Richard Laugharne
Modernism and scientific evidence
Scientific evidence can be viewed as a highly modernist concept. Modernism is the philosophical movement emerging from the enlightenment and is characterised by rationalism, materialism and reductionism. Nature follows rules that are reasonable and found by measuring features of the material world. If the material world is complex it can be understood by breaking it down by its component parts and measuring how these parts work and how they interact. In practice this philosophy results in the observation and meas-urement of the universe. The non-material world is regarded as of dubious validity, such as belief systems which are impossible to verify through observation. From many different observations general rules are looked for, with an underlying assumption that the fragments of observation can lead to the discovery of universal laws that will then predict future observations. The observers are assumed not to affect the system being observed and to be impartial in interpreting their measurements. This distance between observer and observed leads to the objectivity of the truth which is found.
Scientific evidence in mental health has endeavoured to utilize this model despite some inherent difficulties. Many of the phenomena of mental illness are hard to locate in a material world and scientists have tried to measure subjective experience through the patient’s own reports instead. Nevertheless a quantification of reductionist components of mental experience has been the mainstay of mental health research.
Evidence-based medicine has its roots in the modernist paradigm and this model has a remarkable track record in its effects on our lives. The consequences of science and technology have provided human beings with greater efficiency in production, greater prosperity (for some) and improved health through medicine.
Few would argue that there have been huge benefits. However, the other side of the coin has included the capacity and reality of military destruction on a truly devastating scale and the possibility of ecological disaster leading to destruction of life on a similar if not greater scale. At a more intimate level people feel dehumanized by the scientific world view. They are reduced to a complex machine by medics, a means of production by industrialists and businessmen, and a means to power by politicians.
The postmodern challenge to a scientific world view
The postmodern challenge to modernist scientific thinking is difficult to summarize, and indeed avoids easy definition. The most straightforward summary is in what it rejects—the modern paradigm. First it rejects the idea of meta-narratives, big stories explaining reality, and hence the concept of universality. Science can be
seen as a meta-narrative, tyrannical in its assumption that the truths it establishes are superior to other world views (Lyotard 1984). Instead micro-narratives relevant to certain people at a certain time and place are acceptable without demanding relevance to all.
Second the concept of objectivity is rejected. Many in our society question the idea of a scientific community disinterested in the results of its observations. Scientists seek knowledge not for pursuit of truth but for power, whether that power is through status or commercial interest. Does a pharamaceutical company honestly claim objectivity when financing a scientist? Has the scientific community effectively created a climate in which negative findings have equal status to positive findings? In mental health the relationships between knowledge and power have a special relevance as psychiatrists have to balance their role of advancing the medical science of treating the mentally ill with the social role given to the profession of depriving certain citizens of their liberty on the grounds of mental illness.
Third postmodern thought asserts there are different views of truth. In mental health different viewpoints have consistently been put forward by patients, carers, clinicians (with differing views from each profession), purchasers of care and the public. Each cites different evidence to support their viewpoints. There is evidence from biological, psychological and social research with differing methodologies. Psychoanalytic models cite forms of evidence that are different to the research given by behavioural or biological models.
In a modernist world a single universal group of laws would be sought from all this data. In a postmodern world this is not only futile but also unacceptable. And an acceptance of uncertainty should underline the differing views present.
Conflicts with scientific evidence-based medicine
The postmodern viewpoint can seem a nihilistic rejection of enlightenment values, the consequences of which could lead to chaos. However, postmodern thinking is already having an impact on mental health care and on society as a whole. The rise of the user movement in mental health care has many postmodern features (Laugharne 1999). The user movement challenges the objectivity of scientific medicine, arguing that the selected evidence supports the power of clinicians and the use of medication, creating wealth for the pharmaceutical industry (Perkins 2000). The evidence of patients, clearly subjective, is given more validity than observations from non-patients. Another challenge is to the application of research on groups of patients to individual patients. Each person wants to be treated as an individual and not as a member of a diagnostic group on whom a uniform treatment is applied. This is a fundamental challenge to the concept of treatment guidelines, when effectively people are reduced to a diagnosis. In other words, in a postmodern world different people require different treatments according to different truths.
