Evidence-based medicine, user involvement and the post-modern paradigm

This book discusses the evidence-based assessment of deliberate self-harm, and covers the special problems of general psychiatric practice when alcohol misuse and severe personality disorder complicate the picture. Chapters relating to depressive disorders begin by focusing on opportunities for psycho-social intervention and liaison with primary care. There are comparisons of 'old' and 'new' antidepressants, and reviews of strategies for preventing relapse and recurrence, and managing resistant depression. The special problems of emergency treatment and depression in older patients are identified. There are expert overviews of brief dynamic psychotherapy, cognitive approaches to treatment, lithium therapy and modern ECT practice. Many chapters emphasise the importance of the rational integration of biological and psychological treatments. There is helpful advice on the specific problems in managing obsessive-compulsive disorder and eating disorders, in dealing with somatisation, and in providing support and treatment for the victims of severe trauma.


Modern versus post-modern
Modernism is a product of the Enlightenment and as such, in human history, is relatively recent. Its main outlook on reality is rationalist, materialist and reductionist. This is the basis of scientific endeavour: that the material world follows logical rules that can be measured. From these measurements we can form rational as sumptions that explain the world, test these assumptions and so apply these rules to effect change through technology. This philosophy actually took a long time to effect medicine, but has now made a huge impact (Leggett, 1997). Few would deny that modern medicine has hugely benefited the human race in many ways -and that modernism has brought the human race close to self-destruction through military tech nology and ecological disaster (if the worst predictions prove to be accurate).
Modernism as a philosophy began to look less than complete at the end of the last century and the twentieth century has hastened that revision. One reason is that it has denied the individuality of people, reducing them either to their compo nent parts (as in the emphasis of their disease in medicine) or to a cog in an inhuman machine (a criticism of both communism and capitalism). People want to be valued, and they often do not feel so in the modern world. Another factor is that science, which often claims to have the objective truth at a given moment, soon disproves this very truth. At the end of the last century Newtonian physics appeared to explain all reality from the motion of small particles to the motion of the planets. Time and space were absolute. Twen tieth century science has undermined this model. The theories of relativity, quantum mechanics and chaos have made time and space far less certain and absolute, and nature's patterns less linear and predictable. Medicine still works largely by nineteenth century science. Perhaps because twentieth century develop ments in science are so complicated applying these theories as a doctor is overwhelmingly daunting. However, chaos theory may have specific applications to psychiatry (Reid, 1998).
Many people have rejected a modernism that has claimed to discover absolute truth through observation, measurement and reason. They do not accept that reality can be reduced to what is measured and seek a view of the world which incorporates the whole and does not reduce it to component parts. Post-modernism is a difficult theory to define. It has origins in linguistics and is concerned with the process of knowing and how our minds are part of that process. It does not hold to objective reality but the relative reality for that individual participating in the process. Beliefs do not arise in isolation and scientific discourse is rooted in the social community of scientists (Mathers & Rowland, 1997). Thus, the main values of post-modern theory are those of uncertainty, difference in views and experience of reality and multifaceted descriptions of truth. Leggett (1997) predicts that as a consequence of this movement, patients may turn away from statistically determined treatments as having no relevance to them as an individual: 'What is right for the majority may not be right for me'.

Evidence-based medicine
The movement to evidence-based medicine is clearly modernist. The underlying philosophy is that medical interventions should be rational, be measurable and observed to have benefited the recipient of the intervention. This benefit will usually have used a measure of a certain variable of the individual rather than a measure of the whole person. In psychiatry the necessity of measurement has led to the proliferation of rating scales -scales for mood, psychotic symp toms, even of strength of spiritual belief and loneliness. One of the reasons for the success of cognitive therapy has been in demonstrating its effectiveness through the use of rating scales. The 'gold standard' of evidence-based medicine is the randomised-controlled trial, and the Cochrane Library provides easily accessible infor mation on the evidence from these trials.
Evidence-based medicine is very good for dealing with inconsistencies between health care professionals. It stops 'quackery' -practitioners inflicting their maverick theories on the unsus pecting patient. However, problems arise when the patient wants to be treated as an individual and questions whether he or she fits into a statistical norm -he or she may feel that they are not an individual being cared for, but a syndrome or disease being treated. Evidence-based medi cine is not music to a post-modern ear.

