What Now? | delay @ tutti-nove

This is blog entry six of a series of six. You can access the other entries by clicking their titles above.

In the five preceding entries, we considered significant ways in which the contemporary call for evidence-based practices meets contradictory inclinations in the various actors involved: politicians, diagnosticians, researchers, physicians and other caregivers, patients, activists, health insurance companies and other institutions. We examined more specifically how these contradictory forces have played out over the past forty years in shaping one of psychiatry’s premier manuals—the DSM.

Evidence is not synonymous with science. Political, economic, and moral motives each played a role in shaping evidence during both the invention of the PTSD diagnosis for the DSM-III in 1980 and the passing of the new PTSD law in Denmark in 2013. Evidence is colored by the eye of the beholder, which eye invariably sees on the basis of an underlying theory. Here, reality is in flagrant contradiction with the declared intention of the DSM to be theory neutral. Add to this both the manual’s inability to live up to its intended purpose as a tool at the service of scientific research and the troubling ease with which it can be reduced to an administrative checklist, and it is tempting to wonder if time had not come to disbar the DSM system.

Giving the thought serious consideration is certainly a healthy thing to do. Nevertheless, until a viable alternative is implementable, the answer must be no. We don’t need once again to throw the baby out with the bathwater as happened when the DSM abandoned psychoanalysis for the benefit of evidence-based medicine. Rather, analyze the paradigm, that is to say, the paradigms. We need systems and categories. It is difficult to think or act without them. They too have a place at the heart of scientific endeavor as well as in the life of the subject. Yet they represent several dangers. Once established, they are prone to discourage observation and thinking. Most significantly, the irrational rationality of each human subject unfolds at some variance with systems and categories, below their radar, so to speak. Hence, with these difficulties in mind and the DSM system reflecting a prevalent mind-set, an open, thorough, critical analysis is called for if we are to find a solution that better links subjects and sciences.

A good place to start is to abandon the thought of theory neutrality. When humans manifest themselves as subjects—as it is fitting they do—there is no such thing as theory neutrality; besides, there are no objective facts—even from the point of view of science—without their being colored by a theory of some kind. It is a highly dubious enterprise to equate facts with evidence. Even in an evidence-based practice, the best current evidence is combined with the physician’s clinical expertise. The idea of course is to strengthen the scientific approach to clinical practice, but note that the definition—taken from three of the founders of modern evidence-based medicine—places clinical expertise on par with evidence. Thus, the practitioner’s clinical expertise is not evidence-based, it is based on experience.

At a time when evidence is in high favor and the prestige conferred by experience is so-so, therapists may be tempted to let the evidence their professional environment considers most current indiscriminately dictate their work procedures. Hence, the evidence-based practically becomes synonymous with experience and clinical expertise. In that kind of environment, if a clinician only imagines there is no evidence for this or that, concluding that the phenomenon in question is of no interest will be the obvious next step. It all looks very practical and efficient; a way of producing quick diagnoses when waiting lists are long and the pressure is on to meet the mandatory quota of services. It might also be a way to save the resources a more thoughtful examination might incur. One thing is certain, however, it is a thoroughly tested method—the historical evidence is overwhelming—to undermine the underlying principles of any practice.

Humanity has been through all this countless times, in matters both big and small. Many precious contributions have landed in the cemetery of good ideas. Is evidence going there too?

End

Note

This final blog entry of six was penned in the shadow of the attack on Charlie Hebdo and completed 2015-01-07 as the immense rally starting at the Place de la République in Paris was under way.

2015-01-11 + 2015-10-05