Richard Laugharne, MRCPsych and Jonathan Laugharne, MRCPsych
Department of Mental Health, School of Postgraduate Medicine and Health Sciences, University of Exeter, Wonford House Hospital, Dryden Road, Exeter EX2 5AF, UK
Correspondence to: Dr Richard Laugharne E-mail: firstname.lastname@example.org
Mental health care is a complex activity. Those involved include patients, carers, clinicians, purchasers and the public, and these groups have different perspectives and viewpoints on mental healthcare. These viewpoints can be conflicting, and an understanding of their differences is vital for planning. One example is the contrast between the ideas behind evidence-based medicine and user empowerment, which can reflect the differences between a modern and a postmodern view of the world1. Here we discuss the potential impact of postmodern philosophical and cultural change.
Modernism has its basis in the Englightenment and is the worldview on which science itself is based. The fundamental principles are rationalism, materialism and reductionism. Nature acts as a unified whole. Rather than rely on non-material sources of truth or revelation (the basis of religious worldviews), the modernist observes and measures. To understand the world we must reduce the whole to measurable components, and so come up with theories to explain reality. That which cannot be measured cannot be proven and so its validity is questionable. This modern worldview has its origins in the works of such thinkers and scientists as Bacon, Copernicus, Galileo, Newton, Descartes, Kant and Hume. It offers a clear model of reality that is open for verification to any who wish to repeat the observations of others. In that sense it is transparent and accountable. Dominating intellectual thought for the past 400 years it has yielded revolutions in agriculture, industry and medicine. One of the greatest achievements of science has been the reduction of suffering through disease, and improvements in the length and quality of life.
However, there have been criticisms of modernism as well. The reductionist principle has denied the importance of the whole individual and the whole community. A strong foundation for moral values has been elusive in a universe denying non-material reality. As technology becomes more complex and difficult to understand, the layperson relies increasingly on the specialist's interpretation of reality. Perhaps the greatest criticism of the scientific revolution has been in the misuse of its knowledge. Because of the military developments and ecological consequences of science and technology, new generations question whether the benefits of the Enlightenment have been worth the cost of its destructive power. The negative impact of certain scientific developments has broken the spirit of trust, and society keeps an ever closer eye on what scientists are doing.
Postmodernism is an elusive concept, stemming from many disciplines including linguistics, literature, architecture, philosophy and science2. One clear pattern to postmodern thought is in its reaction to and rejection of certain aspects of the philosophy underlying modernism.
The rejection of truth and objectivity
One of the first philosophers to undermine the foundations of modernism was Friedrich Nietzsche3. Attacking the Enlightenment concept of truth he argued that, if we reject a ‘transcendent being’ handing us absolute truth and only value observations of the material world, the result is a world made up of fragments of observation. No two things or occurrences are the same. We construct concepts to bring these fragments to a unifying whole but these concepts deny the multiplicity of reality. The combining of these concepts in an effort to comprehend the world is, according to Nietzsche, an illusion. He calls into question the entire enterprise of rationalistic human knowledge on the grounds that the process of fabricating reality is an arbitrary and individual manner. ‘Truth’ is a function of language:
‘What, then, is truth? A mobile army of metaphors, metonyms and anthropomorphisms—in short a sum of human relations, which have been enhanced, transposed, and embellished poetically and rhetorically, and which after long use seem firm, canonical and obligatory to a people; truths are illusions of which one has forgotten that this is what they are; metaphors which are worn out and without sensuous power’4.
With such nihilistic ideas Nietzsche heralded the erosion of the concepts of universal truth and objective truth, and it was continued by Foucault in the twentieth century. In his influential writings Foucault advocated the acceptance of difference and ‘otherness’ rather than the universal and ‘sameness’5.
Suspicion of metanarratives
The French philosopher Jean-François Lyotard argued that the postmodern age is marked by the demise of metanarratives (total explanation of reality) and the emergence of micronarratives in their place6. Put more simply there is a disillusionment with the unifying ‘big stories’ offered by science, religion or politics to explain the way reality is. Instead people look towards the narratives of individuals or local communities, which are seen as less tyrannical—less demanding of mass allegiance. Instead of ignoring those who do not conform to a grand theory of everything, post-modern theory celebrates individual difference and non-conformity. All claims of proof or truth are treated with suspicion: ‘Scientists, technicians and instruments are purchased not to find truth but to augment power’.
Criticism of science
Lyotard consistently challenges the legitimization of positivist science. He argues that science is not manifest as a unified flow of progress aiming to increase human knowledge. Instead it has developed into clusters of ill-defined and shifting areas of enquiry. Scientists are no longer seeking ‘truth’ but augmenting power. ‘The question now asked... is no longer “Is it true?” but “What use is it?”... “Is it saleable?”... “Is it efficient?” ’6. Foucault's writings likewise dismiss as untenable the concept of the disinterested observer and criticize scientists' claim to objective knowledge, seeing them as claiming knowledge to establish power. He challenges any concept of order, stating that there is no such thing as natural order but only discourse.
