Relevant question.

I agree with your statement. In my opinion it belongs to the neglect of ethical issues in clinical decisions. Psychiatrists are rarely trained in philosophy so they do not know enough about relevant issues of ethics. The first naturalistic fallacy for example teaches us, that from what we know we cannot draw conclusions on what we should do. And what we should does always depend on ethical decisions. Therefor all-encomassing theories are not sufficient for clinical decisions and bear the danger to threat dignity and respect of persons.

Additionally theories as well as research in the field often follow the concept of objectivity, but clinical decisions include subjects, individuals and persons. There is a gap between research results and concrete clinical treatments.

Regards Thomas

I fully agree with you, but I fear that psychiatry and medicine in general are going in the opposite direction. I believe that EBM is a dramatic example of reductionism, cutting out the complexity and the contamination of knowledge, true salt of scientific progress. It's crasy to assert that what can not be measured does not exist.

Giacinto,

I agree. There is a reductionism problem. I presented this problem on many congresses in speeches about the limitations of research in music therapy and psychotherapy (see attachment). In my opinion this was not the idea of EBM, as conceptualized by Sackett and others. They suggested ‘clinician expertise’ in combination with best evidence. But during the last decade the role of empirical evidences was exaggerated. The reason for that may be on one hand the gap between researchers and practitioners (see the question on my page) and on the other hand the fact that the implementation of EBM in health care systems change the idea of EBM from best practice to surveillance and control because of limited financial resources. The consequence is a hierarchical system that is more interested in cost efficiency than in human affairs.

Regards Thomas

Http://www.psychomedia.it/pm/science/nonlin/buscaglia-pezzoni-ing.htm

Thank you,

do you have this as pdf. It would be more easy for me to handle it this way.

Regards Thomas

Here it is!

Thank you Giacinto,

I am sure that you already know the work of Michel Foucault, who I think is relevant in this discussion too. He for example stated that to forget the genealogy of psychiatric concepts can lead to severe problems. And that concepts that are used in medicine and psychiatry often are exercises of power.

Do you believe that there was no relevant change since the anti-psychiatry movement?

Regards Thomas

Maladie mentale et personnalité. Presses universitaires de France, Paris 1954; ab 2. Auflage 1962: Maladie mentale et psychologie.

Psychologie und Geisteskrankheit. Suhrkamp, Frankfurt am Main 1968.

Histoire de la folie à l’âge classique: Folie et déraison. Plon, Paris 1961.

Wahnsinn und Gesellschaft. Eine Geschichte des Wahns im Zeitalter der Vernunft. Suhrkamp, Frankfurt am Main 1969.

As someone who has visited more than his fair share of share of therapists and psychiatrists, I am offering only my experience. However, it does seem relevant and I am fairly knowledgeable about these issues from a (couch) layperson's perspective. Almost across the board, during the most extreme period of pharmacotherapy as the proposed best and often only solution, I've time and time again encountered psychiatrists who clearly displayed having failed to s much as read prescribing directions. Almost none, for instance, did not appear dumbstruck and disbelieving when I tried to explain the extensive withdrawal syndrome associated with benzodiazepines. Most psychiatrists seemed to have a pet diagnosis. More than once, I happened to know one or more patients visiting that same psychiatrist, and we discovered that we each had been diagnosed as bipolar or borderline disorder cases. In the worst case, I was diagnosed as bipolar and, despite a year of being tried on every anti-bipolar cocktail with the result of a zombie-like utter lack of self, had to be the one to say, "Why don't we try taking me off these meds. If I worsen, we can assume I'm bipolar, and if not, then we can assume we're on the wrong path." As expected, while I hardly returned to normal, I did at least feel alive. The response -- a true first -- was an apology from the psychiatrist! Yes, thanks for wasting a year of my life. But it was not a learning experience for him. We later nearly came to blows when he refused to simply discuss an aspect of my diagnosis. Given what like 90 percent of the psychiatrists knew about what they prescribed, the idea that they spend the slightest time keeping pace with medical literature is an almost laughable scenario. In fact, of all the psychiatrists I've visited, only one demonstrated doing so often explaining options I'd never before been told or aspects of medications I didn't know...and I had by then trained myself to learn this material for myself, as I would advise any first time psychiatrist visitor to do. Otherwise, God help her. In other words, what I've observed is diagnosis based on what I'll call habitated observations. One begins to see every patient as bipolar, etc. As to power, that seems to me most psychiatrists chief interest...or at the least cultural cache. Most follow-up visits with psychiatrists consist of, "How are you doing? How's your sex life? Here's your prescriptions." I saw very little medical art r science. I saw what looked more like a treadmill.

Dear Thomas,

who is particularly susceptible to faults caused by reductionism, can withstand extreme thesis, which, paradoxically, result in a denial of the patient's needs, so not too different from those that reduce mental illness to a mere neurobiological phenomenon: "mental illness does not exist"

in certain historical periods, the need to protect vulnerable or treated unfairly groups, bring some supporters to deny the reality and the truth, presumably for tactical reasons or with the idea that the wrongs suffered previously justify drastic and extreme positions as those of their opponents. In the end, these statements appear unsustainable and undermines the credibility of all the claims made, even the most well founded.

Michel Foucault? He is certainly a great author

Dear Giacinto,

I agree. But trying to find a way out of the misery means to integrate a lot of critical perspectives. The history of psychiatry is full of ethical problems and interventions that harmed human dignity. So no one can blame people who exaggerate an extreme position against these developments. Psychiatry deals with human minds, so a humanistic perspective is necessary in every case. Reductionism harms, because it reduces real humans and human events to theoretical assumptions.

Regards Thomas

What an interesting and relevant question. Thanks Giacinto for bringing it in, and both Thomas and Paul for their comments.

I have always been worried about phylosophy of psychiatry. When I consider this "reductionist" issue, I always end up figuring what is behind, what feeds and sustains it. It is, of course, a very complex question that involves ideologic, episthemologic as well as more pragmatic considerations, some of them already cited by you (lack of proper training for physicians, perversion of EBM, erasing ethical considerations, and so on).

In my view there is an actor which obtains extremely high (economical) benefit from this reductionist approach to mental illness and is its main promoter and sustainer: pharmaceutical industry. They have infiltrated health systems and academy in such a manner that makes it hard for doctors and students to avoid being permeated by reductionisim in one way or another. Before further developing this, what do you thnik about it?

I totally agree with your point of view. The commercial interests of multinational pharmaceutical companies are crucial. Doctors, at least in our country, have not shown sufficient culture and intellectual honesty to oppose this scheme. It is not easy to oppose a model that ensures money, prestige and career.