Event Title
Clinical expertise as scientific method: A brief history of psychopharmocology
Start Date
26-6-2010 9:00 AM
End Date
26-6-2010 10:30 AM
Description
This presentation is part of the Constructing Race and Sexuality track.
This paper argues that the role of clinical expertise in the discovery and refinement of theories in pharmacological psychiatry provides a valuable perspective on the role of values in scientific research. There are three points this paper will address. First, that the traditional divide in the philosophy of science between the context of discovery and the context of justification does not adequately address the role of clinical expertise in current psychiatric research. An analysis of the nature of psychiatric expertise provides a new way of understanding the role of creativity at the level of the individual in ongoing research. Second, I argue that this kind of expertise is necessary for the progress of psychiatry as a scientific discipline, and that it can be best understood under the rubric of feminist epistemology. Finally, the conclusions of this paper can be generalized to address the question of whether or not psychiatry should be counted as a scientific discipline.
It is widely agreed upon by researchers and practicing psychiatrists alike that the context in which antidepressant (and other psychotherapeutic) drugs were discovered differs greatly from the current context of theory refinement and justification. Clinical expertise played a key role in the discovery of imipramine, to name one example: the experienced observations of side effects lead practicing clinicians to interpret the reactions of their patients to imipramine as evidence for a new theory of depression and other affective disorders. Since the discovery of antidepressants, the method of research has changed markedly, now focussing on randomized controlled trials and other standardized methods for medical research. I argue that this has in fact hindered the potential for both refinement and justification to the same degree that it has rejected clinical expertise as a valid source of empirical data. In fact, the progress that is now being made is due to the continued use of clinical expertise by practicing psychiatrists and clinicians, as off-label prescription leads to new interpretations of otherwise stagnant theories. In its attempt to legitimize itself as a scientific discipline, pharmacological psychiatry had in fact precluded its own ability to draw legitimate scientific conclusions.
Feminist epistemology provides one way to understand the use of clinical expertise throughout the scientific process. Feminists argue that values influence scientists at all levels of the process; psychiatric expertise provides a way to understand the nature of that influence. Practicing psychiatrists work from within theoretical frameworks, and yet practice creatively by prescribing drugs in ways that are not predicted by nor validated by those theoretical frameworks. In this context, values are not reduced to external influences, but play a role in the individual’s ability to use the empirical evidence at hand and to make insightful observations. It is in the practice of off-label prescribing that progress can be and has been made in psychopharmacological research. The values that encourage a psychiatrist to prescribe off-label are values that come from her training as well as her goals as a psychiatrist. Like the psychopharmacological researcher, the psychiatrist seeks to understand her patient. She also uses empirical evidence gathered by personal experience with drugs and with patients in order to move beyond theoretical frameworks and to produce predictable results. In fact, the original intention of diagnostic manuals such as the DSM was to incorporate this use of clinical expertise into the formal methods of data-collection, an intention that has been superceded by the current emphasis on evidence-based practice in medicine. I argue this is the result of a conceived divide between the contexts of discovery and justification in science that has been integrated into psychiatric research because of its efforts to attain perceived scientific legitimacy. However, legitimacy comes with the refinement and justification of scientific theories, and increased predictive power, which cannot happen without the help of clinical expertise.
Thomas Kuhn argues that normal science is a practice of puzzle-solving, rather than spontaneity. Given the conclusions I draw in this paper, I argue that his picture is too simplistic to prescribe appropriate scientific activity to psychopharmacologists. In maintaining the contextual divide, Kuhn’s analysis of what counts and doesn’t count as a science in contemporary society results in a de-legitimization of clinical expertise which in turn contributes to a perception that practicing psychiatrists do not count as scientists in the same way that psychopharmacological researchers, using standardized methods, do. Prioritizing the role of clinical expertise not only in the context of discovery but as a necessary ingredient for the refinement of psychopharmacological theory provides an understanding of the role that the individual and creativity must play in normal science. Not only the invention of new theoretical frameworks, but the refinement of well-established theories requires the influence of individuals and their values. Interpreted through the lens of clinical expertise, the importance of values in scientific research upheld by feminist epistemologies can be used in turn to argue that psychiatry, whose progress requires the creative use of individual experience in all contexts, is a necessary and therefore legitimate part of the science of psychopharmacology.
