This article was accepted for the Philosophy of Psychiatry Newsletter number 43 of the Royal College of Psychiatrists (Winter 2016/2017)
Evidence based Psychiatry is an epistemological approach to mental health which restricts the sources of valid information to those which follow a particular method. The aim of this article is to rethink the validity and utility of this approach, which has displaced others to become hegemonic.
The origins of the evidence based approach can be traced back to Descartes (1637), who developed the scientific method in order to displace the authority principle as the criterion for truth. The aim of this method was to guarantee the arrival to a clear and distinct truth to anyone who followed it, irrespective of his expertise, prestige or social status. Similarly, the evidence based method wrestles access to “truth” away from “experts” and makes it accessible to “outsiders”. Thus, it legitimizes politicians and managers to take decisions that have an impact on people´s health (namely, choice of treatment), instead of leaving the choice to clinicians (or patients).
At the basis of the evidence based approach lies its commitment to empirical proof and the hierarchization of the value of different research strategies. Thus, meta-analysis is considered as more valid than randomized controlled trials, which are seen as preferable to cohort studies, which in turn rate above the opinion of a group of experts in the field, etc.
The validity of this hierarchy of evidence is undermined by a logical flaw (Whitehead and Russell, 1910). Since it is generated by the opinion of “experts”, it can´t possibly work as the foundation for the strength of higher orders of evidence than that of opinion, which is basically the whole hierarchy. This logical flaw collapses the hierarchy of sources of evidence leaving us without support to assert, just on the grounds of the method used, the superiority of particular research strategies over expert opinion (irrespective of the value that the experts give to that research once they have looked both into its method and its content).
The field of applicability of the evidence based paradigm is also contentious since it is based on facts and events, that is, phenomena (Kant, 1781). Therefore, this empirical approach can usefully be applied to other phenomena. However, it is highly debatable that the human mind can be reduced to its phenomenological aspects. Kant (1788) considered that mind was a “noumenon”, something in itself that could not be reduced to facts and required a non scientific approach. Also, dialectical materialism (Marx, 1906) might be used to consider that even if mind is based on matter, its complexity gives rise to more complex dynamics which can´t be understood solely by studying its components. Alternative epistemological models have been proposed for the study of complex systems, namely systems theory (Von Bertalanffy, 1968).
It is noticeable how some therapeutic approaches, like psychoanalysis have struggled for decades to come to terms with evidence based Psychiatry. While this might reflect some cultural or institutional problems in these approaches, it might also denote the insufficiency of the evidence based approach to apprehend the content and value of these approaches.
This evidence based approach to mental health has been useful to identify adverse effects of some interventions and even to support the effectiveness of some treatments. Furthermore, it has facilitated access to important information to non-initiated people, providing a frame where politicians and managers can talk sensibly about issues like choice of treatment. However, as this approach has almost displaced all others, it appears as if clinicians, academics and other “experts” had nothing to add to the discussion and could not achieve meaningful insights or a deeper understanding than the one provided by “evidence” as defined and rated by the paradigm. Similarly, patient opinion and subjectivity would go out of the window, although political issues in democratic regimes and commercial mindsets seem to be deploying this avenue in parallel to the evidence based one.
I believe that losing the thinking process of the “experts”, however controversial their conclusions might be at times, is highly deleterious and that the use of a reductionist epistemological approach to the exclusion of others can lead to the proliferation of reductionist treatment orientations (as can be illustrated by the progressive closure of Psychotherapy services in the NHS) and the loss of the humanistic component of Psychiatry. As useful as evidence based Psychiatry can be at times, it should be complemented by other approaches.
References
Descartes, R. (1979). Discourse on the Method of Rightly Conducting One´s Reason and of Seeking Truth in the Sciences. Indianapolis: Hackett Classics. First published in 1637.
Kant, I. (1999). Critique of Pure Reason. Cambridge University Press. First published in 1781.
Kant, I. (2015). Critique of Practical Reason. Cambridge University Press. First published in 1788.
Marx, K. (c 1940). Capital: A Critique of Political Economy. New York: Modern Library. First published in 1906.
Von Bertalanffy, L. (2015). General System theory: Foundations, Development, Applications, London: Penguin. First published in 1968.
Whitehead, A. N. and Russell, B. (2015). Principia Mathematica. Ontario: Scholar´s Choice. First published in 1910.
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