13th Congress of the European Association for Psychotherapy
"Widening Boundaries of Europe - Widening Boundaries of Psychotherapy?"
2005, July 7-10 Vilnius Lithuania

Deficiency of evidence and evidence of deficiency - a reflection upon the

philosophy of knowledge applied to evidence based practice in psychotherapy
Michael Robertson

Dept of Psychiatry/Psychological Medicine Royal Prince Alfred Hospital Sydney

 michael.robertson@mayo.net.au

Chapter 1
How do we know what we know?

Knowledge in Psychotherapy
It is both an art and a science

CP Snow's Rede Lecture and the 'two cultures'

-  Science versus the Humanities

-  A culture where the 2 were in dialogue  and not at odds

Scientific Knowledge in Psychotherapy

Evidence based practice

-  Only treatments of proven efficacy should be used

- RCT is king

"Nothing can be said of a treatment until the first patient is randomized in

a study"
    - Archie Cochrane

Knowledge in Psychotherapy

Evidence based practice - criticisms

- Limits of RCT as applied to clinical practice

- Assumption of gaps in knowledge equated with treatments not working

- Biases towards certain forms of treatment

- Dismissive of the 'wisdom of experience'

Knowledge
The Platonic Doctrine of "Doxa" - Opinion as an inferior form of knowledge to

"Episteme" - Science

Knowledge

Francis Bacon's "idols of the mind"

'Idols of the cave'

'Idols of the tribe'

'Idols of the market place'

? Would currently considered as 'heuristic bias'

Knowledge in Psychiatry and Psychology
The limits of the natural sciences applied to human experience

- The later ideas of Husserl all but abandoned traditional phenomenology in

favour of geistenwissenschaft - the intersubjective experience of the world

- Heideggar's notion of "lichtung" applied to Dasein and the notion of a

moral vacuum brought about by the natural sciences attempts to define human

experience

- Is psychology truly the study of the human condition?

Knowledge in Psychiatry and Psychology
Nietzsche -:

- The Birth of Tragedy contrasted Apollonian and Dionysian modes of existence
- Science as a form of Apollonian existence
- Things as they are ordered to be, rather than things as they truly are -

heuristic bias
- Thus Spake Zarathustra - 'truth' should be judged on the merits of whether

it is 'species preserving' or 'species enhancing'

Knowledge in Psychiatry
Foucault
Knowledge/Power
-  Knowledge as 'discourse'
- Composition of knowledge indistinguishable power structures in social

settings.
- Culture, Politics, money etc  favour certain forms of thought over others
- Ideas considered to have 'cultural capital'.
- These ideas are hegemonic and exert firm control over the discourse.

Knowledge
Jean-Francios Lyotard    The Post Modern Condition

- In the information age - knowledge equates with material wealth

- "Scientific" vs "Narrative" knowledge

- Scientific knowledge so dominant it benefits from  the assumption that it

is the only form of knowledge

 
Knowledge
Jean-Francios Lyotard    The Post Modern Condition

- Science, Culture, Political Ideology tied in with military power, diplomacy

in late capitalism

- The rise of "consumer" economies as the ráison d'etre of modern societies

- American world view becomes the idee fixe

- The role of language

Knowledge
Philosophy of Science

Reductionism

Descartes
Rules for the Direction of the Mind (1625-28),

" ... it is only concerning genuinely simple and absolute matters that we can

have certain knowledge ... all human knowledge consists of this one thing,

that we perceive distinctly how these simple natures combine to produce other

things." 

Knowledge
Philosophy of Science

Reductionism

William of Ockham
"Pluralitas non est ponenda sine neccesitate'',
 
"entities should not be multiplied unnecessarily''.
 
'Ockham's razor'
when faced with two equally valid theories we  are compelled study in depth

the simplest of the theories, rather than take the more complex ? Are

psychiatrists are better served considering the physics of neurotransmitters

than complex ideas of Klein or Kohut.

Knowledge
Philosophy of Science

Reductionism

 Are psychiatry and psychology better served considering the physics of 

neurotransmitters in preference to complex ideas of Klein or Kohut ?

