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  • Why Pragmatism Cannot Save Evidence-Based Psychiatry
  • Mona Gupta (bio)
Keywords

pragmatism, EBM, evidence-based psychiatry

In her paper, “Evidence-based medicine in context: A pragmatist approach to psychiatric practice,” Jorid Moen (2015) sets out to advance the debate about role of evidence-based medicine (EBM) in psychiatric practice. She views this debate as dichotomous and unproductive. It is dichotomous in the sense that EBM is linked to foundationalist theories of knowledge, whereas critiques of EBM are often based in anti-foundationalist theory. It is unproductive because neither position offers a way forward. Moen draws on the philosophical tradition of pragmatism in hopes that ‘opposing positions of EBM might be brought to agree that the different perspectives they represent are both relevant and important for psychiatric practice’ (2015, 53). Further, she wants to rethink ‘EBM’s role in psychiatry.’

Moen starts with the idea that the description or ‘vocabulary’ we use for a given phenomenon is articulated from a particular perspective. According to the pragmatist view, a vocabulary should be seen as a tool, evaluated for its usefulness in achieving the desired ends in a given context rather than whether it is truthful or perspective free. This means that if multiple perspectives are useful in achieving certain ends, such as in understanding a patient’s problems, then multiple vocabularies or ways of describing a phenomenon should be allowed. Furthermore, there is no need for these multiple vocabularies to have to be subsumed or trumped by a more basic one. Moen sees clinical problems in psychiatry as needing and benefiting from different vocabularies, presumably because no definitive vocabulary exists at present to describe mental and emotional life.

Moen then goes on to review the five-step procedure of EBM: step 1, converting the need for information into an answerable question; step 2, tracking down the best evidence with which to answer that question; step 3, critically appraising that evidence for its validity; step 4, integrating the critical appraisal with our clinical expertise and with our patient’s unique biology, values, and circumstances; and step 5, evaluating our effectiveness and efficiency in executing steps 1 through 4, seeking ways to improve them both for next time. She points out that these steps are defined and described using a particular vocabulary that results in a particular body of knowledge for psychiatrists. She explores how a pragmatist approach, which [End Page 63] emphasizes usefulness as opposed to truthfulness, could help to expand each step beyond its scope as defined by EBM.

Take step 1 as an example: converting the need for information into an answerable question. Moen argues that an answerable question is one that is answerable according to the methods and assumptions of EBM. This does not necessarily include all questions that are relevant to a particular clinical problem. An answerable question about medication adherence, in EBM terms, might ask what the rate of medication non-adherence is among a certain population of patients. Moen says that there are other questions one can ask about this phenomenon such as: why don’t certain people take medication? This latter research question might help to foster awareness and appreciation of the difficulties some patients go through when they take medication. The author points out that both kinds of questions could offer useful information in practice when a clinician has to address the issue of a patient taking or not taking medication. Furthermore, she notes that it is not helpful to think of one type of information as superior or higher ranked than another as each plays a role in helping to understand the clinical scenario at hand.

Moen thus argues for the idea that evidence-based psychiatry is insufficient as exactly that, as a base for psychiatry, because on a pragmatist view any one kind of knowledge, such as that offered by EBM, is not necessarily the most useful in responding to all clinical questions. Where EBM offers useful information for a given problem in clinical practice, it ought to be given due consideration. And where other types of evidence or knowledge contribute, they too should be given consideration. I agree with Moen on this point. However, once other types of knowledge can...

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