Its time for a new paradigm
Sylvia Caras, PhD
"An error does not become truth by reason of multiplied propagation, nor does truth become error because nobody sees it" Gandhi
Evidence-based, research-based, science-based, best practices ... Lately these phrases have become mantras in the behavioral health literature. An Internet search found 86, 000 web pages containing all the words evidence, science, research, and mental health. (1)
High health care costs created an opportunity for managed care companies to shift public scrutiny from care to costs. Those too-high fees, and public access to information, have combined to reduce medical authority. Trained to make expert opinion judgment calls but overwhelmed by the exponential expansion of information, medical practitioners are finding it hard to not know, finding it hard to handle the changes, and are concerned about a parallel increase in litigiousness and increases in their legal liability. Behavioral health practitioners have responded by searching for evidence to shore up a crumpling paradigm, a paradigm grounded in patient deficits and no more than maintenance. But, "'Good evidence' ... depends on the paradigm in which one is immersed." (Gergen, p 91)
Refuting a paradigm which doesnt admit its assumptions and starts from existential statements is tough. Especially when todays behavioral health practices dismiss the evidence that would falsify the theories. Counter-examples from patient input are discounted; anecdote discarded. When we who are most directly affected tell our stories, recovery is dismissed as wrong diagnosis, and discomfort with medication is called non-compliance.
"Much of what is important to peoples recovery has not been uncovered by current evidence-based practices. ... When evidence-based practices are promulgated for replication without taking subjective measures into account, possible important philosophical elements of a practice may be omitted because they are not empirically linked to the traditional outcomes reported." (Anthony). Ducker wonders if the focus might better be shifted from the patient to what is helpful about provider characteristics and recovery contexts. (2)
The federal government, major research funder, infuses with a research budget what then become science-based practices. But, WHOs Ustun notes "a huge gap between efficacy in clinical trials and effectiveness in actual health care practice." (Ustun). Since science-based material is evaluated by scientific criteria and scientific evidence and scientists, it self-perpetuates. Public priorities are established by elected officials via the budget that they vote to accept. Directions are chosen by consensus and then peer-reviewed thus maintaining the status quo or making for very slow change.
Science "tends to do only those things that scientists find easy to do and want to do anyway. It concentrates almost obsessively on minor matters that happen to worry the public. (The reduction of results to usefulness is engineering.) Real science, the wondering about how the world works and the design of simple experiments to test theories that thus come to mind, is like its companion creative activity, art, and best done quietly and inexpensively." (Lovelock, p 15)
Just when science is finding its understandings more relative, fuzzy, chaotic, non-local, and influenced by the very observation, behavioral health is emphasizing the manufacture of what it is naming evidence and research --.todays mental health paradigm is technological. But soul and feelings, and maybe even the brain, are instead non-linear, complex, holistic. The system of top-down technical assistance from experts (Green) and a single orthodoxy is being replaced at the grass roots level by a multiplicity of interventions, individual self-care, self-determination and consumer-direction, and an inclusion of the spiritual.
What are considered best practices, which usually include medication, may be so sedating that it is too much of a struggle to develop good adaptations. The experience of madness may result in being extra sensitive to ones environment (McLaren), transitions and change may require careful planning and self-determined behavioral rules, many small life events may be frightening. Instead of suppressing what is different, a new model could intervene in ways that support what is not. It could locate the positive potential in those it would serve.
Todays evidence-based efforts attempt to reinforce the power differential and generate a badly fitting paradigm for understanding emotional wellness. Preston noted at a SOCSI discussion, "The more input, the more truth."(3) Its time to listen to those who have been mad, hear our truth, and develop a model for offering services that will advance real healing.
Evidence-based, research-based, science-based, best practices ... The field doth protest too much.
© Sylvia Caras, PhD, 2001
Anthony, William. The need for recovery-compatible evidence-based practices. Mental Health Weekly, November 5, 2001
Gergen, Kenneth. The saturated self, Basic Books, 1991Green, Lawrence. Can public health researchers and agencies reconcile the push from funding bodies and the pull from communities? Am J Public Health. 2001:91:1926-1929
Lovelock, James. Healing gaia, 1991, New York: Harmony
McLaren, N. The future of psychiatry: a critical analysis of the theoretical basis of psychiatry, www.futurevison.com
Rosenstock, L and Lee, L J. Attacks on science: the risks to evidence-based policy. AJPH, January 2002, 92:1, p 14 - 17
Ustun, T Bedirhan. Mainstreaming mental health. Bulletin of the World Health Organization, 2000, 78 (4), p 413.
1. An Internet search on November 29, using Google, returned, for "research" "mental health", one million hits, for "science" "mental health", 525, 000 hits; for "evidence" "mental health", 442, 000 hits and for evidence reserach science "mental health" 138,000 hits overall and 85,700 in the last year. And the American Journal of Public Health warns against the "threats to science" and the need to "strengthen the crdibility of scientific evidence." (Rosenstock )
2. Marc Ducker, personal correspondence, November 28 2001
3. Donna Preston, comment at the September 2001 discussion of this subject at the regular meeting of the CMHS NAC Subcommittee on Consumer/Survivor Issues