Knowledge
Jurgen Habermas
Knowledge and Human Interests

Knowledge constitutive interests divides knowledge into three categories -:

- Technical empirical knowledge

- Practical Interpretive knowledge

- Emancipatory knowledge

Knowledge
Jurgen Habermas
Knowledge and Human Interests

Technical empirical knowledge
Arises out of the Enlightenment and is, in essence, scientific.

Technical empirical modes of understanding involve developing a theory and

then making sets of highly contrived observations that seek to either prove

or disprove the theory.
 
Knowledge
Jurgen Habermas
Knowledge and Human Interests
Practical Interpretive knowledge
 
Seeks to measure the world as it is lived in. Learning and knowledge evolve

from observing the world as it comes.

At the core of this is language and interpretation.

This form of knowledge is represented by the wisdom of experience

Knowledge
Jurgen Habermas
Knowledge and Human Interests
Emancipatory knowledge
Achieved through a process of 'critical reflection', ponder the state of our

knoweldge, and what has brought us to think in such ways.

To emancipate one's thinking is to think about what we think, why we think it

and what has influenced us to think this way  eg culture, influence

Knowledge
Jurgen Habermas
Knowledge and Human Interests

To Habermas, Technical Empirical knowledge is so enamoured with itself that

it poorly tolerates challenges to it as a basis of knowledge.

When referring to science Habermas, terms this dominance as being 'scientism'

- science's belief in its own supreme power.

There is therefore a 'hegemony' of science over knowledge.
Knowledge
To summarise

Chapter 2

The troubling case of Dr Osheroff

Raphael Osheroff via Gerald Klerman
- 42 year old renal physician
- In 3rd marriage
- "brief periods of depression and anxiety"
- Treated with TCAD and Individual PsychoRx
- 'moderate improvement'
- Poorly compliant
- More severe depression
- Admitted to Chestnut Lodge in Jan 1979

Raphael Osheroff via Gerald Klerman
- In Chestnut Lodge 7 months
- No antidepressants
- Diagnosed "Narcissistic Personality Disorder"
- Prescribed Individual Therapy 4x per week
- Deteriorated with significant WL
- Increased psychomotor agitation
- Family interceded
- Admitted to Silver Hill hospital

Raphael Osheroff via Gerald Klerman
- In Silver Hill diagnosed Bipolar Depressed
- Psychotic features
- No evidence of Narcissistic PD
- Commenced on PTZ and TCA
- "Improved" in 3 weeks
- Home after 3 months

- Official diagnosis Bipolar Depression, not psychotic depression because of

custody issues

Raphael Osheroff via Gerald Klerman
"It should be concluded that there is no evidence for the value of any

psychotherapy in the treatment of depressive states.."

Raphael Osheroff via Alan Stone
- 1st  marriage in college - lasted 21 months and ended with an infidelity
- 2nd  marriage to nurse as intern, wife left the marriage after children

born
- Became severely depressed - ' a life devoid of satisfaction'

Raphael Osheroff via Alan Stone
- Medical practice boomed and he opened private dialysis centre
- Married a medical student after 'a whirlwind romance'
- "one of the most celebrated and sought after medical couples"
- Marriage ended in context of 2nd wife wanting custody of the 2 children and

his 'inconsiderate behaviour during the birth of the third
- Arguments with his colleagues

Raphael Osheroff via Alan Stone
- Saw three different psychiatrists
- 2 tried antidepressants; some individual psychotherapy
- Lack of compliance

" when Dr Osheroff entered Chestnut Lodge he was not a neophyte as to

psychiatry or its various therapeutic approached"

Raphael Osheroff via Alan Stone
- At Chestnut Lodge Osheroff developed -:
 
" a negative therapeutic reaction and a negative transference to both the

therapist and the hospital"

"...was in revolt against his treatment"

"he had escaped, if not narcissistically triumphed over, Chestnut Lodge and

his therapist. His negative transference had been vindicated"

Raphael Osheroff via Alan Stone

"Klerman's proposals could have serious consequences for the innovation,

diversity, and independent thought essential to scientific progress in

psychiatry"

Osheroff-v-Chestnut Lodge
Issues particular to Osheroff-v-Chestnut Lodge

The implications for psychotherapy research
How do we know what we know in psychotherapy?