Course Director: Michael Musalek
Anton Proksch Institute
Gräfin Zichy Gasse 4-6
A-1230 Vienna, Austria
The development and introduction of “Evidence-based Medicine” some twenty years ago marked a milestone in medical history. Unlike ‘Eminence-based Medicine’ – which had previously dominated the field and in which just a few recognised experts determined medical standards – Evidence-based Medicine (EbM) uses statistical findings from cohort studies as the basis for rational medical practice. EbM is ultimately based on the doctrine of neo-positivism, according to which only empirically verifiable data are regarded as meaningful. With statistical significance thus becoming the essential criterion, empirical findings from control-group-secured cohort studies and probability relationships are translated into medical truths. Strict interpretations of EbM (of the kind we are increasingly encountering today), in which findings from statistical meta-analyses come to be recognised as confirmed knowledge, immediately exposed the limitations of EbM in clinical practice, leading some authors to refer to EbM as “corset medicine”.
Alongside a number of other limitations, the main problem ensuing from today’s rather narrow interpretations of EbM is that the criteria used for quality assurance in medical research are being directly transferred to quality assurance in clinical practice. In reality, however, the medical researcher and the doctor administering treatment find themselves in completely different situations. Only a few years after the development of EbM, without actually mentioning it specifically, H.G. Gadamer wrote an essay entitled “Über die verborgene Gesundheit” (On Hidden Health, 1991/1993) in which he expressed the desire to see greater awareness of the differences between medical research and the actual art of healing – a difference that automatically existed between knowledge of things in general and the specific application of knowledge in the individual case, between theoretical treatises or hypotheses and the practical application of knowledge.
In the natural sciences, at least, research analysis must inherently be based on a positivist-reductionist approach. The latter has the patient divided into individual components and functions that then become the subject of research as constructs of illness. The “subject of treatment” in clinical practice is, however, never just a single component, a single function or a particular construct of illness, but always a sick human being in all his or her complexity. Whereas the main job of the researcher is to provide an analysis that is easy to follow and can be checked by others – in other words an analysis that correctly reduces, separates and abstracts data – the task of the clinician is to help alleviate the patient’s suffering as far as possible and to induce and support a process of healing.
The basis for a psychiatry understood not only as a scientific discipline but also fundamentally as an art of healing applied in clinical practice is not simply the analysis of pathologically determined factors, but rather the synthesis of all the individual pieces of information to which psychiatrists have access on account of their academic knowledge, their experience and their observations and assessments and which enable them to formulate a multidimensional treatment plan that reflects the complex nature of human beings. Adhering to the findings of individual studies without seeking to synthesise them in any way not only fails to improve the possibilities for treatment (which is said to be the supreme objective of EbM), but inevitably leads to a restriction and hence a deterioration of the treatment situation. As a rule, individuals do not behave like the average members of a study group. People suffering from mental illnesses are not clones of study groups; they are originals. Not to mention the fact that – contrary to what the prevailing symptom-based medicine would have us believe – in everyday clinical practice what we encounter is not the illnesses themselves but rather whole human beings suffering from particular pathological states.
Considerations like these formed the starting point for evolving a form of psychiatry that focuses not only on fragments and constructs but again on the whole person. This approach, which we call Human-based Psychiatry (HbM), no longer finds its theoretical basis in the positivism of the modern era, but rather owes its central maxims to the post-modernist ideal that ultimate truths or objectivity in identifying the final cause of illness remain hidden from us for theoretical reasons alone: all being is always dependent on context and thus subject to change; language as the basis of our thinking has multiple meanings, and it changes in and through its use; the observer always remains part of the system, so that he himself becomes an important part of the input leading to the results that he then describes as “objective”. A medicine built on such foundations must not necessarily culminate in an “anything goes” situation without truths or reference points. On the contrary: HbM as envisaged here, focuses on the whole person. The absence of ultimate truths opens up the possibility of simultaneously recognising different, even apparently contradictory truths, which may emerge in the course of multidimensional diagnosis.
The main theoretical premise of HbM, the dependence of being on context, enables the simultaneous coexistence of several apparently contradictory “truths”. EbM and HbM are thus not mutually exclusive opposites; rather, despite superficial differences in methods of diagnosis and treatment, EbM must be integrated into HbM as an indispensable component of the latter. Since the chief focus of HbM is no longer a pathological construct but rather a human being suffering from an illness, the multidimensional diagnostics of HbM as an extension of traditional categorial diagnostics (the domain of EbM) must be primarily oriented towards individual phenomena. The aim is to analyse the phenomenon itself and above all the underlying mechanisms from different perspectives (e.g. psychological, biological, interactional, economic and social etc.) in order to create a basis for a pathogenesis-oriented therapy.
