The Elephant Path

Although I would rather have called this story ‘goat tracks’ – simply because of the cheerful, adventurous name – ‘elephant path’ turns out to be a better title for what I mean to say. I looked it up.

An elephant goes straight through the jungle towards its goal. Simply because it is the shortest route, hence the name. The most logical route, by the way – especially when you have little time. A goat track is therefore the path that did not exist yet, difficult to walk. You have to make an effort to plough through it. It is clearly not the obvious route. Not your preferred route…

I believe it was Swaab who explained that an art appraiser sees in a single glance that a painting is a forgery. And that the argumentation only follows afterwards. But do correct me – I could not find who discussed it. In any case, the narrative follows what the brain recognises.

When I had already been working in forensic care for a very long time, I started working at Vesalius. An outpatient clinic for people with brain injury, which has unfortunately since closed. Before I started, I shadowed for a day. I sat in on a consultation with the clinical psychologist who had worked there for years. After the patient had left the room, I – still pondering her – hesitantly remarked that she also seemed somewhat hypomanic to me. The psychologist said kindly but firmly: ‘Yes. Or she is somewhat disinhibited because of her brain injury’.

That remark was the start of a learning process for me. Not even a thinking process, because that implies far too much awareness, too many thoughts. No, a much slower process than that. A process that unfolds imperceptibly – outside of consciousness – because you encounter the same kind of complaints, or combination of complaints, in people more often.

And with every next patient, your brain (re)cognises these complaints more easily. You – or at least your ‘conscious you’ – are actually detached from that. You don’t notice it; it happens. A new pattern of recognition emerges.

The easiest comparison is with a new set of colours you have added to your paint palette. Sometimes you can make do with the new set. More often you mix them with a few colours you already had. Or even with your entire old set.

This is – in my view – also the reason why it is difficult to learn from books what you have not yet truly encountered. Even when the book states very clearly which complaints occur together. However strange that sounds. That conscious knowledge then has to be very much at the ready. It also explains why junior colleagues in particular suddenly see that other explanation while the professor does not. They do not yet have fixed patterns of recognition. And they still have fresh, ready knowledge of a broader palette of symptoms and problems. Valuable, therefore!

Back to that experienced colleague for a moment; they have been walking that old path for a very long time. That path simply remains a good deal easier. You know the way there; it goes by itself. With a new path you don’t always know whether it is right. Which signs belong to the route and which do not? Which direction should you take, and what else should you pay attention to?

For example, someone who has not yet dealt much with people with brain injury often does not know that it can seem as if these people are still capable of a great deal. Simply based on the impression they make in the consulting room. They do not know that their intelligence or coping strategies can compensate for a lot. Or even how independently they present themselves while the opposite is true. For instance because they have limited insight into what they can do. And sometimes things do still work out, but they take more – or even great – effort. This often takes its toll. Because people are continuously overtaxed. But sometimes their intelligent impression is hard to reconcile with everything they say they cannot do; it then becomes almost implausible.

You learn to understand this once you have dealt with enough of these people and remain curious about their answers, or about additions to your questions about what they say they cannot do. Family members can often explain this well: what now goes differently, goes wrong, or no longer happens at all.

In other words: you need to meet enough people who have the complaints in order to learn to (re)cognise the pattern. Your brain then ‘sees’ it faster. That works – I think – well for an art appraiser. But in healthcare this is a problem, because if you know those patients too little from your own experience, you can go badly wrong. And that makes all the difference to whether you help them. Or (precisely) not!

Because as long as you know that other pattern (your old elephant path) much better – and the new one not yet, or not well enough – in people with brain injury you will keep attributing concentration problems and impulsivity to the classification ADHD. You will keep seeing the excessive talking as a symptom of hypomania. The emotional volatility – which fits overtaxing or poor impulse inhibition so well – as something that really belongs to ‘borderline’. Even when there is no sign whatsoever of the associated dynamics in relationships. And also when these complaints only arose around one’s fifties, around the age of menopause. Relatively late, of course, for the label ‘personality disorder’, for which this pattern must be observable throughout life.

Why does this happen? I think because your brain tries to work efficiently. Which makes it inclined to resolve those incongruencies for you, to put them out of play. What does not fit carries less meaning for your interpretation of the complaints. That is then interindividual variation, nothing more. This happens unconsciously and not wilfully. What does not help is having hardly any time to pause and question yourself about this. Why would you leave an old, automatic and smoothly running path when the alternative is a new path that is still quite a challenge?

In any case, the point is to develop another perspective on the same – or at least comparable – behaviour or the same complaints. An additional or alternative explanation. A new pattern to get to know and to investigate.

OK then, here it comes: getting to know such a new pattern is, in fact, that ‘goat track’. The goat track, which in turn can become a new elephant path. Alongside the path that already exists.

Though I always like to sniff around a little longer to see whether the route really fits. Or whether I should have taken that other, old one after all. Or – more often – a combination of both.

Because you can imagine that in people who meet the criteria for ADHD – through their impulsivity and poor concentration – an accident is lurking just around the corner. And therefore brain injury as well. Something I knew from the books: people with ADHD have a higher risk of accidents. Yet I only truly grasped this when I worked in care for these people with brain injury. That usually both are at play.

You should therefore not fixate blindly on one path or the other, but remain aware that there can be several paths. Several colours exist for the palette.