The established concept of steady scientific progress was further challenged by Thomas Kuhn7, who argued that shifts in scientific theory are not merely an additive process whereby new research adds to previous knowledge. Rather, science is a dynamic historical phenomenon. A scientific theory exists whilst reality seems to be consistent with that theory. No theory can encapsulate all data and, as new research contradicts the prevailing theory, finally someone proposes a new explanation that more successfully accounts for the anomalies. He termed the transition a paradigm shift. But the conclusion is that science is a discourse rather than a mechanistic process—social, not neutral and objective. Science cannot lead to definitive statements about objective reality. Every experiment relies on a network of theories, opinions, ideas and traditions of a community. Kuhn further argued that the paradigm advocated by the scientist determines how that scientist views the world, including the instruments and measures chosen in observations. Claims of objectivity are questioned.
Kuhn's ideas have been carried forward by those concerned at the implications of science as a social discourse. Questions have been asked about political power, the method of choosing problems, prejudice and value systems in scientific communities and how these affect science8. And beyond is the issue of how science is associated with risks and uncertainties. This is illustrated by such controversies as the bovine spongiform encephalopathy (BSE) crisis, the safety of genetically modified foods and the advent of global warming. The paradigm of science that offered certainty is losing its validity. According to the philosophers of science Silvio Funtowicz and Jerry Ravetz, science is now moving into a postnormal phase9.
In postnormal science ‘facts are uncertain, values in dispute, stakes high and decisions urgent’. Conventional, normal, science may still be valid when levels of risk and uncertainty are low but it is not valid when decision stakes or system uncertainties are high. The development of these ideas is directly linked to the growing acceptance of the unpredictability of non-linear systems through the development of chaos and complexity theories. The recognition of such complex systems has impacted many disciplines from economics to meteorology to medicine10.
Postnormal science requires that science expand its boundaries to include different validation processes, perspectives and types of knowledge. In particular it requires scientific expertise to meet with public concerns. A dialogue is opened up between all stakeholders. This could include scientists, social scientists, journalists, activists, and interested members of the public. The quality of the scientific work is assessed not just by experts but by an extended peer community who use extended facts which can even include anecdotal evidence and statistics gathered by a community. Quality replaces truth as the ongoing principle. Good quality traditional science is not rejected— it is reiterated or fed back in an integrating social process. Thus postnormal science leads to a democratization of science and allows the wider public to join discussion of the social, political and cultural implications of the scientific process.
In summary, postmodern thought has challenged several aspects of the philosophy of science. It has disputed the assumptions that different observations will coalesce into universal truths, that the observers are separate from the observations made, that scientists are impartial to the interpretation of their data and that scientists are not influenced by the power resulting from knowledge discovered. Scientific discovery is a social process rooted in discourse amongst the scientific community. Postnormal science has some strong postmodern ideas—notably, that uncertainty is inevitable in complex systems and that the search for an absolute truth is suspect. Quality, not truth, becomes the goal. And the evaluation of observations should not be left to a scientific elite but extended to all those with an interest in the quality of the results. But science is not rejected and the judgments of scientists are not ignored. Scientific work is essential to the process but the views of scientists are open to challenge.
POSTMODERNISM AND PSYCHIATRY
We come now to examine the implications of postmodern thinking and postnormal science for our own specialty, psychiatry. Psychiatry does indeed have qualities consistent with a postmodern worldview. It uses several different theoretical models to understand and explain the mental experiences and behaviours of patients. One framework incorporates biological, psychological and social views of reality. Therefore, when a patient has symptoms characteristic of depression and there is a family history of the disorder, we may think in biological terms and prescribe a drug that will alter neurotransmitters in the patient's brain. However, an abusive childhood might suggest a psychological cause that would respond best to a talking therapy. It then emerges that the patient was well until unemployment and debt led to family tensions. Even within these differing frameworks, further differences in worldviews are possible. Should the talking therapy be based on a psychodynamic worldview or a cognitive behavioural model? One possible reaction to these differing perspectives is to take the modernist road of drawing these theoretical strands together into a ‘biopsycho-social model’. This creation of a universal truth or meta-narrative from differing realities, which all have their evidence and adherents, would be rejected by postmodernists.
Psychiatry as a discipline interacts with and draws from a wide range of other disciplines including philosophy, law, social sciences, criminology, psychology and basic sciences. It therefore incorporates disciplines that are value laden rather than value neutral.
