> But if we want to change the rules -- if we ignore or don't bother to
> test and control for the effects of chance, time, placebo, suggestion,
> self-fulfilling prophecy, etc. -- we move further from Medicine and into
> the waiting embrace of the Hermeneutic Circle (which, as you know,
> could amount to no more than a folie a deux, shared by you and me, and
> have nothing to do with anyone or anything else: some, by the way,
> revel triumphantly in this "uniqueness" and "individuality," not
> realising that it guarantees that there's absolutely no need for anyone
> to pay any attention to it at all, much less teach it to others,
> whether didactically or polemically; because it's just true for you and
I agree with what you say about 'curing' people, whether with drugs,
surgery or psychological approaches needing to be systematic in order
to be reliable. This does not preclude psychological therapies; but the
system of validation for psychological therapies will be fundamentally
different from that of medical therapies; we cannot analyse blood
samples and identify foreign bodies. We rely much more on hypotheses
and constructs, and whether they work with a particular set of symptoms
that we label as 'depression' or 'anxiety' etc. And let's face it, we
haven't even got a particularly reliable system for diagnosis of any of
the 'mental illnesses' yet - possibly because we are dealing with
continua with these problems. As you say, the more psychological the
problem, the more doubt there is. Given this, we have to continually
question the way in which we view the underlying assumptions used in
formulating 'cures'. These are philosophical questions.
> Nick, these journalistic generalities are not the way to come to a
> reliable conclusion about such things. Let me put it very starkly:
> Suppose what was at issue was a virulent form of cancer in someone you
> loved, and your decision about whether to recommend one form of treatment or
> the other were based on the strength of the evidence above: Would you
> feel comfortable recommending against pharmacology and in favour of
> the (counterpart of) the "enabling" approach based on what you have read
> in favour of one and the other so far?
It is always possible to identify a worst case scenario that calls a
particular view into question (e.g. clinial depression, cancer).
My argument is not against drugs, it is against where the emphasis
lies in the world of treatment. Yes, antidepressants and ECT do work
with those with severe depression, but they are not the only solution,
and quite often are not any solution. If the emphasis is on a
biological model, other disorders further down the continuum are in
danger of being treated in the same way. And there is evidence that an
enabling approach works better in the long term for some people than
drugs. Drugs do not get to the root of problems. Just look at the
wealth of research that indicates the amount of good a GP can do just
by listening to a patient, rather than reaching for the prescription
pad. Just because this kind of research catches the public imagination
and is reported in a popular fashion does not invalidate it.
I think that this 'enabling' movement is an important step and an
antidote to the over reductionistic explanations of medicine. That is
not to denegrate medicine entirely, but the emphasis is not yet in the
right place. The status quo that has for the past century favoured
drugs needs to be challenged - this is now happening; and not just in
the psychological disciplines. The relationship between state of mind
and immune system is being explored (PNI - Pelletier, 1992); is this
not an enabling appoach? But still there are financial considerations
when challenging the pharmacological industry....
To sum up:
1) I don't deny that psychological therapies are disputable. But their
infancy and lack of appeal to an established way of thinking need to be
borne in mind when considering reasons for lack of progress.
2) The methods of investigation should indeed be subject to the rigours
accorded the pharmacological approach, in order to isolate effective
from ineffective. But at the moment lack of definition precludes
methods comparable with medicine (Boyle, 1994).
3) The emphasis presently on drug therapy is in danger of getting in
the way of methods that get at underlying social and psychological
problems (Prozac Nation; cited The Guardian, 18th Feb, 1995).
Drugs are not, and will never be a single cure for any mental
dysfunction. They are merely an adjunct.
Good stuff, Nick
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