User involvement
User involvement is a movement with its roots in a consumerist model of market economics together with advocacy of civil rights for the sufferers of mental illness. It is concerned with what people want -their 'needs' are often seen as being determined by paternalistic professionals. In this sense the movement has post-modern leanings, an emphasis is placed on the individual's perception of their need and not on being part of a population with common problems and common solutions.
The rise of counselling in general practice is an example of the tensions between evidence-based medicine and user involvement. This service has often been met with scepticism by psychiatrists citing claims of a lack of evidence for its effectiveness. But general practitioners claim that they are providing what their patients' want. The position of some psychotherapies has also been questioned because of a lack of empirical evidence of their effectiveness. This is partly because, as more interactive disciplines, they are much hard er to research. Counselling and psychotherapy are often what patients want because they feel they are treated as individuals telling their own, unique stories. The narrative of peoples' lives has always been given importance -the story of the person, their family, their community, for exam ple in psychiatric history-taking (Beveridge. 1998;Greenhalgh, 1999). However, patients often feel alienated by less personal interventions and rifts develop between clinicians and patients.

Discussion
It is likely that the conflict between modernism and post-modernism will affect many areas of society. Times of change in world views often lead to turmoil and chaos. There is a chance that post-modernism is a passing phenomenon, and some commentators view it as destructive, believing medicine should stick with a tried and trusted modernist paradigm (Charlton, 1993). But if post-modernism is here to stay, medicine will need to live with the tension. Psychiatry has always had post-modern leanings. The psychia tric establishment has often seemed at pains to extinguish the work of R. D. Laing, saying his ideas were flawed and did not work. The public at large, however, refuse to forget him, perhaps because he listened to patients and did not reduce them to their psychopathological compo nents. There is a pressure on the profession to make our model more modernist through evi dence-based medicine and outcome measures. The leaders of our profession are good research ers, but not necessarily good clinicians (though undoubtedly some are excellent at both). They have a lot to lose by questioning the modernist paradigm which has brought so much good to the world through medicine. If we do not question it, patients will.
There may be an increase in differences between what the psychiatrist advises and what the patient wants. As well as the psychiatrist dealing with this dilemma, patients must also take responsibility for this situation. Doctors cannot be expected to use scant resources on interventions they have strong reasons to believe will be ineffective. The potential for difficulties is exacerbated by the new powers of coercion and detention being suggested in mental health by the government.
Medicine and psychiatry need to assert them selves as humanities which include the art of compassion and scientific endeavour as compo nents. They are not primarily sciences, but incorporate science as part of the whole. There is a vital role for evidence-based medicine, but we must not become slaves to it (as many of its proponents have recognised). We should select and examine our junior doctors on their ability to listen to and incorporate patients' narratives into their care as well as evaluate evidence (Greenhalgh, 1999). We need to ensure that doctors are not confined by time pressures to deliver empiri cal interventions and leave the human side of mental health care to colleagues in other profes sions (who are then accused of not being evidence-based in their work). Finally, we need to prepare for the tension between the modern and post-modern world views with the strengths and weaknesses of both. This tension will probably be with us for decades.

Edited by Alan Lee
This book discusses the evidence-based assessment of deliberate self-harm, and covers the special problems of general psychiatric practice when alcohol misuse and severe personality disorder complicate the picture. Chapters relating to depressive disorders begin by focusing on opportunities for psycho-social intervention and liaison with primary care. There are comparisons of 'old' and 'new' antidepressants, and reviews of strategies for preventing relapse and recurrence, and managing resistant depression. The special problems of emergency treatment and depression in older patients are identified.
There are expert overviews of brief dynamic psychotherapy, cognitive approaches to treatment, lithium therapy and modern ECT practice. Many chapters emphasise the importance of the rational integration of biological and psychological treatments. There is helpful advice on the specific problems in managing obsessive-compulsive disorder and eating disorders, in dealing with somatisation, and in providing support and treatment for the victims of severe trauma.