The most striking postmodern perspective on psychiatry is the interaction between science and power. Few professional groups claiming a scientific foundation are given such power over the liberty of their fellow human beings. Psychiatrists claim to be able to relieve illness through scientifically based treatments and are then given power by society to force those treatments on certain individuals. This licence will rightly be challenged in any society with freedom of expression. The arguments on the pros and cons of coercive treatment will include not just science but also moral and ethical dimensions. Hence non-material perspectives need to be incorporated.
POSTNORMAL SCIENCE AND PSYCHIATRY
The concepts of postnormal science may be useful for psychiatry. The practice of mental health delivery undoubtedly involves substantial levels of risk and uncertainty. Non-linear systems are everywhere—in patients' environments, in family systems, in services and even at the brain's molecular level. Those working within psychiatry are already in a limited dialogue with an extended peer community in the form of user groups and other interested community representations. Psychiatrists experience extended peer review of their activities by mental health review tribunal panels that include legal and lay members. It is clear that users of services want a say in the interpretation of evidence and the choice of treatments offered at individual as well as societal level. They will not be satisfied with peer review by experts only who have no experience of receiving treatment. An extended peer review appears democratic and fair. Finally the pursuit of quality rather than an elusive ‘truth’ appears to accord with the wishes of the users of mental health care. A recent piece of research on users' opinions of care (conducted exclusively by those with an experience of mental illness, thus openly rejecting the need of disinterested objectivity of observers) suggested dissatisfaction with scientific treatments whereby patients are grouped together according to current diagnostic categories; rather they favoured treatments that emphasize individuality and uniqueness including spiritual needs11.
Many of these issues are also relevant for other medical disciplines. General practice, with its long-term relationships between doctors and patients can likewise look to postmodernism12. The recent controversy over the MMR vaccine illustrates that a paternalistic instruction on the best evidence does not conclude the debate; patients and politicians entered the ‘extended peer review’. Eventually the immunization history of the Prime Minister's youngest son was demanded as a source of evidence. Palliative care clearly demands scientific evidence, but less reductionist concepts such as patient choice and dignity are again important.
DECISION MAKING IN MENTAL HEALTH CARE
How do we evaluate psychiatric care? This has been one of the key questions of the past decade, and scientific methodology is one answer. The prominence given to evidence-based medicine (EBM) can be seen as an attempt to reassert modernism within the field, with an underlying assumption that if enough research is done, an absolute answer will be found. Yet even EBM has at its heart a debate about quality—which types of study give the best quality information, and which individual studies are conducted to adequate standards. Linked to EBM is the establishment of the National Institute for Clinical Excellence (NICE) in the UK to make judgments on the effectiveness of medical treatments. It is noteworthy that early judgments from NICE have generated considerable public criticism, especially from those most directly affected by the disorders in question. On the one hand, there have been suspicions that the commercial interests of pharmaceutical companies have been too influential; on the other, drug companies suspect political interference to bring down National Health Service costs. Claims of scientific objectivity are difficult to maintain when strict detachment from commercial and political interests is impossible. In England the National Institute for Mental Health has been established with the aims of involving service users and working with NICE to achieve evidence-based services. Potential conflicts do not seem to be recognized and it is assumed that consensus can be achieved.
If mental health care is to become more democratic and responsive to individual wishes, it must take account of patient demands. However, in a centralized service it is difficult to see how this can be achieved. First, the centre controls the budget and cannot give unlimited services to individuals. Second, treatment being free at the point of delivery, there is no reason why the user should not make unreasonable demands on a limited resource. In a nationalized system government has the twin challenges of controlling expenditure from taxation—which means limiting service—and enacting the democratic will by delivering promises made in an election. In both of these roles individual choice is reduced. Centralized decision makers will look to experts, whether in scientific medicine or in ‘user involvement’. In this system, the majority decides for a minority and individual choice is secondary.
If the government reduces investment in clinical services or research, commercial interests will move in. Private medicine will provide clinical services with a goal of making a profit, and the pharmaceutical industry will finance research with the same goal. Both will rely on individual choice to take up the services and individuals will thus gain in autonomy. However, choice is dependent on wealth and the poor may have no choice at all. We cannot divorce science from ethics.
Psychiatry has many postmodern tendencies. However, scientific modernism is one of its foundation stones. Postnormal science offers a way forward that gives science an important place in the future of psychiatry but acknowledges the need to create a more democratic framework for evaluating all forms of evidence. If this is accepted there is no need for psychiatry to strain to be ‘modern’ through an overemphasis on EBM or biologism. As a postnormal clinical science, psychiatry can legitimately build on the foundations it has already laid through increased dialogue with individual patients, user groups, politicians and other bodies.
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