Shaman or traditional medicine relies on non-scientific revelation, narratology, and other spiritual and anthropological phenomena as a method for healing. There are branches of western medicine (i.e. complementary and alternative, holistic medicine, etc) whereby it's explicitly aiming to model after traditional therapeutics. Psychiatry, as it stands, is not one of these branches, and in practice is moving away from that. There's a lot of interest in psychedelics right now, for example, but while the experimental practice of using psychedelics draws from what we know from shaman narratives, the evidence is obtained from very classical clinical development pipelines.
I also think the market is totally different and you don't capture good value if you think of yourself as comparable to a shaman. The most profitable things in medicine are expensive, technologically driven things that aim toward a well-reimbursed demographic. Think elective surgery. Think IVF. There's nothing shamanistic about these practices--EVEN THOUGH many aspects of the practices have a degree of "underdeterminism" (in your words) to them.
I like your posts analysing the market dynamics of our field and find them incredibly useful. I think you are perhaps conflating what is incentivized by economic structures with customary or typical practice. Strictly speaking whether or not it is profitable is irrelevant to whether or not something is solidly within the medical model and doesn't really enter into the argument.
I would argue that most profitable psychiatry practices are much more similar to IVF practices than a Tarot reader.
That's fine, but I think refusing to engage with typical psychiatric practice as it is actually performed and insisting on limiting your analysis simply to high-end boutique places is question-begging. That is, if you focus only on the sector that tries hardest to look like the rest of medicine of course when you look at it it looks more or less like medicine.
There's also nothing mysterious about any of this: good manual-driven therapy with high fidelity and good medication management practices have high retainment. Inefficient, ineffective and wishy-washy unprincipled practice (common in NPs, etc) confuses patients and decreases retainment.
It's interesting that psychotherapy research in general has been moving away from the idea of highly specific protocols that are unique to particular disorders in favor of identifying suites of interventions that target areas of difficulty and processes of change transdiagnostically (Cf
Amazon product ). Similarly, although the common factors literature makes claims it often can't entirely support, there is a reasonable amount of data now suggesting that protocol fidelity
per se is usually not the most important factor in predicting good treatment outcomes in therapy. What does emerge from the literature is that having a coherent model of change that you can articulate to the patient and get buy-in for is extremely important and definitely explains your astute observation that a lack of this decreases retainment, but note this doesn't really separate us from traditional healers either.
This belies the idea that psychotherapy is increasingly based on a highly specific, technical treatments that can be specified in some way based on caseness rather than taking into account an awful lot of contingent details about a person's history, temperament, circumstances etc.
But that's what science is. Science is a specific kind of process ("culture") where a specific type of knowledge is generated. It's not a value judgment. Placebo effects are real, observable scientific findings (sometimes). Practicing medicine predicated on known scientific evidence is evidence-based practice. Why would practicing based on evidence on placebo be not evidence-based? I.e. if I know that a particular agent is more similar to placebo and the relative risks vs. benefits favor the use of a placebo-like agent vs. another agent, perhaps I would suggest that agent as the first-line treatment.
I think you'll find I never said harnessing placebo effects couldn't be evidence-based. Right now the placebo literature is underspecified with respect to how to actually
utilize placebos in real-world clinical contexts to greatest effect but in principle I can imagine that being uncovered at some point.
I am a bit confused about the thrust of your argument, though. Are you saying that literally anything in principle amenable to empirical study is scientific? That only makes it seem more like scientific is being stretched into a semantically weak/empty label. What would not count as scientific in this view?
Evidence-based medicine in some ways has been argued to be anti-scientific by some philosophers of medicine, in the sense that it is strictly empiricist. That is to say, evidence-based medicine says follow the data, no matter what. In the EBM paradigm, if data contradicts theory, so much the worse for theory. You don't need to understand why, just need to know the observed what. Science (at least in anything like a positivist or Hempelian understanding) is about theory making predictions confirmed or disconfirmed by data, or at least conforming to postdictions.
I would never suggest placebo-like agents for patients with opioid use disorder, or even severe chronic depression, for example. The fact that there is an indication specificity is based on scientific evidence. If I was a shaman I'd say here is a potion, it cures all.
You may underestimate the specificity of what shamanic work actually looks like based on the nature of the complaints. I agree with you however that there are some illnesses we treat that fit tolerably well into the medical model, or at least as well as the sorts of disorders that are bread and butter in other cognitive specialities.
Good discussion.