The increase in influence of evidence-based medicine has been enhanced by the need to keep health costs under control. It is quite reasonable to try to control costs by insisting that treatments are backed up by evidence. However there are two problems with this approach. First it assumes there is enough evidence to make a judgement on the options available and that this evidence is objective. Second the evidence is often interpreted by a panel of professionals and is therefore paternalistic in nature. As patients have increased access to information and evidence through the internet, why can not they make their own interpretation of the evidence? Here we come to the externally vexed question of how much health care can be influenced by consumerism. When most aspects of commercial life are governed by consumerism, the expensive business of health-care delivery will not continue as a process of experts telling consumers what they can and cannot have, especially when the consumers have access to the evidence, and can criticize its inadequacy and observe its lack of objectivity. The professional cry for the need for more and better research to come to a
final objective reality is a demand for Utopia as naïve as any religious cult. An unarguable and objective truth through scientific research in mental health is, according to postmodern thought, impossible.
Despite the increasing importance given to evidence-based medicine in health, the public is refusing to reject treatments that are argued to have a lack of evidence base. A recent piece of qualitative research, carried out by users on users, found one of the greatest demands by patients was for increased access to complementary medicine (Mental Health Foundation 2000). Another study on the use of alternative medicine reported that ‘the majority of alternative medicine users appear to be doing so not so much as a result of being dissatisfied with conventional medicine but largely because they find these health care alternatives to be more congruent with their own values, beliefs and philosophical orientations towards health and life’ (Astin 1998, p. 1548). It appears that ‘in the modern era, the effectiveness of health-care interventions has increased, but has also been accompanied by an increase in alienation and dissatisfaction’
(Gray 1999, p. 1552).
Spiritual belief and moral frameworks have always had an uneasy relationship with the modernist philosophy because of their non-material foundations. Whilst many scientists have had strong religious faith and seen evidence for the existence of God in the natural world, the scientific model has worked without need for a spiritual or moral explanation. But the importance of spiritual belief has been repeatedly found when patients have been asked what helps them most with living with mental health problems (Mental Health Foundation 1997, 2000).
Evidence in a postmodern society
The modernist model of scientific evidence is robust. It has a clear philosophy and a track record of some remarkable successes that have benefited humankind enormously. Any philosophy that has survived and thrived for about 400 years can cope with some strong challenges. But these challenges will not go away and must be met. Science in the past has looked at other ways of viewing reality as inferior.
The scientist questions the validity of narrative statements and concludes that they are never subject to argumentation or proof. He classifies them as belonging to a different mentality: savage, primitive, underdeveloped, backward, alienated, composed of opinions, customs, authority, prejudice, ignorance, ideology. Narratives are fables, myths, legends, fit only for women and children. At best, attempts are made to throw some rays of light into this obscurantism, to civilize, educate, develop.
(Lyotard 1984) The future must surely be not to reject scientific evidence in mental health care but first to acknowledge its strengths and limitations and learn to present it as a valuable source of information that can co-exist with other forms of evidence. Practitioners of scientific viewpoints can accept the validity of other positions such as users, carers, purchasers and the public. Whilst an acceptance of the doubtfulness of objectivity of scientific evidence is needed, the acceptability of openly subjective evidence from sufferers of mental illness needs to be acknowledged by the scientific community.
The practice of mental health care should not be a scientific exercise but an exercise in humanity, informed by ethical and moral choices. We as clinicians are educated in the scientific method and should advocate for its inclusion in the overall narrative of mental health care provision. We should not expect this evidence to be supreme over other evidence or ‘trump’ evidence from other sources. Different forms of evidence from different people with different viewpoints may not create chaos but enrich the decisions that
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are made and lead to an ethical service acceptable to the people who matter most, the recipients of mental health care.