Clinical expertise as scientific method: A brief history of psychopharmocology
This presentation is part of the Constructing Race and Sexuality track.
This paper argues that the role of clinical expertise in the discovery and refinement of theories in pharmacological psychiatry provides a valuable perspective on the role of values in scientific research. There are three points this paper will address. First, that the traditional divide in the philosophy of science between the context of discovery and the context of justification does not adequately address the role of clinical expertise in current psychiatric research. An analysis of the nature of psychiatric expertise provides a new way of understanding the role of creativity at the level of the individual in ongoing research. Second, I argue that this kind of expertise is necessary for the progress of psychiatry as a scientific discipline, and that it can be best understood under the rubric of feminist epistemology. Finally, the conclusions of this paper can be generalized to address the question of whether or not psychiatry should be counted as a scientific discipline.
It is widely agreed upon by researchers and practicing psychiatrists alike that the context in which antidepressant (and other psychotherapeutic) drugs were discovered differs greatly from the current context of theory refinement and justification. Clinical expertise played a key role in the discovery of imipramine, to name one example: the experienced observations of side effects lead practicing clinicians to interpret the reactions of their patients to imipramine as evidence for a new theory of depression and other affective disorders. Since the discovery of antidepressants, the method of research has changed markedly, now focussing on randomized controlled trials and other standardized methods for medical research. I argue that this has in fact hindered the potential for both refinement and justification to the same degree that it has rejected clinical expertise as a valid source of empirical data. In fact, the progress that is now being made is due to the continued use of clinical expertise by practicing psychiatrists and clinicians, as off-label prescription leads to new interpretations of otherwise stagnant theories. In its attempt to legitimize itself as a scientific discipline, pharmacological psychiatry had in fact precluded its own ability to draw legitimate scientific conclusions.
Feminist epistemology provides one way to understand the use of clinical expertise throughout the scientific process. Feminists argue that values influence scientists at all levels of the process; psychiatric expertise provides a way to understand the nature of that influence. Practicing psychiatrists work from within theoretical frameworks, and yet practice creatively by prescribing drugs in ways that are not predicted by nor validated by those theoretical frameworks. In this context, values are not reduced to external influences, but play a role in the individual’s ability to use the empirical evidence at hand and to make insightful observations. It is in the practice of off-label prescribing that progress can be and has been made in psychopharmacological research. The values that encourage a psychiatrist to prescribe off-label are values that come from her training as well as her goals as a psychiatrist. Like the psychopharmacological researcher, the psychiatrist seeks to understand her patient. She also uses empirical evidence gathered by personal experience with drugs and with patients in order to move beyond theoretical frameworks and to produce predictable results. In fact, the original intention of diagnostic manuals such as the DSM was to incorporate this use of clinical expertise into the formal methods of data-collection, an intention that has been superceded by the current emphasis on evidence-based practice in medicine. I argue this is the result of a conceived divide between the contexts of discovery and justification in science that has been integrated into psychiatric research because of its efforts to attain perceived scientific legitimacy. However, legitimacy comes with the refinement and justification of scientific theories, and increased predictive power, which cannot happen without the help of clinical expertise.
Thomas Kuhn argues that normal science is a practice of puzzle-solving, rather than spontaneity. Given the conclusions I draw in this paper, I argue that his picture is too simplistic to prescribe appropriate scientific activity to psychopharmacologists. In maintaining the contextual divide, Kuhn’s analysis of what counts and doesn’t count as a science in contemporary society results in a de-legitimization of clinical expertise which in turn contributes to a perception that practicing psychiatrists do not count as scientists in the same way that psychopharmacological researchers, using standardized methods, do. Prioritizing the role of clinical expertise not only in the context of discovery but as a necessary ingredient for the refinement of psychopharmacological theory provides an understanding of the role that the individual and creativity must play in normal science. Not only the invention of new theoretical frameworks, but the refinement of well-established theories requires the influence of individuals and their values. Interpreted through the lens of clinical expertise, the importance of values in scientific research upheld by feminist epistemologies can be used in turn to argue that psychiatry, whose progress requires the creative use of individual experience in all contexts, is a necessary and therefore legitimate part of the science of psychopharmacology.