Mental illnesses are not concrete constructs, which simply emerge and then continue to exist merely for this reason. Rather they are dynamic processes subject to a certain patho-plasticity whose course is determined by disease-preserving factors. Hence multidimensional diagnostics of this kind must likewise always be process-oriented. Illness in general and mental illness in particular arise not only as natural phenomena but also in the narratives associated with them (Fulford et al, 2003) . These narratives not only provide meaning that is intertwined with the pathological process but actually interfere in the pathological process as disease-preserving factors and thus themselves become elements determining the illness. Understanding pathological events and the narratives connected with them thus has a special role to play in a differential process of diagnosis.
Probably the most important difference between EbM and HbM is in the treatment aims. In HbM the goal is no longer simply to make illnesses disappear but rather to allow the previously sick patient to return to a life that is as autonomous and happy as possible. In other words: the human being with all his or her potential and limitations once again becomes the measure of all things. This also implies, however, that the multidimensional diagnostics of HbM are oriented not only towards symptoms, pathogenesis, process and understanding but also to a great degree towards the patient’s resources.
HbM treatment above all involves a completely different therapist-patient relationship. The former monologue directed at medical analysis should be replaced by a warm-hearted dialogue; where “psychoeducation” used to play a primary role, a more profound understanding must now evolve based on the principle of reciprocity. The treatment of the individual now focuses not exclusively on his or her deficiencies but instead on resource-oriented strategies. The idea is to create the space and the atmosphere in which all that can be done for the person afflicted by mental illness becomes possible. In contrast to earlier moralising approaches to therapy, in which the therapist told the patient, like a kind of coloniser or a missionary, what was right or wrong with his life, HbM therapy focuses on patients’ wishes and potentials for development, which the therapist strives to find out in the course of real dialogue.
A human-centred treatment of this kind should not only look at the patient’s deficiencies but of course at his or her resources as well. This would also require the development of a new aesthetic in psychiatry, to create an appropriate basis for a therapeutic process of this kind. Particularly helpful in this respect is the work of social aesthetics published in recent years. A. Berleant, one of the fathers of social aesthetics, wrote in a seminal article in 2005: “Social aesthetics is … an aesthetic of the situation. … Like every aesthetic order, social aesthetics is contextual. It is also highly perceptual, for intense perceptual awareness is the foundation of aesthetics. Furthermore factors similar to those in every aesthetic field are at work in social aesthetics, although their specific identity may be different … creative processes are at work in its participants, who emphasize and shape the perceptual features.” The main components of social aesthetics are “full acceptance of others (esteem), heightened perception (perception of all sensuous qualities), freshness and excitement of discovery (fascination), recognition of the uniqueness (person/situation), full personal involvement (engagement/opening), relinquishment of restrictions and exclusivity, abandonment of separateness (places/atmospheres), and mutual responsiveness.”
A social aesthetic for psychiatry, which has already begun but must be further developed, has the task of cultivating interaction between the patient and the therapist – in particular the initial contact, which is so important for the further progress of treatments – to fill empty rituals and modes of behaviour in the therapeutic setting with humanity, to create a fruitful atmosphere in the treatment room and to incorporate genuine friendliness in the day-to-day hospital environment, to deconstruct barriers and to open up boundaries and to facilitate enjoyable situations and relationships despite the suffering caused by illness in order to open to the patient aesthetically agreeable perspectives for the future. Treatment options and forms of therapy that have been and can continue to be developed from such a social aesthetic do not, as in evidence-based medicine, put the disease construct at the centre of the diagnostic and therapeutic interest, but have as their primary aim reopening the possibility of a largely autonomous and joyful life for the patient. A humanistic therapy approach of this kind, in which the person once again becomes the measure of all things, can only be realised in clinical practice via multidimensional diagnosis methods and treatment within the scope of inter-disciplinary cooperation.
- Fulford B., Sadler J., Stanghellini G., Morris K. Nature and Narrative. International perspectives in philosophy and psychiatry. Oxford: Oxford University Press, 2003.
- Berleant A. Ideas for a Social Aesthetic. In: Light A, Smith JM (eds). The Aesthetics of Everyday Life. New York: Columbia University Press, 2005.