), and subtract (pace activity) the causal factors. This was felt to
improve Jack’s self efficacy and sense of control over his condition. 8 | CO NC LUSIO NS
In this respect, the vector model is dynamic and represents causality
as complex and situation dependent on a range of factors that vary Philosophical considerations of causation with respect to dispositions,
contextually in time. Jack reflected on his progress and recognised tendencies, and powers have utility in clinical practice. They facilitate
that, for him, a key element that changed his perspective was a positive person‐centred care, holistic clinical management, and provide oppor-
change on his focus of attention. He also reflected on his experience tunities for individualised clinical reasoning and communication. The
and felt that “there is no da vinci code” or singular mechanism that evidence‐based medicine approach to healthcare is not derived from
would improve his situation in isolation and that he felt empowered a scientifically neutral ontology but stem from a Humean account
to take control of his situation and explore solutions for himself. A year for causation.4 Anjum states that the

FIGURE 6 Different ontologies motivate different scientific approaches. From Anjum51 with permission. EBM indicates evidence‐based medicine;
PCH, person‐centered healthcare
8 LOW

biomedical model is justified in the assumption of 9. Davidsen AS. How does the general practitioner understand the
reductionism, for instance, and statistical methods are patient? A qualitative study about psychological interventions in gen-
eral practice. Psychol Psychother Theory Res Pract. 2009;82(2):199–217.
appropriate for generating individual probabilities if we
10. Mumford S, Anjum R. Getting Causes From Powers. Oxford: Oxford Uni-
assume frequentism. Mereologicial composition, against
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genuine holism, seems warranted and the regularity
11. Yunus M. Central sensitivity syndromes: a new paradigm and group
theory of causation supports universal treatment and nosology for fibromyalgia and overlapping conditions, and the related
finding causes through homogeneity.54 issues of disease verses illness. Seminars in Arthritis Research.
2008;37(6):339–352.
In contrast to this, a dispositional ontology accommodates holism, 12. Mishler EG. Viewpoint: Critical perspective on the biomedical model.
complexity, heterogeneity, individual propensities, or causal mecha- In: Mishler EG, Amarasingham LR, Osherson SD, AHauser ST, Waxler
nisms to create a person‐centred approach that favours uniqueness. NE, Liem R, eds. Social Contexts of Health, Illness and Patient Care.
Cambridge: Cambridge University Press; 1981:1–23.
This is summarised by Anjum4 in Figure 6.
13. Nettleton S. ‘I just want permission to be ill’: towards sociology of
The novel framework discussed aims to empower both the patient
medically unexplained symptoms. Soc Sci Med. 2006;62(5):1167–1178.
and the therapist as well as provide professional autonomy of collabo-
14. Lyng S. Holistic Health and Biomedical Medicine: A counter System Anal-
rative decision making, thus enabling a unique view of the situation ysis. Albany. New York: State University of New York Press; 1990.
prior to discussing and engaging in treatment, which is grounded in a
15. Telles JL, Pollack MH. Feeling sick: the experience and ligitimisation of
dispositional ontology. The framework attempts to bridge the chasm illness. Soc Sci Med. 1981;15(3):243–251.
between the therapist and patient’s intersubjective viewpoints while 16. National Institute for Clinical Excellence. Low back pain in adults: early
respecting each other’s autonomy and engage each other to achieve management. CG88 (2009). Available at: https://www.nice.org.uk/
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reflection, reflexivity, and context sensitivity within both the patient 17. O’Sullivan P. Common misconceptions about back pain in sport: Tiger
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18. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review
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model may play a promising further part in future clinical practice and tions. AJNR Am J Neuroradiol. 2015;36(4):811–816.
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ACKNOWLEDGEMEN TS
20. Cournoyea M, Kennedy AG. Causal explanatory plurism and medically
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