Nicholas Gruen has argued that it’s much harder to realise evidence-based policy – both institutionally and intellectually – than many calling for it realise. Here he explains how putatively ‘scientific’ and ‘objective’ approaches can, paradoxically, compromise their efficacy by squeezing out empathy and relatedness.
Russ Roberts has (yet another) great interview on EconTalk. He’s always been gregarious in his interests, but is becoming more so—and also more sceptical of social progress and of economics as a master discipline. Be that as it may, on listening to this interview with psychiatrist Gary Greenberg on the placebo effect it struck me that a phenomenon of some interest to me might be far more general than I’d imagined.
War on empathy
Empathy tends to get squeezed out of interactions between bureaucracy and the life world. And even professions that one might imagine would be built on empathy — like social work — often operate according to other professional imperatives. Hence, the power of finding ways for the community to administer social repair through the empathic bond of peers rather than professionals, as The Australian Centre for Social Innovation (TACSI), which I chaired until the end of 2016, tried to do with Family by Family.
In any event, the basic idea promoted by Greenwood (slightly extrapolated by me) is this: as medicine was made more scientific, the placebo effect was discovered, and then marginalised. Yet it was of unarguable therapeutic power. Of course it’s entirely appropriate that, if one is looking for drug therapies, one wants to find drugs that, other things being equal, do better than sugar pills.
But in the process, the trail goes cold on keeping the placebo effect in the frame, not only for what it might help us understand, but, more remarkably, even for its therapeutic potential. There’s been vanishingly little investigation of the joint effect of the drug and the placebo acting together. And it turns out that, investigating the placebo effect more broadly, it seems likely that it has something to do with empathic bonds — between some source of authority like the doctor and the patient. Or perhaps from anyone.
War on confidence
We seem to do better when we feel ourselves to be of concern to others, not just mentally, but physically. Whodda thunk?
Note also Greenberg’s comment, “confidence is probably one of the most poorly understood and one of the most important aspects of our daily lives”.
Surely enough, confidence was critical in Family by Family. Single mothers had so internalised the description of themselves as bad mothers (and by any comparative standard they had certainly done some bad mothering), that they were crushed and unable to change. Every one of the success stories that I learned of seemed to me to operate very directly, through confidence.“Confidence is probably one of the most poorly understood and one of the most important aspects of our daily lives.”
To extrapolate further, we’re at the stage in drug therapy that we got to with our understanding of genetic causes of disease. Having discovered lots of low-hanging fruit, it’s all getting a lot harder. And it seems the world is more complex—vastly more complex—than the relentlessly reductive models we’ve had in our heads but which generated the early successes.
Of course, one of the things reinforcing all this is commercial interest. You can patent and market a molecule, so the ‘drug theory of physical wellness’ is well supported by the pharmaceutical capital market. Mobilising the placebo effect — much less so. (This is something that’s not handled as crisply as it might have been in the podcast, IMO.)
The fruit that’s not hanging so low are all the chronic maladies that dominate our health discourse today — obesity, diabetes, anxiety and depression, irritable bowel syndrome, chronic fatigue syndrome, to name a few. Drug therapy has worked poorly here. It’s possible, perhaps likely that, by understanding the placebo effect — or those things that drive it — renewed progress might be possible.
The war on context
This hasn’t just been a war (however inadvertent) on empathy and on the importance of confidence. It’s been a war on context.
A certain paradigm of science is asserted in which science offers knowledge that is lifted from context. Of course, if you can do it, and your goal is mastery of nature, well and good. You’d expect this to be the low-hanging fruit and you should go pick it.
Alas, the lavish rewards this produces — for outcomes, methodologies, disciplines and careers — then compromises what might be the next phase of progress in areas where context matters.
I almost wrote ‘more difficult’ areas. But context-dependent knowledge also exists on a spectrum from low-to-high-hanging fruit (slaps wrist for mixed metaphor).
A program like Family by Family isn’t rocket science. It makes a lot more sense than most standard practice now. It’s just countercultural in the empathy-starved careerist bureaucracy we’ve built to deliver child protection services — an environment that has been unable to even detect strongly above-average performance, let alone find ways to learn from and spread it.
This kind of knowledge is scientific knowledge too, but arises when one adapts one’s scientific tools to the task at hand, rather than simply aping techniques that worked elsewhere.
With the renewed enthusiasm towards evidence-based policy in the context of the Thodey Review (while we expand cashless welfare cards for political reasons contrary to all the evidence) the test will be whether anything we do will promote rigour, thoughtfulness and attention to what the evidence is telling us given our objectives and the multiple contexts in which we want to achieve them.
The two alternatives to this are that nice words are said about the report and it’s ignored, or it provokes a new birth of scientism in which the quest for contextless knowledge generates little useful knowledge at all.
Postscript: Nicholas Gruen is interviewed by Leon Gettler on the subject of this post